10 Focus on FIT When thinking this through it is important to recognise the strength of primary care as ‘the good gatekeeper’ while secondary care is the obligate investigator. So this measured, safety netted, clinical risk assessment of FIT negative patients should lie with primary care. THE FUTURE? Currently the role of FIT both to support DG30 and most particularly NG12 is uncertain. A great deal of work is going on at the moment and we will have a much clearer idea soon. I have it in mind that a pathway will develop something like the diagram below [Figure 2]. The future pathway will start with patients with lower gastrointestinal symptoms in the broadest sense (though there may be a number of exclusions such as rectal mass/ iron deficient anaemia and possibly fresh rectal bleeding in the young). We know that the specificity of FIT is lower in younger patients so you have to factor in a pragmatic age cut-off where fCAL may become a more useful test. I have chosen 50 years. All patients over 50 years with lower gastrointestinal symptoms, where there is diagnostic uncertainty, irrespective of whether they currently do not fulfil NICE NG12, will have a FIT. I do not think rectal bleeding will prevent the use of FIT. GPs will also include patients younger than 50 years where CRC is suspected. Because FIT is such a good diagnostic I think it acceptable to widen the net and not to be proscriptive. Those who are FIT positive will be referred into the ‘two week wait’ pathway. Those under 50 years and in whom CRC is not suspected should enter the fCAL pathway1. For those who are FIT negative, if cancer is still suspected then an urgent referral should be made anyway. Perhaps a CT will be the first investigation here. Otherwise these patients should be treated symptomatically and then reviewed within primary care. If still symptomatic and under 60 years they should then enter the fCAL pathway but if older than 60 years, a routine referral should be made. In time I suspect a workable and pragmatic pathway such as this will evolve. Overall, Dr Turvill concludes FIT is an excellent test and will capture almost all CRC. However, we must remain cognisant of its limitations and ensure that FIT negative follow-ups are conducted to avoid excess referral, and therefore dilution of the benefits of FIT, and encourage the partnering of FIT with clinical suspicion to ensure we capture as many of those cancers as possible. A video of Dr. Turvill’s presentation can be seen at www.faecal-immunochemical-test. co.uk/events. Reference: 1. www.valeofyorkccg.nhs.uk/rss/data/uploads/ gastroenterology/faecal-calprotectin/faecalcalprotectin-leaflet-gp-0180816.pdf FIT Negative Follow-Up continued ..... Figure 2: Potential Digestive Diseases Patient Pathway as proposed by Dr. James Turvill
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