POCFIT study makes an impression

A research project sponsored by GUTS has earned the accolade of publication in several medical journals. We have been keenly following the progress of this study, which was authored by Will Maclean working alongside colleagues from the SE Bowel Cancer Screening Hub and the Royal Surrey NHS Trust. We are delighted it has received this well-deserved recognition.

The COVID-19 pandemic has been an unprecedented challenge for the healthcare system, which has had to deal with a surge in hospitalizations generated by coronavirus 2. Across the NHS, elective surgery has been post-poned and outpatient appointments suspended, and staff have been reassigned. In a rapid reprioritization of care surgical special- ties have proceeded with only selected operations, and surgery in COVID-19-positive patients has generally been avoided. For colorectal cancer (CRC), deferral to nonsurgical modalities for Stage II/III rectal and metastatic CRC has been a workable alternative. These measures have shaped care for known disease, but difficulties remain in the diagnosis of CRC at the point of referral from primary care.

From mid-March 2020, routine access to colonoscopy became unavailable. Faecal occult blood testing requests from the NHS colorectal screening pathway were therefore paused nationally. However, the 2-week-wait pathway for fast-track referrals from primary care continued, although there was an initial fall in referral numbers. The resultant delay in cancer diagnoses is likely to have a downstream impact on patient outcomes and mortality. The Office for National Statistics has reported that excess mortality has increased by a factor greater than can be explained solely by those who had ‘coronavirus’ listed on their death certificate. Italy has already reported a drop in cancer diagnoses by 39% this year.

There has been a critical need to continue the triage of referrals to identify emergent cancers in the community. This has had to be conducted remotely and at scale. Faecal immunochemical testing (FIT) quantifies haemoglobin in faeces and is sensitive to the presence and severity of colorectal neoplasia

When normal access to colonoscopy services was stopped due to the COVID-19 pandemic, the Royal Surrey NHS Foundation Trust (RSFT) redesigned the TWW colorectal pathway to incorporate FIT. We report the cancer diagnostic outcomes and their relationship to FIT results and the change in resource allocation.

From 26 March to 2 July 2020 there were 391 colorectal TWW referrals. Ten patients were excluded due to five hospitalizations and five cancellations, leaving 381 referrals for analysis.

In this study, rapid implementation of FIT has successfully been incorporated into the management of symptomatic colorectal patients on the TWW pathway. Those with CRC were successfully triaged to their investigations for timely diagnosis. This pathway followed both local and national guidance. The proportion of CRC diagnoses from all referrals did not statistically differ from pre-COVID-19 levels despite colonoscopy rates being reduced by 28%, suggesting more effective utilization of this resource. In addition, there was a high level of compliance in providing samples (95%), which demonstrates how patients are able and willing to perform FIT.

The colorectal team at RSFT will aim to continue incorporating FIT into all TWW referrals as we have shown it to be an effective triage tool with respect to resource management.

In response to the COVID-19 pandemic, we have rapidly adopted a new, safe and effective pathway by incorporating FIT for the triage of TWW patients. Routine use of FIT served as an invaluable adjunct allowing the identification and prioritization of those in most need of colonoscopy, and improved rationalization towards alternative investigations. This enabled access to colonoscopy for those most in need at the same time as reducing the overall proportion of those undergoing colonoscopy.

Our congratulations to Will on the success of his project.

Will Maclean (right) with GUTS Chairman and surgeon Iain Jourdan and the testing kit.

For further details the following reports are available:
Adoption During COVID
Diagnostic Accuracy POCFIT. Colo Dis
Comparison of QRG with FGW CCLM

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