Assessing the use of Faecal Immunochemical Testing (FIT) with red flag symptoms to improve referral pathways for suspected colorectal cancer

Aims Colorectal cancer (CRC) is the 4th most common malignancy in the UK. Colonoscopy is the gold-standard for its detection. Due to the impact of bowel cancer screening programmes on endoscopy services, colonoscopy demand has outstripped capacity in pockets across the UK. To mitigate this, more streamlined pathways have been developed around the framework set out in the 2022 British Society of Gastroenterology FIT guidelines. This Quality Improvement Project examines a new FIT based pathway in University Hospitals Birmingham (UHB) and its impact on CRC detection and colonoscopy services.

Methods We used retrospective data to compare patients referred for colonoscopy in a 6 month period before the guideline change (Apr-Sep 2022) and in the same 6 month period after the guideline change (Apr-Sep 2023). A sub-group analysis of 200 consecutive patients before and after the guideline changed (n=400) was used to analyse diagnostic outcomes and individual demographic and biochemical data. Using SPSS, statistical and regression analyses were performed [1] [2] [3].

Results In the 6 month period in 2022, there were 5,799 2 week wait referrals from primary care. In the same period in 2023, there were 4,105. A reduction of 1,694 referrals (29%). Despite this diminution, sub-group analysis revealed that there was no statistical difference in neoplasia detection after the guideline change (P=0.2271). It also revealed a statistical difference in the detection of gastrointestinal pathology (P=0.0027). Using Spearman Rank analysis, there was a correlation between age (P=0.015), haemoglobin (P=<0.001), ferritin (P=0.021), platelets (P=0.006) and FIT result (P=0.037) with the detection of either polyps or neoplasia. There was also a correlation between the detection of neoplasia only, with age (P=0.03) and FIT result (P=0.004). Regression analysis of FIT positive patients, highlighted that those patients with a positive FIT and White British ethnicity (P=0.025), Index of Multiple Deprivation decile 1 (P=0.025) or rectal bleeding (P=0.025) were more likely to have either polyps or a neoplasia diagnosis.

Conclusions Demands upon 2 week wait colonoscopy services have been greatly reduced by the refined referral criteria for CRC. This improvement was concurrent with preservation of cancer detection and improved polyp detection rate. Sub-group analysis highlighted potential demographic and clinical features that could be used in the future to further risk stratify patients on the suspected cancer pathway.

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Monahan KJ, Davies MM, Abulafi M, Banerjea A, Nicholson BD, Arasaradnam R.. et al. 'Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG). Gut 2022; 71 (10) pp: 1939-1962 Available from
• 2 Issa I, Noureddine M.. 'Colorectal cancer screening: An updated review of the available options'. World J Gastroenterol 2017; 23 (28) pp: 5086-5096 Available from
• 3 Ho KMA, Banerjee A, Lawler M, Rutter MD, Lovat LB.. 'Predicting endoscopic activity recovery in England after COVID-19: a national analysis The Lancet Gastroenterology ' Hepatology. 2021 [cited 2024 March 21; 6 (5): pp 2021; 381-390 Available from doi:10.1016%2FS2468-1253(21)00058-3.

Publication History

Article published online:
27 March 2025