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‘Patients dying’ due to CCGs’ lack of colorectal cancer tests, says NICE lead

Exclusive CCGs are costing thousands of lives and contributing to poor care by not providing GPs with access to faecal occult bloods testing in line with NICE recommendations on colorectal cancer, the GP behind NICE’s guidance has said.

Professor Willie Hamilton, a GP in Exeter and clinical lead of NICE’s guideline development group for suspected cancer guidance, said that there was a lack of access to these tests due to CCG budget pressures, labs’ reluctance to accept large numbers of tests from GPs and a ‘lingering suspicion’ that NICE got its cancer risk thresholds wrong.

He told Pulse that CCGs have been ‘poisoned by surgeons’, who have dissuaded commissioners from funding faecal occult blood testing (FOBT) and faecal immunochemical testing (FITs), arguing that they are not as effective as colonoscopy.

As a result, some patients are needlessly being given colonoscopies while others - who would benefit from FOBTs and FITs - are being left with nothing, he said.

Under NICE’s 400 page long guidance on cancer diagnosis and referral, FOBTs should be used for patients with a risk of colorectal cancer with a 1% to 3% risk, such as those with symptoms such as mild anaemia, with those above 3% having direct access to colonoscopy. 

At a Pulse Live event in Birmingham this month, a delegate said they were unable to access for FOBTs for at-risk groups and asked what should be done.

Professor Hamilton replied: ’I think you’ll have to say to them “medico-= legally you’re in deep trouble”, honestly, because there are patients dying in this country.

‘If you request a faecal occult blood and they say “we’re not going to do it” you’re going to have to say to them “I presume you’ll therefore be interested in a letter from the MDU whenever one of my patients is admitted as a bit of an emergency”.’

He added it didn’t matter whether FOBTs or FITs were offered, but one of them had to be offered as an option for patients who didn’t qualify for colonoscopy.

By not doing so, CCGs and labs were ’contributing to poor care’, he said.

He said: ’They’ve of course been poisoned by the surgeons. The surgeons believe colonoscopy is better than FOBTs, they’re right, but FOBTs are better than nothing. Therefore, in a patient group who would get nothing, a FOBT or a FIT is entirely sensible.’

He added that: ‘At least a quarter of this group are being listed for colonoscopy even though they don’t fulfil the colonoscopy requirements in the NICE guidance, and [by implementing the guidance] the CCGs can save pots of cash, patients can be diagnosed early, and we can save a thousand lives.’

Professor Hamilton later told Pulse that there was ’a lot of slowness re FIT/FOB testing with lab reluctance’, and this was partly due to a ’lurking suspicion NICE got it wrong - which we didn’t’.

He added: ‘Other pathway changes to direct tests are slow because it takes time, and most CCGs are under severe financial pressure, with the tangible financial rewards of avoiding emergencies etc not immediately visible.’

In the opening session of the same Pulse Live event, a panel of leading GPs had criticised the disconnect between NICE guidance and the realities of practise. Dr Dermot Ryan, an  honorary clinical fellow at the University of Edinburgh said: ’NICE is increasingly irresponsible in not identifying resources necessary to implement the recommendations it makes, they say “it’s not within their remit”, and I think that’s just ducking the bullet.’

And Dr Zoe Norris of the action group GP Survival said that the size of new NICE guidelines left GPs ‘practising in ignorance’ and vulnerable to legal challenge.

Readers' comments (15)

  • i pleaded to have fob available.. my ccg permits it and lab does the test. they say it is not useful test because of false positive . lab do not want to do it for this reason. nice guide line inclusion is recent . fob was discouraged since 2012

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  • Professor Hamilton has some interesting views on faecal tests. I do agree with some of them, particularly the strong view that faecal tests have an important role in assessment of patients with lower abdominal symptoms and possible colorectal cancer.

    However, very importantly, Professor Hamilton is totally wrong in one of his statements: it really DOES matter which of the traditional guaiac-based FOBT (gFOBT) or FIT is used in the context of assessment of patients presenting in primary care with symptoms.z

    One of the confounders in the present debate is that gFOBT and FIT are being considered as just different versions of the same test. They are definitely not. They are as different as apples and oranges. In contrast to traditional (and now obsolete) gFOBT, FIT (faecal immunochemical tests for haemoglobin) require one sample only collected into hygienic and easy to handle specimen collection devices. The results of FIT are not interfered with by dietary constituents. FIT are very specific for lower GI bleeding.

    However, the really important issue is that, while good evidence for the use of gFOBT might be lacking, there is now excellent, peer-reviewed published evidence that FIT can be used very successfully in primary care to direct the scarce colonoscopy resource to those who will benefit most.

    It is fact that a negative FIT result - that is, a very low or undetectable faecal haemoglobin concentration - has a very high Negative Predictive Value for significant colorectal disease (cancer plus higher-risk adenoma plus IBD). Thus, a negative FIT result means that GPs can give reassurance that significant disease is not present and colonoscopy is not required.

    Instead of arguing about whether NICE got it right or wrong (they probably did both, in fact), the considerable evidence for the utility of FIT in assessment of the symptomatic should be objectively weighed up. Senior laboratory staff everywhere should work with GPs, gastroenterologists and other health care professionals to get funding to introduce FIT into the routine repertoire as soon as possible.

    I am convinced that introduction of FIT is THE way ahead and certainly is much less expensive than enhancing endoscopy resources. When you read the evidence, you should be too! You can start at: http://gut.bmj.com/content/early/2015/08/20/gutjnl-2015-309579.full.pdf+html?sid=05798a11-483c-4743-9915-0967eae00815

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  • brilliant explaination mr/dr callum fraser.i was told FIT is cheap test to do.why do they not do DIT on national screening?

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  • Vinci Ho

    We have same problem of ordering FOB here in Liverpool
    Patient found with iron deficiency anaemia should be invesigated for both upper and GI lesions(apart from young ladies with menorrhagia).more so lower GI as stomach cancer is never as prevalent as colorectal ones. Are we sending everybody to sigmoidoscopy and colonoscopy otherwise while a simpler ,non-invasive test is not available??

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  • Thanks for comment #3. In fact, the Scottish Government has already approved funding for FIT to replace gFOBT in the Scottish Bowel Screening Programme and work is well under way to facilitate this change. The UK National Screening Programme has a consultation out at the moment on using FIT for screening for CRC:
    http://legacy.screening.nhs.uk/bowelcancer.

    Of course, screening is for assessment of the asymptomatic. FIT are replacing gFOBT everywhere for CRC screening, usually in specialist centres such as the five Hubs of the BSCP in England and the single Centre in Scotland.

    Evaluation of the symptomatic is different. FIT should still be used - everywhere - not as a guide to identify the (very) few at highest risk to be referred for colonoscopy but for all who present to their GP with the symptoms well described in NICE NG12. Again, introduction of FIT in this clinical setting is beginning to happen in Scotland.

    FIT should be used in both settings (and for surveillance of known colorectal disease) but, where the test is done and how the results are interpreted, are rather different.

    Professor Calum G Fraser is a clinical biochemist - a professional in laboratory medicine.

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  • thanks prof fraser . it is very useful infomation.

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  • Russell Thorpe

    All very worthy but will we ever match the results of our European neighbours when we strive so hard not to fully investigate "symptomatic" patients?

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  • Please read this BMJ response which puts the objection far more clearly.
    http://www.bmj.com/content/350/bmj.h3044/rr-0

    It is unacceptable to use these emotive terms as reported in this article when referring to such a poorly performing test as is currently available (FOB not FIT.) The idea that most GPs are not already referring for further investigation a 50 yr old with IDA is also worryingly out of touch. I hope they aren't being persuaded that a FOB is sufficient exclusion value.

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  • Professor Fraser, thank you- your summary and explanation is extremely clear and helpful, particularly in regard to the negative predictive value of the test.
    Please clarify - when you say that " a negative FIT result means that GPs can give reassurance that significant disease is not present and colonoscopy is not required", I assume you're referring to colorectal cancer only?
    I'm asking the question genuinely, rather than challenging what you say.
    My concern is that sometimes we (GPs) can wrongly decide that a test that excludes one pathology in a symptomatic patient results in us disregarding alternative, non-cancaerous but still serious, pathology.

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  • PS. I'm only referring to other GI causes of the symptoms under investigation, of course.

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