History should include key features such as:

• abdominal pain, weight loss, rectal bleeding, change in bowel habit,
• recent travel history,
• changes in medication with a potential for gastrointestinal side-effects,
• changes in diet, and
• family history of cancers that could be related to Lynch syndrome, including Uterine, Stomach, Liver and Kidney.

Examination should include:

• Full abdominal examination
• Rectal examination

1. Prior to all referrals
   1. Stool: Faecal Immunochemical Test
   2. FBC, Ferritin, B12, Folate, Renal, LFT, CRP
   3. Coeliac status should be known
2. If referring with diarrhoea
   1. Stool: MC&S
   2. TFTs, Bone Profile

NICE recommends referral for suspected cancer based on the following criteria.

Colorectal cancer

1. Aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings (consider):
   1. abdominal pain;
   2. change in bowel habit;
   3. weight loss;
   4. iron-deficiency anaemia
2. Aged 40 and over with unexplained weight loss and abdominal pain
3. Aged 50 and over with unexplained rectal bleeding
4. Aged 60 and over with either of:
   1. iron-deficiency anaemia or
   2. changes in bowel habit
5. Rectal or abdominal (but not pelvic) mass (consider)
6. Patient with low-risk symptoms testing positive for FIT 10

All patients with suspected colorectal cancer (including those with rectal bleeding – see guidance below on sample collection) should have a Faecal Immunochemical Test (FIT) completed prior to referral via the ‘Suspected Lower GI Cancer’ pathway.

Anal cancer

1. Unexplained anal mass or unexplained anal ulceration – to be referred without need for FIT test.

FIT ordering and sample collection

1. Faecal Immunochemical Testing (FIT) picks up human haemoglobin in stool in microscopic quantities. Local assays can pick up as little as 2mcg/g, but 10mcg/g is considered to be the threshold for abnormality in the symptomatic patient.

Please note that the national screening programme also uses fit, but at a threshold of abnormality in the asymptomatic patient of 120mcg/g. This is not considered adequate to exclude serious disease in the symptomatic patient. A recent normal screening FIT should therefore not affect your decision making in assessing the symptomatic patient.

Who should get a FIT test?

1. All patients for whom you are considering lower GI cancer referral based on the criteria above except for those with an anal mass or anal ulceration should have a FIT test prior to your final decision to refer.
2. Patients over the age of 50 with abdominal or other symptoms not meeting the referral criteria above may also benefit from FIT testing. This includes patients Non Site Specific (NSS) symptoms prior to consideration for referral to an NSS pathway

How do I order a FIT test?

1. You can order FIT on your order comms system or using the paper forms supplied. The forms do not include a criterion for FIT to support a suspected cancer referral, but don’t worry: the test will be carried out by the laboratory irrespective of the criterion marked on the form. Forms will be updated in due course or replaced entirely by electronic order comms.

How should the FIT sample be collected?

1. There are clear collection instructions in the test kit.
2. AccuRx have a system wide pathway template that you can send to the patient giving instructions, and that subsequently will automatically prompt the patient to return the kit.
3. Patients with overt rectal bleeding should still complete a FIT test but should sample a section of stool that is not overtly contaminated with blood.

Can I refer without a FIT test?

In exceptional circumstances a patient may be either unable or unwilling to complete a FIT test. If this is the case, and the GP has significant concern about the possibility of a colorectal cancer, a referral can be sent explaining why a FIT test has not been possible.

Could waiting for the FIT test result cause the patient harm?

In exceptional circumstances the GP may encounter a patient with symptoms of such severity that they are concerned a delay associated with FIT testing will adversely affect outcome. If this is the case, we recommend the clinician consider whether inpatient rather than outpatient assessment is the correct route. The delays incurred by FIT testing, a few days at most, do not represent a concerning delay to cancer treatment.

FIT result interpretation

How should I interpret a FIT test result?

1. All patients with a positive FIT test should be referred to investigate possible cancer via the Lower GI Suspected Cancer Pathway, quoting the FIT result in the referral.

2. All patients with iron deficiency anaemia (IDA) should be referred to the lower GI pathway irrespective of FIT result, but should still be accompanied by the FIT test. This is because anaemia is known to reduce FIT test accuracy and patients with IDA still need investigating as usual. The British Gastroenterology Society recommends that IDA should be investigated with both upper and lower GI endoscopy.

3. In patients meeting the criteria for referral for suspected cancer, but who have a negative FIT result, the likelihood of colorectal cancer is extremely low.

a. Consider whether there are factors such as anaemia present that could give an inaccurate FIT result. If this is the case, refer the patient to the Lower GI Suspected Cancer Pathway.

b. Where the patients’ symptoms raise a high clinical concern of serious disease, for example (but not restricted to) the presence of abdominal pain in combination with weight loss, consider referral to a suspected cancer pathway for a non-colorectal site such as upper GI, Urology or Gynaecology if the criteria for these pathways are met.

• If the patient does not meet the criteria for another site-specific pathway, consider appropriate pre-referral testing and subsequent referral to a Non-Site-Specific (NSS) pathway if one is available. If your local trust does not offer an NSS pathway, consider:
  • referral to the best-fit site-specific suspected cancer pathway even if the criteria are not met. This could include lower-GI or the other pathways listed above.
  • discussing with the radiologist of the day whether direct access to cross sectional imaging may be appropriate.

c. Where patients’ symptoms are associated with a lower risk of cancer, for example less pronounced changes in bowel habit as an isolated symptom, consider reassessment of the patient with appropriate safety netting. Under these circumstances you might also consider performing a second FIT test. You could also consider seeking advice on symptom management via a routine referral.

d. If despite a negative FIT test, you continue to have strong suspicion of a colorectal cancer, you can continue to refer to the Lower GI Suspected Cancer pathway.

4. In patients over the age of 50 who do not meet the criteria for suspected cancer referral to any site, but in whom you have ordered a FIT test giving a negative result.

a. Manage the patient in primary care with appropriate safety netting.

b. If symptoms persist or deteriorate, reassess the patient and consider referral as appropriate.

Secondary Care Pathway

Referrals will be triaged, and this may result in the patient

1. The patient going straight to endoscopy.
2. The patient going straight to CT.
3. Further remote assessment of the patient using telephone or video.
4. The patient coming to clinic.

Please prepare the patient for these possible outcomes, and explain that because they are being investigated for possible cancer it is important they attend the earliest possible appointment offered.

Referral Instructions

e-Referral service:

• Specialty: 2WW
• Clinic type: 2WW Lower GI
• Service: 2WW Colorectal Surgery/Lower GI - NDHCT - NDDH - RBZ

Referral Forms

Suspected Lower GI cancer referral form - No Merge Fields

Suspected Lower GI cancer referral form - Emis

Suspected Lower-GI cancer-referral form-Systmone

Evidence

Link to full reference guide to NICE referral guidelines for suspected cancer

Link to NHSE letter on using FIT in the Lower GI pathway

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: November 2016

Updated: December 2022