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)

Executive Summary of Recommendations

FIT in Primary Care

1. We recommend that FIT should be used by primary care clinicians to prioritise patients with clinical features of colorectal cancer for referral for urgent investigation
2. We recommend that a FIT threshold of fHb ≥10μg Hb/g should be used in primary care to select patients with lower gastrointestinal symptoms for an urgent referral pathway for colorectal cancer investigation
3. We recommend that patients should not be excluded from referral from primary care for symptoms on the basis of FIT testing alone

Advice for clinicians where patients have not returned a FIT test

4. We suggest that clinicians should follow up patients with no FIT result to encourage them to return a sample or, where the kit has been lost or inadequately submitted, offer a further test
5. We suggest that patients who decline to return a FIT test should be counselled that evaluation of their symptoms is incomplete, and be encouraged to complete their test
6. We suggest that where no FIT result can be obtained, clinicians should use existing national and local guidelines to assess risk of colorectal cancer

Safety Netting

7. We recommend that some patients with symptoms of suspected colorectal cancer may be managed in primary care if fHb <10μg Hb/g, and provided appropriate safety netting is in place
8. We suggest that patients with a fHb <10μg Hb/g but with persistent and unexplained symptoms for whom the GP has ongoing clinical concern should be referred to secondary care for evaluation
9. We recommend that safety netting protocols should incorporate advice and strategies for the diagnosis of colorectal and extra-colonic cancer, as well as other serious gastro-intestinal conditions

Diagnostic accuracy of FIT for CRC with suspected cancer signs or symptoms

10. FIT is a triage tool to identify those patients with symptoms of suspected colorectal cancer who should undergo further colorectal investigation
11. We suggest that FIT be utilised for people with iron deficiency anaemia within primary care to inform urgency of referral
12. We suggest referral of patients with persistent / recurrent anorectal bleeding for flexible sigmoidoscopy if fHb <10μg Hb/g
13. There is currently insufficient evidence to recommend variations in the fHb threshold for referral from primary care according to patient related-factors
14. There is currently insufficient evidence to confirm whether diagnostic accuracy is impacted by the type of FIT analyser used
15. There is currently insufficient evidence to recommend including FIT in a risk score with other clinical features to identify patients with symptoms of suspected colorectal cancer
16. We suggest that FIT may be used to stratify adult patients aged younger than 50 years with bowel symptoms suspicious of a diagnosis of colorectal cancer

Investigation in secondary care

17. Colonoscopy is considered the standard method of investigation, however other methods of colorectal imaging may be appropriate in some patients
18. We recommend that for patients with symptoms of a suspected diagnosis of colorectal cancer, CT Colonography is equivalent to colonoscopy for detection of colorectal cancer (the choice of modality should be determined by the local expertise and availability)
19. There is currently insufficient evidence to support use of a specific quantitative FIT threshold to recommend the selection of CT Colonography versus colonoscopy


20. On the basis of limited evidence, clinicians and patients consider FIT as an acceptable test for symptomatic colorectal cancer in most circumstances
21. We recommend that services should consider ways of promoting a high proportion of patients to return FIT kits


22. We recommend that clinicians actively prevent discrimination at any stage of the diagnostic pathway as symptomatic FIT testing is rolled out, with a focus on equity of access and application to all patients with lower GI symptoms


23. We recommend that FIT, as a diagnostic triage tool, can be implemented safely at primary care level, and that a programme of education be developed to facilitate implementation of FIT in primary care

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