Gastroenterology Today Summer 2021

FEATURE
ENCOURAGING UPTAKE OF FAECAL
IMMUNOCHEMICAL TESTS (FIT) IN ASSESSMENT
OF PATIENTS WITH LOWER BOWEL SYMPTOMS
Keywords: Faecal immunochemical test (FIT), COVID-19, bespoke, FIT-KIT, triaging, endoscopy, waiting time.
Abstract
GASTROENTEROLOGY TODAY - SUMMER 2021
6
In April 2020, all non-urgent endoscopy procedures were
suspended due to the COVID-19 pandemic. Consequently,
those referred for colorectal cancer (CRC) investigation in
England under the NG12 1 and DG30 2 guidelines faced increasing
waiting times. It became necessary to triage these patients to
allocate resources effectively. However, the pandemic makes
patient contact challenging, reducing the number of face-toface
consultations to minimise the spread of COVID-19. Faecal
immunochemical tests (FIT) offer a unique solution since the
process can be managed “contact free”, reducing risk to patients
and health workers. Faecal sample collection by patients is still
novel, compared to other sample collection methods such as
for blood tests. However, patients are often reluctant to handle
faecal samples. A solution must, therefore, have a patient-centred
approach to encourage sample collection and return, while
ensuring good quality samples for analysis. The answer lies
in the provision of bespoke patient literature. Trust and Health
Board specific leaflets with local phone numbers, QR-codes,
barcodes, and clear visuals, with non-clinical instructional text,
provide much needed support to FIT pathways which, in turn, has
aided the management of endoscopy waiting lists. The bespoke
leaflets result in noticeable increases in return rates, and the
quality of samples received by laboratories are also much
improved.
The onset of the COVID-19 pandemic caused widespread disruption to
many clinical diagnostic pathways. Already overburdened endoscopy
services faced considerable reductions, resulting in fewer procedures
and, in consequence, fewer diagnoses of colorectal cancer (CRC) and
other significant bowel diseases. CRC is highly treatable if detected in
its early stages 3 and long-term quality of life is much improved following
successful treatment. However, the waiting times for endoscopy have
resulted, and still are resulting, in concerning delays to diagnosis 4 .
Therefore, a supporting pathway is a necessary prerequisite to alleviate
pressure on the service and prioritise those with the most severe
symptoms for further investigation.
Use of FIT
It is widely appreciated that FIT is the ideal tool to use, not only to
continue supporting the existing primary care pathways, as guided by
NICE NG12 1 and DG30, 2 but also for use in secondary care and triaging
patients on waiting lists. National guidelines published in both England 5
and Scotland 6 outline how FIT can be used to support CRC referrals in
the pandemic, by using higher faecal haemoglobin concentration (f-Hb)
thresholds than that recommended originally for the low-risk cohort
under DG30. 2
The f-Hb is proportional to the risk of severe disease and has been
proven to be a valuable marker even in those referred with rectal
bleeding 7 , suggesting that FIT is suitable in both high- and low-risk
patient groups. This is further supported by recent diagnostic accuracy
studies, highlighting that the negative predictive value (NPV) for CRC
is over 98.9% 8 even when using a high threshold of 150 µg Hb/g
faeces. Other possible thresholds for investigation have been very
recently documented in detail 9 . However, ubiquitous use of FIT in the
triage for further investigation of patients presenting with symptoms
is still relatively novel in terms of sample collection and logistics, so,
while technically FIT is a suitable test, its application must be carefully
managed to ensure the issues with overburdened services are resolved,
and not just relocated.
Managing Remote Sample Collection
GP consultations dropped by 30% between the end of March and end
of May 2020 10 , and primary care is the most common starting point
for referral for patients with suspected CRC. With this decrease, there
was concern surrounding the use of FIT and how well clinical pathways
could be supported. To address this, innovative logistics strategies
were required because good engagement is a key driver to motivating
patients to collect and sample faeces and return these samples for
analysis. Since telephone and video consultations increased sharply, it
was considered that the FIT sample collection device and instructions
for use, could be posted out to the patient, as well as being collectable
at the GP surgery. After the sample is collected by the patient, the
device is either posted back to the laboratory or dropped off at the GP
surgery for onward transport. These approaches make the complete
process between consultation and the generation of a result “contact
free” and therefore considerably reduces the risk of spreading
COVID-19. With the sample collection, handling, transport, and
other logistics now in place, encouraging correct use is clearly a vital
consideration.
Maximising Uptake
With such reliance on samples collected by patients, uptake is vital. With
faecal samples, there are the associated “fear” and “disgust” factors
which deter some patients from collecting the sample, in spite of the