Leading Edge 2021 Issue 2

8 LEADING EDGE - 2021-2 A Flexible FIT Ensuring Services are Relevant Throughout the COVID-19 Pandemic The faecal immunochemical test (FIT) is used to identify microscopic traces of haemoglobin in faeces which is a common indicator of significant bowel disease (SBD). Primarily used in colorectal cancer (CRC) referral pathways, FIT has been in routine use across the UK for several years, aiding the assessment of symptomatic patients referred from primary care. It has also been adopted as the testing method within the national bowel screening programmes. The COVID-19 pandemic caused widespread challenges to the health service and many routine diagnostics were disrupted. As a result, the applications for FIT diversified leading to its implementation in a range of pathways; from secondary care triaging to bowel surveillance, to Vague Symptoms Pathways (VSP). The proven diagnostic efficacy, and the patient-centric nature of the associated FIT-KITs (a pack containing everything the patient needs to take and return their sample), has allowed FIT to progress naturally into these pathways. This is helping ensure patients are wellmanaged and resource is allocated effectively during the ongoing peaks and troughs of the pandemic. Benefits of FIT In July 2017, the National Institute of Health and Care Excellence (NICE) published its diagnostic guidance, DG30 , on the use of FIT in primary care, to help guide referral for patients with suspected colorectal cancer (CRC). As a result, the demand for FIT soared, and primary care pathways were set-up across the UK to help support the referral process. Towards the end of 2019, health services were seeing real advantages following the implementation of FIT: endoscopy waiting lists were reducing, and procedure waiting times were decreasing, resulting in better patient management. FIT was also being used more frequently in other pathways, not just primary care referral: Vague Symptoms Pathways (VSP) and Rapid Diagnostic Pathways (RDP) have been using FIT as a convenient method to gauge bowel health in individuals who may not otherwise fall into the DG30, or NG12 , pathways. Moreover, FIT has been shown to identify not only CRC, but a range of other significant bowel diseases (SBD), including inflammatory bowel disease (IBD), and high-risk adenoma (HRA) , which furthers the scope for the application of FIT in lower-GI diagnostics. Challenges of the Pandemic The advent of COVID-19 caused unprecedented disruption to a huge number of diagnostic services, threatening to undermine the work achieved so far with FIT implementation. During the initial stages of the pandemic, the risk of COVID-transmission through faecal samples was unknown, and as all non-urgent procedures were halted, the endoscopy waiting lists increased drastically. FIT demand dropped substantially as testing was halted to allow risk-assessments and restructuring to cope with the additional strains on the NHS. Access to GPs and healthcare settings were restricted, and individuals were more reluctant to discuss symptoms with their GP for fear of having to attend the practice in person. From June 2020, laboratory analysis of FIT samples began to ramp-up, yet the pathways originally bringing in the FIT samples had changed. One of the most obvious changes was the increase in the number of samples from secondary care. Patient Triage Patients awaiting further investigation following a referral were facing extended waiting times: and, as with many SBD cases, typically the earlier the diagnosis, the better the long-term prognosis. A higher concentration of faecal haemoglobin (f-Hb) is associated with more severe disease3, and therefore FIT is used to help triage patients, in conjunction with clinical suspicion, to manage the scarce endoscopy resource. It has allowed the patients with the most severe symptoms (and therefore those most at risk of severe disease) to be prioritised accordingly or assessed via other channels. Additionally, in the absence of f-Hb, the risk of severe disease is low, and these patients may often be better managed via a less invasive referral route, as colonoscopies are not without risk. Increased Test Uptake FIT and the associated FIT-KITs, have been well aligned with changes to patient’s healthseeking behaviours, increasing uptake of the test and improving sample quality. By giving patients contact-free access to a home-based sample collection kit, whether it be a COVID-19 test or a FIT-KIT, patients are increasingly familiar with following instructions, collecting samples, and returning them – even engaging more with follow-up and results. By reducing the fearfactor associated with faecal testing, and making the kits as user-friendly as possible, more people are engaging with the diagnostic pathway, which in turn increases the value of the test to the healthcare service. Name Date of Sample 107AIE 00000024 2021.05.31 M / F Date of Birth LOT Secondary care triaging Bowel surveillance 2m 2m