Current impacts
Workload.
Participants described changes to workload, particularly the administrative burden associated with symptomatic FIT. These changes were experienced differently by health professionals and administrative staff, and across primary and secondary care:
‘Making sure everyone has to have a FIT test beforehand effectively puts increasing pressure on primary care.’
(P001, GP, female [F])
‘The amount of active triage that has gone on … that does carry a burden of admin time.’
(P008, Gastroenterologist, male [M])
Implementing symptomatic FIT in primary care entailed additional workload associated with ordering tests and obtaining results, but most notably from following up patients who had not returned their test:
‘It creates work for our admin staff, because I’m then messaging them going “I haven’t got this FIT test result back. Can you ring the patient and see if he’s willing to do the FIT test? So, can we re-request it?”’
(P007, GP, F)
Additional primary care workload was also perceived by some to have arisen from the management of FIT-negative patients, who may have previously been referred for further investigation. By contrast, others acknowledged that a negative result could reduce the need for ‘watchful waiting’, saving time associated with follow-up consultations:
‘Primary care physicians [used to] see a patient when they have those symptoms … refer them and that’s job done … In the new pathway … GPs will have to wait for the results … Then take a decision. Then review the patient again if the patient’s negative … the work implication of that is significant.’
(P011, Gastroenterologist, M)
‘I don’t think there’s any significant additional workload from doing the test or from interpreting the results … overall workload … is reduced … because when you’re using time as your diagnostic tool you need further consultations … that saving in time is probably the most significant element.’
(P006, GP, M)
In secondary care there were mixed views on the impact of symptomatic FIT on numbers of definitive investigations performed:
‘The numbers going to colonoscopy have fallen by about half from this pathway.’
(P008, Gastroenterologist, M)
‘We’ve noticed a significant reduction in the number of CT colonograms we’re doing for this diagnostic population.’
(P030, Radiologist, M)
‘I think there’s been an increase in referrals.’
(P023, Nurse Endoscopist, F)
‘I don’t know if the number of referrals has impacted, because it’s been so variable.’
(P012, Gastroenterologist, M)
The relative burden of additional work associated with symptomatic FIT was identified by some as primarily impacting primary care:
‘It’s then putting it on us to chase it, so it’s another appointment sometimes, so you’re doubling workload. Instead of saying “Look, FIT test done, let the hospital chase it.” Why do we have to chase it? Because they’ll still look and triage the thing, it’s about targets for them.’
(P004, GP, F)
Minimising additional GP workload was seen as important to the success of symptomatic FIT. Proposed solutions included provision of additional resources at the primary care network (PCN) level, and additional specialist nurse time in secondary care for triage:
‘If there could be a mechanism by which we can have a person who is responsible at a PCN level to chase the patient who is missed out, to chase the patient with the results, ensure that that pathway is there. We need to reduce the workload because they [GPs] are already overworked.’
(P011, Gastroenterologist, M)
‘Due to securing some extra funding for extra nurse specialists to do the triage step, we’ve agreed in the short-term to trial all patients being referred at the point they send the FIT off. So, the FIT and the referral will then be acted upon in secondary care by the triage step.’
(P030, Radiologist, M)
Primary care decision making.
FIT was welcomed by many GPs, especially those with less experience, as a means to increase confidence in clinical decision making and manage risk:
‘It’s a really good tool to make a decision, especially for relatively inexperienced GPs. I’m not maybe as accustomed to kind of taking on risk as a more senior clinician. So, for someone like me, your juniors, I think it’s a really good tool to add a bit of information and weighting to a decision you’re making.’
(P003, GP, M)
Seeing the ‘right’ patients at the ‘right’ time.
In secondary care time spent delivering symptomatic FIT was seen as a useful investment; it was perceived to target investigations at those most at risk, and move colonoscopy away from a diagnostic tool, towards a primarily therapeutic one:
‘FIT has allowed us to investigate the right patients, the more higher-risk patients and try and meaningfully distribute our diagnostics.’
(P022, Consultant Nurse, F)
‘I’d much rather … have colonoscopy moving in the direction of ERCP [endoscopic retrograde cholangiopancreatography] and be a therapeutic test, rather than a diagnostic test.’
(P008, Gastroenterologist, M)
However, participants felt that the anticipated benefits (reducing endoscopy burden or increasing cancer yield) were not necessarily realised. Possible explanations included overuse of FIT by GPs driving unnecessary investigation of patients with false-positive FIT results. There was also acknowledgment that concerns about potential for legal reprisals may drive overuse of FIT:
‘The referrals apparently have gone up but the cancers that we’re picking up have not gone up.’
(P027, Colorectal Cancer and Stoma Nurse, F)
‘We were hoping that FIT would reduce the amount of fast-track investigations that we were doing, but actually it’s had the opposite effect … GPs seem to have latched on to doing FITs for all sorts of indications and, of course, some of those FITs are going to turn up positive … so we’re getting referred patients with slightly positive FITs for colonoscopy as a fast track, when previously they wouldn’t have even been referred.’
(P020, Surgeon, M)
‘There’s a fear of medicolegal reprisal if they [GPs] miss a cancer.’
(P010, Gastroenterologist, M)
There were also concerns that negative FIT results could ‘downgrade’ the importance of symptoms and introduce delays in the diagnosis and treatment of non-cancer conditions:
‘A lot more people are sort of going through the process because they’re FIT negative, discharged, but then promptly being re-referred back because the GPs in primary care want advice on management. So, I think with our current process it’s actually prolonging patient pathways.’
(P009, Gastroenterologist, M)
‘I think there’s big concerns about downgrading all these patients … they may have very severe symptoms still, but just because their FIT test is negative, they get downgraded … so they take two years to see them. I think we all share that concern. It’s just moving a problem to elsewhere really.’
(P015, Surgeon, M)
This participant also reflected that symptomatic FIT had reduced the number of low-risk patients on the suspected cancer pathway, which allowed more time to see patients with non-cancer conditions:
‘It frees a bit more space in outpatients to see patients with other conditions, more equally needy benign conditions, such as inflammatory bowel disease.’
(P015, Surgeon, M)
Even for patients with positive FIT results, there were concerns about timeliness of investigation, because of perceived delays arising from requesting, processing, and reporting FIT prior to referral, although the clinical significance of such delays was questioned:
‘If I examine someone who has a suspected mass in the abdomen and has had weight loss, the [DG30] NICE guidelines would say we can refer [urgently]. The FIT testing protocol currently would say I need to give the FIT test to the patient to do the FIT test, they need to return that test; if they don’t return it, I need to chase that test. All of that delays the two-week-wait referral.’
(P001, GP, F)
‘It adds a little extra work in doing the test, interpreting it, delaying it. It means there’s sometimes a short delay for patients in getting the referral but it’s unlikely to be of any clinical significance.’
(P006, GP, M)
Areas of uncertainty
Rectal bleeding.
Participants expressed uncertainty and mixed opinions as to the appropriateness of FIT in patients with active rectal bleeding:
‘If somebody’s had like a haemorrhoidal bleed, it’s inevitable that we’re going to get a result above four hundred [µg Hb/g faeces]. And I think those are sometimes, in my opinion, the least likely to find pathology.’
(P024, Nurse Endoscopist, F)
‘[The GP] might have got in a history, some bleeding from like an innocent pile or something, they’re given a FIT test, but there’s probably going to be blood in that and then they end up with like a two-week-wait colonoscopy.’
(P003, GP, M)
Safety netting.
Safety netting of patients with a negative FIT result was frequently raised, particularly in the context of worsening symptoms, or a family history of cancer:
‘I don’t think you have a robust system that you go, “oh your FIT’s less than ten [µg Hb/g faeces], we’re never going to see you on a cancer pathway”. You turn round and go “actually, this patient’s symptoms are getting worse, it’s becoming a bit more alarming. Yes, their FIT was negative, but let’s either do a process where they have another FIT, or actually they go for a colonoscopy” and allow our primary care colleagues, who are phenomenal diagnosticians and clinicians, to use their experience and knowledge.’
(P030, Radiologist, M)
‘You can combine a FIT and family history risk, but it would be a little bit of a step backwards to just work with FIT for them, because so much work has already been done on assessing their risk because of their family history.’
(P023, Nurse Endoscopist, F)
The possibility of missing a cancer at a site beyond the colon was also a concern. Some participants discussed using other tests alongside FIT to improve cancer detection and diagnosis of other conditions:
‘There’s a relatively high incidence of upper GI cancers and pancreatic cancers that are detected in the course of patients having other investigations alongside a FIT test … there has to be something built in to pick up other cancers that wouldn’t necessarily cause a high FIT but can produce the same type of symptoms … I think the evidence needs to come along and become more mature in the role of how other blood tests would fit into that whole pathway … whether there’s a role for one of these multi-cancer detection tests, either alongside, or potentially instead of, FIT.’
(P015, Surgeon, M)
Repeat FIT.
There was uncertainty as to when, and for whom, repeating a FIT would be appropriate, but suggestions that this could play a role in safety netting of some groups of patients, such as those with rectal bleeding, or ‘borderline’ faecal Hb concentrations:
‘Where you’ve got a negative FIT, you do as a backstop, second FIT at a later stage to ensure that it’s a correct number. I don’t see any major issues with that. I think it needs to be evidence-based if it’s going to be implemented.’
(P030, Radiologist, M)
‘There’s the other question of whether a second FIT test can be done as a part of your safety-netting work … I think that is a reasonable thing to do and that is at the point of your six-week review for patients who’re FIT negative, and the patient’s symptoms have persisted, I think there is no harm in doing a second FIT test at that time.’
(P011, Gastroenterologist, M)
Several participants wanted more evidence and guidance on the application of repeat FIT, in relation to both patient groups, and clinically appropriate intervals between tests:
‘I don’t think the evidence base is, there’s not much around this, but I don’t think they should be on the same day, I think they should at least be on different days maybe and I think a study would be needed to determine that.’
(P026, Inflammatory Bowel Disease Nurse, F)
‘If the patient’s reluctant to have tests because their symptoms are settling down, but the FIT is perhaps eleven or twelve [µg Hb/g faeces], so just over the border of positive. We might say, “well let’s repeat the FIT in say six weeks’ time and if it’s negative then you don’t need any tests, if it’s positive then maybe we should be taking a look.”’
(P022, Consultant Nurse, F)
Positive result threshold.
Several participants discussed the threshold for a positive FIT result, in relation to concerns about missed cancers and the lack of differentiation between mildly and substantially raised Hb concentrations. Some had confidence that the current threshold was set appropriately by people with expertise; others suggested it was arbitrary or wanted to see the evidence base:
‘We’re using a cut-off which is an arbitrary cut-off based on a consensus statement not on firm evidence.’
(P001, GP, F)
‘There’s a big difference, for me, between a patient who has had a FIT done for very iffy indications and it’s fifteen [µg Hb/g faeces], which technically is raised, and then the patient who has suspicious symptoms and a FIT of over four hundred [µg Hb/g faeces], yet the system we have lumps those patients all in together.’
(P020, Surgeon, M)
