Investigating suspected colorectal cancer with faecal immunochemical testing (FIT) in primary care: a review of international guidance

Sarah Bailey, University of Exeter

Colorectal cancer is the third most common cancer worldwide, accounting for around 10% of all new cancers, and is the second most common cause of cancer death (1). As the symptoms of colorectal cancer are often vague and frequently caused by benign conditions, selection for investigation can be difficult. As a result, colorectal cancer is often diagnosed at an advanced stage, leaving few curative options (2). Diagnosing colorectal cancer at an earlier stage results in better treatment options and improved survival (3, 4).

Researchers and clinicians are trying to find ways to diagnose colorectal cancer at an earlier stage; one way to achieve this is to investigate people for possible colorectal cancer when they have low risk symptoms, such as stomach ache. The faecal immunochemical test (FIT) has been developed to triage patient with low risk symptoms of colorectal cancer. Those with a positive FIT go on for further investigation, usually by colonoscopy. A negative FIT means that colorectal cancer is extremely unlikely, and the patient does not need any further investigation, although they are advised to see their GP again if their symptoms persist.

The FIT works by detecting small amounts of haemoglobin in a stool sample. Early stage colorectal cancer can cause bleeding into the gut, and the FIT detects that bleeding. Even if the patient has a positive FIT, it does not mean they definitely have cancer – only around 7% do.

Sarah Bailey and Marije van Melle’s poster presentation for systematic review, now published in Family Practice.

FIT has been rolled out across the UK for testing patients with low risk symptoms of colorectal cancer, but guidance for using the test varies in different countries. In this systematic review, led by Dr Sarah Bailey and Dr Marije van Melle and published in Family Practice (5), we reviewed current worldwide recommendations around the assessment of colorectal cancer symptoms to determine how FIT is used to triage patients with symptoms of possible colorectal cancer in primary care.

We found that worldwide guidance for primary care clinicians on the use of FIT varies greatly, and FIT is only recommended for primary care symptomatic patients in three countries: Australia, Spain, and the UK (excluding Scotland). These recommendations are based on a systematic review of studies that included patients with lower GI symptoms suggestive of colorectal cancer (6). That review reported the sensitivity of FIT as 92.1% – 100% (meaning at least 92% of patient with colorectal cancer are identified as such by the test), and specificity as 76.6% – 85.5% (at least 76% of patients without colorectal cancer are correctly identified). Of the 10 studies included in that systematic review, only one was based in primary care (7), where FIT was still performed at the point of referral, rather than to triage referrals.

The evidence on FIT to date comes from heterogenous populations at different stages of the care pathway, with different thresholds, and different assays used; this heterogeneity adds to the difficulty in making clear recommendations. Future updates to recommendations for investigating possible colorectal cancer may begin to integrate FIT for this low-risk CRC symptoms group as more evidence emerges. There is also a lack of evidence about patient preferences for testing with FIT versus colonoscopy; a gap which must be addressed.

 

 

 

References

  1. International Agency for Research on Cancer. Colorectal cancer-Globocan 2018. The Global Cancer Observatory. 2019
  2. McPhail S, Johnson S, Greenberg D, Peake M, Rous B. Stage at diagnosis and early mortality from cancer in England. Br J Cancer. 2015
  3. Statistics O of N. Cancer survival by stage at diagnosis for England (experimental statistics): Adults diagnosed 2012, 2013 and 2014 and followed up to 2015. Off Natl Stat. 2016
  4. Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, et al. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer [Internet]. 2015;112 Suppl:S92-107. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25734382
  5. van Melle M, Yep Manzanob S, Wilson H, Hamilton W, Walter FM, Bailey SER. Faecal immunochemical test to triage patients with abdominal symptoms for suspected colorectal cancer in primary care: review of international use and guidelines. Family Practice. 2020;1-9. Available from: https://pubmed.ncbi.nlm.nih.gov/32377668/
  6. Westwood M, Ramos IC, Lang S, Luyendijk M, Zaim R, Stirk L, et al. Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: A systematic review and cost-effectiveness analysis. Health Technology Assessment. 2017
  7. Mowat C, Digby J, Strachan JA, Wilson R, Carey FA, Fraser CG, et al. Faecal haemoglobin and faecal calprotectin as indicators of bowel disease in patients presenting to primary care with bowel symptoms. Gut. 2016

Making a meal of it: How I sank my teeth into a Cochrane systematic review

Dr Jo Butterworth, GP and NIHR Doctoral Research Fellow.

 

 

 

 

“How are you 300 ahead of me?!” said my colleague, arriving at her desk to start a new day’s work. “Sorry?” I said, finishing off a mouthful of breakfast bar. I already knew what she meant. We’d been ‘competing’ like this for a few days now, egging each other on to maintain our momentum and get through the work on schedule. “Titles and abstracts! You’ve screened 300 overnight!” My mind went back to yesterday evening, sitting in the kitchen watching the potato wedges turn crispy in the oven whilst I flicked through “just a few more” articles on my mobile screening app. I guess that’s the way with screening isn’t it? At the start it’s like being confronted with a gigantic raw potato but once you’ve peeled the skin, gotten rid of a few knobbly bits, you just keep chipping away…

“… if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes.”

In the case of our review of interventions, the evidence was fairly small fry and study authors had chosen different outcomes resulting in a lack of data which could be combined in our analysis. We reached the nevertheless important conclusion that further research was warranted and we made suggestions as to how research teams might go about this.

I never set out to lead on a Cochrane review; my funders thought it might be more than I could chew. However, when both I and the team from Manchester applied to update an existing review, Cochrane served up a sharing platter and suggested that we start with a clean slate. Now, when you’re posing your question and designing your search strategy, you’re just at the tip of the iceberg, with little real idea about where this might lead in terms of the workload ahead.  Well, I can tell you now that there is nothing bite-sized about a Cochrane review.

Serving up and submitting a Cochrane review is what I imagine being a contestant on a well-known television cooking show might be like. You know you won’t get through to the next round if it doesn’t look, smell and taste just as the judges expect. However, there is plenty of guidance available to authors to ensure that their writing is up to standard.

There is also a lot of suggested text, which must not be left out, even if it does not seem applicable. For example, you’re expected to say something like, “if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes”.

Carrying out a Cochrane review is, all-in-all, a highly valuable learning experience and it is the gold standard approach to a systematic review. I am grateful that I have been through the process and for the more sophisticated research palate that I have undoubtedly acquired along the way.

 

Reference:

Butterworth_JE, Hays_R, McDonagh_STJ, Richards_SH, Bower_P, Campbell_J. Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD013124. DOI: 10.1002/14651858.CD013124.pub2 .

Society for Academic Primary Care ASM 2019 Exeter – in tweets

All of us here in the Primary Care Research Group really enjoyed hosting the Annual Scientific Meeting (ASM) of the Society for Academic Primary Care (SAPC) 3-5th July 2019 at the fabulous Forum on the University of Exeter’s Streatham Campus. Three days of excellent quality primary care research, catching up with colleagues and friends, forging new connections and collaborations, fun sporting events, a scrumptious conference dinner and above all, beautiful weather!

We would like to share this link with you so that you might see a Twitter snapshot of this great meeting – see if you can spot your Twitter contributions and photographs!

SAPC ASM 2019 Exeter – in tweets – best tried in desktop rather than mobile.

Many thanks to all who attended and all who helped organise this conference, we are still buzzing and very proud to have hosted you all in Exeter this year and are already looking forward to SAPC ASM in Leeds 2020.

Enjoy!

Introducing the ERICA trial – a trial of Electronic Risk Assessment Tools to help GPs identify cancer sooner

We know that about 10,000 UK cancer deaths a year would not occur if the UK performed as well as its European counterparts in diagnosing cancer early. Much of the problem lies in General Practice – it’s very difficult to identify the patient who may have a cancer explaining their symptoms. There has been a lot of important work conducted by Prof Willie Hamilton and his colleagues who have identified which symptoms of possible cancer actually matter. These studies have led to the development of Risk Assessment Tools (generally abbreviated to RATs). The RATs tell GPs what the patients’ risk of having a possible cancer is and is reported as a percentage. This figure can be calculated for single symptoms (e.g. the risk of cancer of the lung with coughing blood is 2.4%), as pairs of symptoms (coughing blood accompanied by loss of weight is 9.2%) or as repeated symptoms (a re-attendance with coughing blood is 17%). RATs have been developed for 18 different types of cancer and have been given to all UK GPs practices in either paper, mouse mat, calendar, or web-based forms. RATs are useful but are perhaps not immediately accessible to GPs – a GP needs to be thinking about possible cancer and needs to have to the tools to hand to see what a patient’s risk of cancer is.

Recognising this problem, RATs have subsequently evolved. In partnership with Macmillan, the UK cancer charity, electronic versions for seven major cancers (lung, colorectal, pancreas, oesophago-gastric, bladder, kidney and ovarian) have been developed. These eRATs will be integrated into GPs’ clinical software. Using information in patient’s medical records the eRATs automatically prompt the GP when the risk of one or more of these cancers is above 2%. This is an important improvement on the RATs – GPs will be alerted to the small possibility of cancer when they perhaps were not considering it.

The big question that we need to ask ourselves is do these eRATs work? Will they help us catch cancer sooner? Here, in Exeter, led by Prof Willie Hamilton, our team of experts in cancer diagnostics, general practice, health economics, and many other areas are trying to answer this important question. We will do this via a large trial, a trial we are calling ERICA.

We are looking to recruit 530 practices across England. Half of the practices will be given access to the eRATs and half will not. Practices will be in the trial for about 2 years and out of all the patients diagnosed with cancer during this time we will be looking at the stage of the cancer that they are diagnosed with (early vs. late stage). If the eRATs help GPs we might expect to see an increase in early (vs late) cancer stage diagnosis for patients from practices who used the eRATs compared to the practices who did not use them. The study will also explore other important issues such as how the eRATs impact on patients’ and GPs’ experience of care. We will also look at how the eRATs impact NHS costs and the downstream consequences on NHS services.

This trial represents a significant piece of work – it will be the largest trial of cancer diagnostics in general practice in the UK. This trial has only been made possible via a very generous donation of £2m from the Dennis & Mireille Gillings Foundation. It is also being financially supported by Exeter University and Cancer Research UK.

Oh, and my job? I’m responsible for ensuring that we get the trial done on time and within budget. It’s going to be a fantastic challenge and I’m relishing the prospect of supporting our wonderful team to deliver this vital piece of research. We start recruiting practices in summer 2019. Although we won’t have definitive findings until autumn 2023, please do come back to me to get an update on how we’re doing…

Raff Calitri,  ERICA Trial Manager

  • Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study. Thorax. 2005;60(12):1059-65.
  • Hamilton W, Peters TJ, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ. 2009;339:b2998.
  • Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. Br J Cancer. 2009;101 Suppl 2:S80-6.
  • Hamilton W, Round A, Sharp D, Peters TJ. Clinical features of colorectal cancer before diagnosis: a population-based case-control study. Br J Cancer. 2005;93(4):399-405.
  • Shephard E, Neal R, Rose P, Walter F, Hamilton WT. Clinical features of kidney cancer in primary care: a case-control study using primary care records. Br J Gen Pract. 2013;63(609):e250-5.
  • Shephard EA, Stapley S, Neal RD, Rose P, Walter FM, Hamilton WT. Clinical features of bladder cancer in primary care. Br J Gen Pract. 2012;62(602):e598-604.
  • Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W. The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer. 2013;108(1):25-31.

‘We are likely to “throw the baby out with the bathwater”. If we don’t value continuity’ … Reflections from Professor Phil Evans, a GP in the NHS for half its lifetime

Hi, my name is Dr Phil Evans and I have been working in the NHS for exactly half of its lifetime, and well over half of mine! Of the 70 years since the NHS was formed, I have been working for 35 of them as a doctor and I have recently retired as a GP partner after 30 years in the same practice in Exeter. The NHS has given me a wonderfully stimulating and exciting career. In my opinion, general practice really is the jewel in the crown of the NHS but nevertheless is often under-valued, as are the skills and attributes of its hard-working GPs.

The NHS has given me an amazing opportunity to practise what I preach in terms of promoting continuity of care with the same doctor and the ability to get to know patients and their families, sometimes up to four generations of a single family, over a long period of time. The phrase “from cradle to grave” sums up the whole of general practice. The privilege of meeting patients week after week, year after year and trying to address their changing medical, psychological and social concerns is at the heart of what we do. Each consultation is still however a trip from the known into the unknown.

The partnership model in NHS general practice has allowed me, as a GP partner, not just to see patients but to run our own practice as an organisation that provides high quality medical care in a way that we wished. We could invest in our practice to value patients, promote patient-centred care, but also promote the other attributes that are close to my heart, teaching and research.

The NHS has given me the opportunity to undertake my own research and gain a higher degree in the process, working in our practice to answer important research questions. More recently I have been fortunate to work with other researchers in universities and across the NHS in my national role in the Clinical Research Network (CRN) to promote research and embed research in everyday practice. The CRN is an integral part of the NHS and runs research studies across all parts of the NHS, including general practices. Other countries are very envious of the NHS and its research!

The traditional model of GP working which I have so much appreciated is threatened in the NHS changes when “bigger is better” as far as practices are concerned and there is an emphasis on speed of access rather than developing deeper relationships with patients. We are, in my opinion likely to “throw the baby out with the bathwater” if we don’t value continuity and all its proven advantages – many of which I have experienced as a doctor. We must find ways in the NHS to value continuity, firstly by measuring it, then promoting and incentivising it.

So having worked in the NHS for half of its life it has been a privilege, but I worry that the things I value as GP are now threatened as the NHS moves into its next decade.


Associate Professor in General Practice & Primary Care

“I see no reason why I shouldn’t change careers as I progress through life”… The NHS through the eyes of a University of Exeter medical student

My decision to aim for medicine
The NHS is undoubtedly a source of great pride in this country. The fact that anyone can book into any of the 7,000 GP practices (or 168 acute trusts) in this country and receive top quality care for free is surely one of our greatest achievements. There is a strong argument to spend more on the NHS, as the UK spend less as a proportion of GDP than comparable countries, but that we have been able to achieve this level of access is quite incredible.

That being said, we are a nation of complainers, and the NHS receives more than its fair share of groans, eye rolls, and tut-tut-tuts. I often find myself defending the NHS against these (often totally justified) complaints, because I feel like a real part of the system, and truly believe the NHS to be a national treasure. Perhaps this is part of what first attracted me to a career in medicine.

From my (admittedly limited) experience of working around doctors of all specialties and grades, it is evident that medicine is an arduous job, with long unsociable hours, high pressure, low levels of flexibility and literal life-and-death situations on an almost daily basis for some. This is something that everyone entering this noble career needs to understand; it isn’t all running around with defibrillator paddles shouting “Clear!” and shocking people back to life. It isn’t all chest compressions, medical mysteries, and slow-motion moments either. Medicine is a stressful, difficult, and often frustrating career, and it certainly isn’t for everyone.

For me, this was always vastly overshadowed by the positives of this career. I felt that working with people in what can be the most difficult time of their lives, opportunities for leadership, the requirement for lifelong learning, and the clear career progression (not forgetting the more-than-comfortable salary of course) were all strong enough reasons to look past the angry drunks in A&E, the nights on Geriatrics, and the screaming in Paediatrics. Thankfully I am still of this opinion now and, if anything, am even more confident that I made the right choice when I embarked on this professional journey.

What does the NHS mean to me?
The NHS is much more to me than a network of trusts, deaneries, CCGs and administration teams. It is more than an interconnected web of doctors, nurses, porters, cleaners, ODPs, HCAs, and secretaries, too. It is a symbol of a national ideal that I feel is often lost in the name of ‘strengthening the economy’, ‘encouraging competition’, and ‘streamlining services’: the notion that everyone, no matter their background or income, is entitled to care for their entire life without having to worry about finding the money to pay for it. This basic right, so often taken for granted in the UK, is absolutely fundamental as we strive for equality and justice in this country. The success of the NHS flies in the face of the laissez-faire attitudes of some people in this country, and shows that what we can achieve together is vastly greater than what we can achieve on our own. The progression towards a fair society begins, I believe, with seeing just how powerful a force the united peoples of this country can be. Establishing the premise that everyone deserves to be treated fairly, regardless of their income or background is the first step in achieving true equality, and it is this idea that, for me, the NHS embodies perfectly.

My hopes for a career in the NHS
Like many people in my cohort, I can see my career in the NHS taking a tortuous route. I currently feel that some part of acute medicine is where I want to be – be that A&E, MAU, ICU, anaesthetics etc, but I am certain that I won’t be going straight through a training pathway into a consultancy post as people often felt they had to before. I have always had an interest in medical education, which has only been reinforced by the Masters in Clinical Education I have undertaken this year, and definitely feel this will form a part of my career. I also hope to conduct research alongside my clinical work, and aim to complete a PGCert in Clinical Trials alongside my fifth-year study to further this aim. I am also currently in the latter stages of an application to become a Magistrate, and feel that volunteering and working outside the NHS is important for maintaining morale and avoiding burnout. Finally, I see no reason why I shouldn’t change careers as I progress through life. While the fast pace and more antisocial hours of acute medicine appeal to me now, I have enjoyed my time in primary care so far and would like to consider this as an option as my career and life progress.. I essentially want to have my fingers in as many pies as possible. After all, variety is the spice of life!

My concerns about working in the NHS
My main concern about entering a career in the NHS is that it may not exist by the time I retire. Even within the few years during which I have been conscious of these things, I have seen a gradual effacement of the NHS at the hands of various government and private companies. This of course did not start recently, and goes back in my opinion to the hallowed Blair years of extremely high spending but also privatisations and PFIs. Today, despite the recent announcement of a £20bn funding boost, the NHS remains chronically deplete of money. My worry is that this is part of a concerted effort to devalue and destabilise the NHS so it can be increasingly moved into the private sector – being as it is totally antithetical to the belief that the state should hold as small a role in the lives of working people. Perhaps this is why I argue so vehemently against those who moan about the NHS, as every disillusioned voter is another step towards the end of the NHS.

The NHS I would like to be looking back on
I hope that, at the end of my career, I can look back on an NHS that has not only continued to lead the world in terms of efficiency but has improved outcomes to a world leading level and that has also grown to absorb more aspects of healthcare. Why do we complain about 2 month waits for non-emergency surgery, yet tolerate 2 year waits for dentist lists? Why do we accept a £15 charge to visit an optician, while begrudgingly paying an £8 prescription charge for drugs that would otherwise cost £30?

I believe the NHS will once again be an organisation that can claim to truly support people from cradle to grave, but first we have to ensure that we see its true value, not only as a collection of buildings and workers, but as a bastion of unity, togetherness, and equality unparalleled anywhere in the world.

The First CanTest International School for Cancer Detection Research in Primary Care

Dr Luke Mounce, CanTest Research Fellow

Luke Mounce’s thoughts on attending the CanTest International School for Cancer Detection Research in Primary Care …

Two weeks ago, I had the privilege to attend the inaugural meeting of the CanTest International School for Cancer Detection Research in Primary Care, held from 9-13 April at the stunning Jesus College, Cambridge. CanTest is a collaboration of eight institutions (UK: Cambridge, Exeter, Leeds, UCL; international: Washington, Melbourne, Arhus, Baylor) formed through the CRUK’s first Catalyst Award to promote a paradigm-shift in cancer detection research. The aim of CanTest is to establish the evidence-base, feasibility, and acceptability of diagnostic testing for cancer in primary care. Its motto is “Right place, right time, by your family doctor.”

The CanTest team at the School

The School was attended by 15 senior faculty and 30 junior faculty from the collaborating institutions, a PPI representative, and visiting guest speakers. A packed week of excellent teaching from the senior faculty covered topics such as: identifying existing and emerging technologies/biomarkers for potential use in primary care; challenges in the use of such tests; understanding physician and patient experiences, benefits and harms; use of routine data; cost-effectiveness of tests; and the evaluation of diagnostic tests. The teaching was supplemented by specific skills training in research methods and presentation.

Session at the CanTest School

Not only did the School provide a fantastic overview of the landscape of cancer detection research, it created a fertile environment for networking and establishing new collaborations within CanTest. Junior and senior faculty discussed research and envisioned new directions throughout the week, and the School ended with the junior faculty presenting novel ideas in groups. The senior faculty decided to set aside some funds for one such idea; to create a resource that details all the various data sources available to CanTest researchers across participating countries (or indeed beyond).

There was a great sense throughout the week that everyone was aligned with the vision of CanTest, and of faculty, junior and senior, across all the institutions, pulling together to create the paradigm-shift in cancer detection. It was very exciting to be a part of, and I look forward to the second CanTest International School next year, and to getting stuck into the collaborations formed to make progress over this next year.

Also, I got to go punting for the first time!

Dr Luke Mounce

You can find out more about CanTest on its website, and keep up to date with its progress on Twitter (@CanTest_PC), where you can also follow myself (@LukeMounce).