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Faecal immunochemical (rule-in) testing in general practice

Sarah ER Bailey, Marije A van Melle and Brian D Nicholson
British Journal of General Practice 2019; 69 (681): 178. DOI: https://doi.org/10.3399/bjgp19X702173
Sarah ER Bailey
College of Medicine and Health, University of Exeter, Exeter. Email:
Roles: Research Fellow
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  • For correspondence: S.E.R.Bailey@exeter.ac.uk
Marije A van Melle
Department of Public Health and Primary Care, University of Cambridge, Cambridge.
Roles: Research Associate
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Brian D Nicholson
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.
Roles: GP Clinical Researcher
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D’Souza and colleagues underestimate GPs’ clinical judgement in selecting patients for a faecal immunochemical test (FIT).1 NICE may recommend FIT for ‘low- risk’ symptomatic patients ‘without rectal bleeding who have unexplained (abdominal) symptoms but do not meet the criteria for a suspected cancer’,2 but this has not led to the ‘deluge’ of referrals or worsening of the ‘endoscopy capacity crisis’ in the centres where FIT has been adopted.3

The majority of the estimated 10% of consulting patients with abdominal complaints will not be referred for colonoscopy.1 GPs conduct a careful triage using history and examination, an understanding of their patients’ consulting patterns and comorbidity, preferences for testing, and by deciding when to respond to a positive result. Only a highly selected group of those tested and with a positive FIT are referred.

The NICE positive predictive value (PPV) threshold to rule in patients for urgent referral is 3%: the PPV for a low-risk symptom such as abdominal pain is 2% (increasing with age) compared with 5% for rectal bleeding.4 The PPV of a positive FIT in the low-risk symptomatic population is estimated at 13%.5 If FIT is positive, referral is uncontroversial; if negative, the PPV falls to <1%, making colonoscopy non-referral reasonable. FIT is more likely to result in a reduction of unnecessary (routine) endoscopy referrals for low-risk symptoms.

The UK’s routes to diagnosis data, cited by D’Souza, show us that a higher proportion of cancers are diagnosed at early stage when GPs investigate patients who do not meet 2WW criteria: those eligible for FIT. In order to achieve our nationwide target of 3 in 4 cancers diagnosed at an early stage by 2028,6 offering early investigation (and where necessary, referral) to the correct patients is crucial before more serious symptoms develop.

As a rule-in test for patients with low-risk symptoms, FIT enables the timely detection of cancer and other bowel disease in primary care. It may also play a role as a rule-out test for patients with high-risk symptoms, or in the future replace routine post-polypectomy colonoscopy surveillance. Introducing FIT may have been the most important change in the whole of NG12.4

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REFERENCES

  1. 1.↵
    1. D’Souza N,
    2. Brzezicki A,
    3. Abulafi M
    (2019) Br J Gen Pract, Faecal immunochemical testing in general practice. DOI: https://doi.org/10.3399/bjgp19X700853.
  2. 2.↵
    1. National Institute for Health and Care Excellence
    (2017) Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care. DG30, https://www.nice.org.uk/guidance/dg30/chapter/1-Recommendations (accessed 3 Mar 2019).
  3. 3.↵
    1. Nicholson BD,
    2. James T,
    3. East JE,
    4. et al.
    (2018) Experience of adopting faecal immunochemical testing to meet the NICE colorectal cancer referral criteria for low-risk symptomatic primary care patients in Oxfordshire, UK. Frontline Gastroenterol doi:10.1136/flgastro-2018-101052.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    (2015) National Institute for Health and Care Excellence. Suspected cancer: recognition and referral NG12, http://www.nice.org.uk/guidance/NG12 (accessed 3 Mar 2019).
  5. 5.↵
    1. Juul JS,
    2. Hornung N,
    3. Andersen B,
    4. et al.
    (2018) Br J Cancer, The value of using the faecal immunochemical test in general practice on patients presenting with non-alarm symptoms of colorectal cancer. DOI: http://dx.doi.org/10.1038/s41416-018-0178-7.
  6. 6.↵
    1. Alderwick H,
    2. Dixon J
    (2019) The NHS long term plan. BMJ 364:l84.
    OpenUrlFREE Full Text
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British Journal of General Practice: 69 (681)
British Journal of General Practice
Vol. 69, Issue 681
April 2019
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Faecal immunochemical (rule-in) testing in general practice
Sarah ER Bailey, Marije A van Melle, Brian D Nicholson
British Journal of General Practice 2019; 69 (681): 178. DOI: 10.3399/bjgp19X702173

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Faecal immunochemical (rule-in) testing in general practice
Sarah ER Bailey, Marije A van Melle, Brian D Nicholson
British Journal of General Practice 2019; 69 (681): 178. DOI: 10.3399/bjgp19X702173
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