Perspective 2020

Find out more about FIT at 5 The FIT cut-offs that have been published for triaging during COVID-19 have varied between local guidance, e.g. The London Pathway involves referring only FIT-positive 2 week wait patients at a threshold over 10 µg Hb/g faeces for investigation and patients with a FIT more than 150 µg Hb/g faeces are prioritised for colonoscopy [7]. The cut-offs published recently by Scottish Government are shown below, with two published pathways for use during the pandemic and then during the subsequent recovery period [8]. Increased utilisation of FIT during the COVID-19 pandemic has allowed more focussed referral to services which are unable to operate at full capacity, whilst supporting prudent healthcare. Ongoing clinical audit of these processes and analysis of outcome measures will hopefully provide more national evidence based guidance on the use of FIT in these settings, alongside robust safety netting for FIT negative patients. References 1. World Health Organisation. 2020. Rolling updates on coronavirus disease (COVID-19). 2. NICE. 2017. DG30. Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care. 3. British Society of Gastroenterology. 2020. Endoscopy activity and COVID-19: BSG and JAG guidance – update. 4. Rutter, M.D., Brookes, M., Lee, T.J., et al.2020. Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis. doi: 10.1136/gutjnl-2020-322179 5. rasaradnam, R.P., Bhala, N., Evans, C., et al. 2020. Faecal immunohistochemical testing in the COVID-19 era: balancing risk and costs. The Lancet. Gastroenterology & hepatology; 5(8), 717–719 6. NHS Speciality guides for patient management during the coronavirus pandemic. June 2020. Clinical guide for triaging patients with lower gastrointestinal symptoms. coronavirus/wp-content/uploads/sites/52/2020/06/ C0551-triaging-patients-with-lower-gi-symptoms16-june.pdf 7. D’Souza, N. and Abulafi, M. 2020. Navigating the storm of COVID-19 for patients with suspected bowel cancer. Br J Surg;107(7): e204. doi:10.1002/ bjs.11695 8. Scottish Government. July 2020. Guidance for the use of FIT in the prioritisation of patients with colorectal symptoms now and in the recovery period after COVID.. Version 1.0. publications/coronavirus-covid-19-guidance-for-useof-fit-testing-for-patients-with-colorectal-symptoms. Colonoscopy [When local capacity allows] OR CT Abdo and Pelvis OR Colon Capsule Endoscopy Case by case discussion on investigation, take account of: • Patient Frailty • Severity and persistence of symptoms • Numerical FIT result No investigation Other than where there is significant clinical concern Colorectal Symptoms During COVID-19 Pandemic Scotland FIT and FBC ≥400 µg Hb/g faeces ≥10 to <400 µg Hb/g faeces <10 µg Hb/g faeces During Recovery Period Scotland Colorectal Symptoms FIT and FBC ≥400 µg Hb/g faeces ≥10 to <400 µg Hb/g faeces <10 µg Hb/g faeces Colonoscopy [High Priority] Colonoscopy [Intermediate Priority] OR CT Colonography If access to above still limited, consider: CT Abdo + Pelvis OR Colon Capsule Endoscopy Mode of investigation and urgency dependent on: • Patient frailty • Severity + persistence of symptoms • Numerical FIT Result No investigation Unless Iron Deficiency Anaemia or severe persistent symptoms (Urgent Suspicion of Cancer) If there is doubt about whether or not to proceed with investigation, review within 6 weeks and consider repeating the FIT