Colorectal cancer

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

qFIT testing

  • qFIT tests for occult blood in the stool. It uses antibodies to human haemoglobin so avoids the false positives of the old FOB tests.
  • it is a quantitative test and the risk of significant finding on scope does increase with level
    • qFIT < 10μgHb/g and normal FBC - 0.1% risk colorectal cancer
    • qFIT 10 - 400 - 20% chance significant finding
    • qFIT > 400 - >50% chance of significant finding >20% colorectal cancer
  • note that the qFIT samples sent from the community have a cut-off of 10μgHb/g whereas the bowel screening programme uses a cut off of 80μgHb/g so a negative bowel screening result does not remove the need for qFIT in a symptomatic patient.
  • qFIT has a better negative predictive value than colonoscopy:
    • the risk of bowel cancer in someone with qFIT<10, normal FBC and normal examination is <0.1%
    • this is lower than the population risk
  • qFIT requires breakdown of blood cells to be positive so is not always positive in fresh rectal bleeding. It is still useful in the investigation of rectal bleeding as a negative qFIT means patients can be assessed by sigmoidoscopy rather than colonoscopy
  • qFIT is specific to lower GI bleeding - the haemoglobin is degraded by upper GI enzymes so will be negative in upper GI bleeding
  • qFIT should not be done in the absence of colorectal symptoms or for an acute change in bowel habit (<4 weeks)

Assessment

Symptoms suggestive of colorectal cancer

  • Abdominal mass
  • Palpable ano-rectal mass
  • Persistent (more than four weeks) change in bowel habit especially to looser stools - not simple constipation
  • Abdominal pain with weight loss (also consider upper GI cancer)
  • Unexplained iron deficiency anaemia
  • Repeated ano-rectal bleeding without obvious cause
  • Any blood mixed with stool

Assessment of patients with symptoms suggestive of colorectal cancer should include:

  • Digital rectal examination - it is important to identify a potentially obstructing low rectal tumour so they are seen in clinic rather than direct to colonoscopy
  • FBC, U&E, ferritin, LFT
  • qFIT
  • Do not request CEA or faecal calprotectin

Primary care management

For patients with low risk features:

  • Age under 40 without high risk features
  • Transient symptoms < 4 weeks (No qFIT required)
  • Patients with negative qFIT (<10)

Watch and wait:

  • Assessment and review
  • Consider bowel diary

If ongoing concerns consider repeat qFIT after 4-6 weeks

Who to refer

There are three referral pathways for patients with suspicion of colorectal cancer:

Direct to test colorectal pathway

This is a direct to test pathway for patients meeting the criteria below. Aim is for referral to test within 10 days.

Mandatory tests

  • qFIT, FBC, U&E, ferritin, LFT, rectal exam
  • Note qFIT is not required prior to referral in patients with palpable abdominal or rectal mass but is still useful to send. You can enter 0 in mandatory qFIT field

Indication

  • qFIT > 10 μg Hb/g and symptoms/signs as above
  • Age under 75 years
  • Fit/suitable for outpatient bowel prep

Exclusions

  • Patients on anticoagulants - i.e. warfarin/DOAC
  • Colonoscopy or CT colon performed in past 12 months
  • Declined or unable to complete a qFIT prior to referral
  • Frail patients

Priority options - Urgent suspicion of cancer(USOC) only

Refer via SCI-Gateway...General Surgery...DG USOC DTT Colorectal

 

Clinic review colorectal pathway

This is a fast track pathway with escalated clinic review and diagnostic test. Aiming for referral to test within 15 days

Mandatory tests

  • qFIT, FBC, U&E, ferritin, LFT, rectal exam
  • If there is a clinical reason why DRE/qFIT cannot be completed, document this in the referral
  • qFIT is not required prior to referral in patients with abdominal or rectal mass but still send one if possible

Indication

  • qFIT > 10μgHb/g and symptoms/signs as above
  • Not suitable for the direct to test pathway, e.g. due to age >75
  • Patients with qFIT < 10μgHb/g but with iron deficient anaemia and meet criteria for USOC referral.

Exclusions

  • Patients who decline qFIT

Priority options - Urgent suspicion of cancer(USOC) only

Refer via SCI-Gateway...General Surgery...DG USOC Clinic Rev Colorectal

 

General colorectal pathway

Mandatory tests

  • qFIT, FBC, U&E, ferritin, LFT, rectal exam. Consider second qFIT

Indication

  • qFIT < 10μgHb/g (or who decline qFIT) and symptoms/signs as above and significant clinical concern - Refer Urgent
  • Patients with symptoms requiring secondary care management but without significant clinical concern - Refer Routine

Exclusions

  • None

Priority options - Urgent/Routine/Advice

Refer via SCI-Gateway...General Surgery...DG Colorectal

 

Editorial Information

Last reviewed: 19/01/2024

Next review date: 19/01/2026

Approved By: National cancer pathway

Reviewer name(s): Patrick Collins.