How the use of FIT developed in North Central London
Phase one – NICE DG30 guidance (2019)
The publication of NICE DG30 (diagnostics guidance) provided guidance for patients with less than 3% risk of cancer. GPs ask patients with bowel symptoms to complete a faecal immunochemical test (FIT) at home. If the FIT is negative, the patient has almost certainly no bowel cancer. If the test is positive, the GP will refer the patient to hospital for further tests.
Phase two – care during the pandemic (June 2020)
The faecal immunochemical test (FIT) was incorporated into the NHS England lower gastrointestinal (GI) cancer pathway to ensure appropriate care during the COVID-19 pandemic.
It was used to triage high risk symptomatic patients (who have a more than 3% suspicion of cancer). GPs ask patients with worrying lower abdominal symptoms (other than highly suspicious symptoms, such as a mass), to complete a FIT before referring to hospital. If the FIT is negative, the patient almost certainly has no bowel cancer (99.5% unlikely). If the test is positive the patient will be referred by their GP to hospital for fast-track investigation.
Phase three – safety netting in secondary care and evaluation (July 2022)
In North Central London, from July 2022, the new pathway was introduced for patients who have lower abdominal symptoms but who have a negative FIT test. This means they have a very low risk of having bowel cancer, but it cannot be ruled out entirely.
In a year-long service evaluation project, GPs across north central London refer low risk patients to hospital instead of waiting to see if symptoms worsen over a period of time.
The patients will attend a dedicated follow-up clinic 8-10 weeks after their referral. A consultant or other senior healthcare professional will assess the patient’s repeated FIT and blood test results, which will have been completed before attending the clinic. Any changes in their symptoms will help to define the treatment plan.
The follow-up clinic offers reassurance to the majority of people who do not have cancer and will enable fast track examination for those who need further tests.
By auditing the follow-up pathway, the North Central London Cancer Alliance is building an evidence base for best practice in bowel cancer safety netting.
There is more information here for healthcare professionals about the changes in the lower gastrointestinal (GI) pathway.
Phase four – redefining best practice (summer 2023 onwards)
The clinical evidence gathered from the service evaluation audit will be used to refine how patients with bowel symptoms are looked after on the lower GI cancer pathway. The proposition is that safety netting for symptomatic patients should, in the longer term, move to primary care.