QFIT is far superior to any symptom as predictor of colorectal pathology. For cancer, the highest PPV of a symptom is rectal bleeding at 2.4% This is below the recommended USC threshold of 3%. In addition, QFIT has high negative predictive values at 99.75%.

IDA is defined as Hb lower than 130 in male and 115 in female with evidence of iron deficiency either Ferritin <30 or on iron studies. Where IDA is unexplained, investigation is tailored to likelihood of lower GI pathology. This is measured by QFIT. All unexplained IDA will usually get upper GI endoscopy and colonoscopy if QFIT is positive. A second QFIT is done if first is negative to minimise false negatives. Double negative QFIT patients do not need lower GI investigation.

“Unexplained” usually means ruling out other causes including menstrual bloods loss, malabsorption (e.g. Coeliac), limited dietary intake and other sources of bleeding.

The local and national evidence shows that the risk of colorectal cancer with QFIT of less than 20 is below USC threshold of 3% positive predictive value. In GGC the symptomatic patients with QFIT 10-19 have a 1% prevalence and <10 have a 0.2% prevalence of colorectal cancer respectively. This increases to 2% and 0.7% if patients have IDA. Hence alternative pathway for these IDA patients.

The group of patients with QFIT result <20 currently represents 52% of all referrals for endoscopy. Targeting endoscopy resource to those at higher risk nationally is projected to accelerate diagnoses in 96.7% of patients.

QFIT thresholds are set depending on whether patients have lower GI symptoms or for asymptomatic screening programmes. The new threshold of 20 for USC prioritises those with concerning symptoms and raised QFIT for urgent investigation. The threshold for positive bowel screening is set at 80 in Scotland (120 in England).

Patients who have transient bowel inflammation such as gastroenteritis or acute flare of diverticulitis are likely to have positive QFIT tests. This does not indicate likelihood of underlying cancer. Checking QFIT where in acute illness or if there are no concerning symptoms leads to unnecessary invasive investigation with associated morbidity.

If a patient has persistent concerning symptoms (see box 1) or IDA, then repeat sample can be requested immediately on receipt of a negative first QFIT result. It can be useful to repeat up to 12 months apart if patient has recurrence of symptoms.

NICE guidance currently states: If appropriate, depending on the clinical evaluation, consider QFIT. Only pts with associated symptoms should get QFIT. The new Scottish Referral Guidelines will have a section covering this and non-specific symptoms.

Not at present but local GGC data shows your risk of cancer in under 40's if your QFIT is <100 is extremely low. There is a national working group looking at younger patients. Younger patients with +ve QFIT are more likely to have IBD.

You should not delay referral following one negative QFIT for IDA. Ideally, repeat QFIT and refer on receipt of first negative. These patients need upper GI investigation. QFIT determines whether they need colonoscopy also.

Does not add any further information to the QFIT result and pathway.

If other investigations are clinically indicated these should not be delayed awaiting repeat QFIT result. A single negative QFIT has negative predictive value of 99.75%.

The evidence based national recommendations are that negative QFIT (<10) patients do no longer need colorectal investigations at all (on a single negative QFIT). Only patients with persistent concerning symptoms should have repeat QFIT in primary care to reduce false negative results. QFIT are not currently repeated in secondary care.

These patients will no longer be vetted to routine colonoscopy as is the current practice. If clinical concern and double negative QFIT and other intra-abdominal pathology is excluded patients can be referred and they will be reviewed at OPD clinic.

At present 78% of patients of QFIT negative patients are managed in very effectively primary care and 99.9% have not had any subsequent cancer diagnosis after 1-5 years of follow up. Of those referred with concerning ongoing symptoms 0.3% have a colorectal cancer. A repeat QFIT would reduce these false negatives further.

This should improve access for primary care to specialist clinical assessment rather than just direct to testing.

Patients and referrers will receive information about the waiting times once their referral has been vetted. These will change as the new pathway is implemented. This will be evaluated by the CRUK project team. We work towards the 62-day cancer waiting time target from USC referral to first treatment.

The following was included in GGC “Core Brief” in February 2025.

“Specialties not routinely using QFIT testing kits should refer patients with Iron Deficiency Anaemia to Gastroenterology, or patients with new lower GI symptoms to Colorectal. These referrals should be made using a SCI referral form, this includes patients seen at clinic and inpatients”.