Faecal immunochemical (rule-in) testing in general practice

Bailey, Sarah; Melle, Marije van; Nicholson, Brian D

doi:10.3399/bjgp19x702173

Cited by 3 publications

(5 citation statements)

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“…Analysable results were available for 38 920 patients (Figure 1). This population is described in detail elsewhere [14]. A total of 599 CRCs were detected (1.5%), the majority (58.6%) followed a FIT result of ≥100 μg Hb/g faeces.…”

Section: Resultsmentioning

confidence: 99%

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‘Low’ faecal immunochemical test (FIT) colorectal cancer: a 4‐year comparison of the Nottingham ‘4F’ protocol with FIT10 in symptomatic patients

Bailey,

Morton,

Jones

et al. 2024

Colorectal Disease

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AimThe aim of this work was to evaluate colorectal cancer (CRC) outcomes after ‘low’ (sub‐threshold) faecal immunochemical test (FIT) results in symptomatic patients tested in primary care.MethodThis work comprised a retrospective audit of 35 289 patients with FIT results who had consulted their general practitioner with lower gastrointestinal symptoms and had subsequent CRC diagnoses.The Rapid Colorectal Cancer Diagnosis pathway was introduced in November 2017 to allow incorporation of FIT into clinical practice. The local ‘4F’ protocol combined FIT results with blood tests and digital rectal examination (DRE): FIT, full blood count, ferritin and finger [DRE]. The outcome used was detection rates of CRC, missed CRC and time to diagnosis in local 4F protocols for patients with a subthreshold faecal haemoglobin (fHb) result compared with thresholds of 10 and 20 μg Hb/g faeces.ResultsA single threshold of 10 μg Hb/g faeces identifies a population in whom the risk of CRC is 0.2%, but this would have missed 63 (10.5%) of 599 CRCs in this population. The Nottingham 4F protocol would have missed fewer CRCs [42 of 599 (7%)] despite using a threshold of 20 μg Hb/g faeces for patients with normal blood tests. Subthreshold FIT results in patients subsequently diagnosed with a palpable rectal tumour yielded the longest delays in diagnosis.ConclusionA combination of FIT with blood results and DRE (the 4F protocol) reduced the risk of missed or delayed diagnosis. Further studies on the impact of such protocols on the diagnostic accuracy of FIT are expected. The value of adding blood tests to FIT may be restricted to specific parts of the fHb results spectrum.

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Section: Resultsmentioning

confidence: 99%

“…Trust data and electronic patient records and databases were used for cross‐checking and diagnostic validation for all patients sent a FIT between November 2017 and 31 October 2021. This is described in depth elsewhere [14, 15]. Ethical was approval granted locally (NUH registration number 20‐135C).…”

Section: Methodsmentioning

confidence: 99%

‘Low’ faecal immunochemical test (FIT) colorectal cancer: a 4‐year comparison of the Nottingham ‘4F’ protocol with FIT10 in symptomatic patients

Bailey,

Morton,

Jones

et al. 2024

Colorectal Disease

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“…(48) However, patient noncompliance with FIT of 6.4–16.2% in primary care means there is a clinical need for stratification of CRC risk which doesn’t depend on FIT. (20) The IRM could be used to calculate a patient’s risk of CRC rapidly in the primary care setting, if enough information (age, sex, symptoms, and genotyping data) were available. This could reduce time to diagnosis, however, the clinical utility of this approach requires further investigation.…”

Section: Discussionmentioning

confidence: 99%

“…Addressing this limitation will be an important focus of future work, especially considering that the IRM may be useful for CRC risk prediction in cases of FIT noncompliance, and a recent study showed FIT uptake is lower in the following ethnic groups: Asian, Black, and mixed or other. (20) This highlights the urgent need for openly available genome-wide association study data from ancestrally diverse populations, to develop accurate PRS for more individuals, and reduce health inequalities. (49) The IRM was also less predictive in patients younger than 50, likely due to lower CRC incidence in this age range.…”

Section: Limitationsmentioning

confidence: 99%

“…(17–19) However, FIT uptake varies by age, sex, ethnicity and socioeconomic status, with a 6.4–16.2% noncompliance rate in-clinic. (15,20) Additionally, an evaluation of FIT in clinic showed that of 618 patients with a FIT result over the symptomatic 10ug/g threshold, only 43 (6.97%) had CRC. (21) This study presents a novel method of patient risk stratification in primary care using genetics, symptoms, and patient characteristics, with potential to complement existing methods such as FIT in cases of noncompliance or uncertain results.…”

Section: Introductionmentioning

confidence: 99%

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Colorectal cancer risk stratification using a polygenic risk score in symptomatic patients presenting to primary care – a UK Biobank retrospective cohort study

Mallabar-Rimmer,

Merriel,

Webster

et al. 2023

Preprint

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Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. Accurate cancer risk stratification approaches could increase rates of early CRC diagnosis, improve health outcomes for patients and reduce pressure on diagnostic services. The faecal immunochemical test (FIT) for blood in stool is widely used in primary care to identify symptomatic patients with likely CRC. However, there is a 6–16% noncompliance rate with FIT in clinic and ∼90% of patients over the symptomatic 10µg/g test threshold do not have CRC.A polygenic risk score (PRS) quantifies an individual’s genetic risk of a condition based on many common variants. Existing PRS for CRC have so far been used to stratify asymptomatic populations. We conducted a retrospective cohort study of 53,112 UK Biobank participants with a CRC symptom in their primary care record at age 40+. A PRS based on 207 variants, 5 genetic principal components and 24 other risk factors and markers for CRC were assessed for association with CRC diagnosis within two years of first symptom presentation using logistic regression. Associated variables were included in an integrated risk model and tested for ability to predict CRC diagnosis within two years, using receiver operating characteristic area under the curve (ROCAUC) and Akaike information criterion (AIC).An integrated risk model combining PRS, age, sex and patient-reported symptoms was highly predictive of CRC development (ROCAUC: 0.80, 95% confidence interval: 0.78– 0.81). This model has the potential to improve early diagnosis of CRC, particularly in cases of patient non-compliance with FIT.Lay AbstractBowel cancer is one of the most common types of cancer worldwide, and patients diagnosed earlier have a much better chance of survival. Finding ways to predict which people are at risk of developing bowel cancer is therefore a research priority.In this study, we used genetics and information about patients (such as age and sex) to predict which patients are at high risk of developing bowel cancer within two years of seeing their GP with a symptom. We tested 30 risk factors and identified eight that were more common in patients who developed bowel cancer shortly after experiencing symptoms.These eight risk factors included: older age, being male, larger waist circumference, smoking, higher inherited genetic risk, and presence of two symptoms – change in bowel habit (including constipation or diarrhoea) and/or bleeding from the rectum. On the other hand, stomach pain was the symptom which occurred least in people who developed bowel cancer.Six of the above risk factors, when combined into one measure of risk (called ‘a risk model’) were good at predicting which patients would develop bowel cancer shortly after symptoms. These factors included age, sex, genetic risk, bleeding from the rectum, change in bowel habit and stomach pain.This risk model could help doctors decide which symptomatic patients to send for bowel cancer testing. This would allow earlier detection of bowel cancer which would improve outcomes for patients.

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Recognising Colorectal Cancer in Primary Care

et al. 2021

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Colorectal cancer (CRC) is the third most common cancer worldwide. Primary care professionals can play an important role in both prevention and early detection of CRC. Most CRCs are attributed to modifiable lifestyle factors, which can be addressed within primary care, and promotion of population-based screening programmes can aid early cancer detection in asymptomatic patients. Primary care professionals have a vital role in clinically assessing patients presenting with symptoms that may indicate cancer, as most patients with CRC first present with symptoms. These assessments are often challenging—many of the symptoms of CRC are non-specific and commonly occur in patients presenting with non-malignant disease. The range of options for investigating symptomatic patients in primary care is rapidly growing. Simple tests, such as faecal immunochemical testing (FIT), are now being used to guide decisions around referral for more invasive tests, such as colonoscopy, while direct access to specialist investigations is also becoming more common. Clinical decision support tools (CDSTs) which calculate cancer risk based on symptomatology, patient characteristics and test results can provide an additional resource to guide decisions on further investigation. This article explores the challenges of CRC prevention and detection from the primary care perspective, discusses current evidence-based approaches for CRC detection used in primary care (with examples from UK guidelines), and highlights emerging research which may likely alter practice in the future.

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Faecal immunochemical (rule-in) testing in general practice

Cited by 3 publications

References 4 publications

‘Low’ faecal immunochemical test (FIT) colorectal cancer: a 4‐year comparison of the Nottingham ‘4F’ protocol with FIT10 in symptomatic patients

‘Low’ faecal immunochemical test (FIT) colorectal cancer: a 4‐year comparison of the Nottingham ‘4F’ protocol with FIT10 in symptomatic patients

Colorectal cancer risk stratification using a polygenic risk score in symptomatic patients presenting to primary care – a UK Biobank retrospective cohort study

Recognising Colorectal Cancer in Primary Care

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