GPs should manage certain patients with suspected colorectal cancer with advice and guidance (A&G) from secondary care colleagues, NHS England has said.
New guidance, first published in draft form by the Association of Coloproctology of Great Britain & Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) in June, said that GPs should downgrade some urgent colorectal cancer referrals based on new FIT thresholds.
It said that FIT tests should be used as a triage tool, with patients testing below fHb 10μg Hb/g not referred via the urgent cancer pathway even if their symptoms fulfil NICE criteria.
It added that ‘some patients with symptoms of suspected colorectal cancer may be managed in primary care if fHb <10μg Hb/g’, as long as ‘appropriate safety netting is in place’ and the GP does not have ‘ongoing clinical concern’ about any ‘persistent and unexplained symptoms’.
Now NHS England has urged ‘all GPs’ to implement the guideline’s recommendations ‘in full’.
In a letter sent to practices and PCNs last week, it reiterated that those with ‘a FIT of fHb <10μg Hb/g, a normal full blood count and no ongoing clinical concerns’ should not be referred on a lower GI urgent cancer pathway but should be ‘managed in primary care or referred on an alternative pathway’.
It said that ‘appropriate safety netting must be in place’ when patients are not referred, which could include ‘using advice and guidance via eRS [the NHS e-referral service] to guide management of patients with persistent or troublesome symptoms’.
In an accompanying letter to trusts, NHS England added: ‘The BSG/ACPGBI FIT guidance recommends GPs take responsibility for managing those with a FIT fHb <10μg Hb/g and no ongoing clinical concerns in primary care.
‘Secondary care should make sure systems are in place for GPs to easily access advice and guidance to inform their referral decision.’
NHS England’s GP letter added that clinical teams should also ‘consider’ safety netting via:
- Providing the patient with ‘clear information about who to contact if they develop new symptoms or if their existing symptoms worsen’
- Offering a second FIT test if ‘ongoing clinical concerns remain’
- Referring the patient to a ‘non-specific-symptoms urgent cancer pathway, if appropriate and there are ongoing concerns about possible cancer’
- ‘Management of FIT-negative patients in an outpatient setting following referral on a non-urgent pathway’, where this is in place
Meanwhile, NHS England also suggested that if GPs refer patients with FIT results below the threshold because they have ‘ongoing clinical concerns’, hospital colleagues can bounce these patients back to primary care if they do not agree these ‘clinical concerns’ are present.
Its letter to trusts said: ‘Where patients with a FIT fHb <10ug Hb/g are referred to secondary care and it is agreed at clinical triage, based on referral information which is confirmed following direct communication with the patient, that there are no ongoing reasons for clinical concern, secondary care teams should not offer an endoscopic investigation but should consider the following options.
‘Following a consultation where it is communicated with the patient that they are no longer being investigated for potential cancer, discharge the patient from the lower GI pathway for safety netting delivered by primary care or secondary care.’
It added that patients could also be moved to a routine secondary care pathway if ‘ongoing non-cancer related clinical concerns remain’, referred to another cancer specialty or non-specific symptoms pathway if there is suspicion of another type of cancer, or managed on a ‘non-urgent referral pathway’.
NHS England also said that GPs should:
- Provide patients with ‘advice on the importance of completing a FIT test’
- Build text message reminders ‘into the pathway to encourage patients to complete and return their FIT kit‘
- Ensure they include FIT results on referral forms for any urgent cancer referral
The letter said: ‘Waits on the lower GI pathway have lengthened more than for any other tumour group since the pandemic.
‘By fully implementing the use of FIT in the symptomatic lower GI pathway we will be able to spare patients unnecessary colonoscopies, releasing the capacity to decompress the symptomatic lower GI pathway and ensure the most urgent symptomatic patients are seen more quickly.’
Meanwhile, recently announced changes to the PCN incentive scheme include an amendment to an indicator recognising PCNs for ensuring that lower GI fast-track referrals for suspected cancer are accompanied by a FIT – changing the permissible time between FIT result and referral from seven to 21 days.
And in August, the bowel cancer screening programme was expanded to patients aged 58, who will now be sent a FIT test once they become eligible.