Early diagnosis of bowel cancer is key to saving lives. It is the UK’s second biggest cancer killer with more than 16,500 deaths from the disease every year — one every 30 minutes (Cancer Research UK, 2022a). Yet, it is treatable and curable if detected early. Almost everyone diagnosed at stage I will survive bowel cancer, but sadly early diagnosis has remained stubbornly low with less than 40% of diagnoses at stages I and II (Cancer Research UK, 2022b).  

The UK Government has a target of 75% of all cancers being diagnosed at stage I or II in England by 2028 (Gov.UK, 2022) — other nations, such as Scotland, are contemplating a similar goal — but without changes to the way bowel cancer is diagnosed, or significant investment in the staff and equipment needed, this ambition will not be achieved.  

qFIT — THE KEY TO EARLIER DIAGNOSIS OF BOWEL CANCER?  

This summer has seen some important news about the use of qFIT (quantitative faecal immunochemical test). This is the same as FIT (faecal immunochemical test) for bowel screening, but for use in symptomatic patients, which Bowel Cancer UK believes has the potential to transform bowel cancer diagnosis.  

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) have published new guidance on the use of qFIT in primary care (Monahan et al, 2022). This new guidance, offers advice on the use of qFIT in patients displaying symptoms related to bowel cancer and aims to provide a clear strategy for its use in the diagnostic pathway.  

Some of the key recommendations for use with patients are:  

qFIT should be used by primary care clinicians to prioritise patients with suspected bowel cancer for referral for urgent investigation  

qFIT should be used at a sensitivity level of 10ug/g (micrograms of blood per gram of faeces) in primary care to select patients with lower gastrointestinal symptoms for an urgent referral pathway for further investigation  

Patients should not be excluded from referral from primary care for symptoms on the basis of qFIT testing alone.  

It is essential that this guidance is formally adopted by the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) to ensure that it is fully embedded in diagnostic pathways. It is also vital that these guidelines are communicated effectively to primary care professionals and that patients know about the availability of qFIT when they have concerning symptoms. 

qFIT can help GPs when deciding to refer people with suspected bowel cancer symptoms and it could also help to tackle delays in diagnosing younger patients with the disease. Over 2,600 people under the age of 50 are diagnosed with bowel cancer every year in the UK, and many have to visit their GP on multiple occasions prior to referral (Bowel Cancer UK, 2022). Testing younger patients with qFIT when they first present with non-specific symptoms of bowel cancer may prevent delayed diagnosis.  

LOWERING THE BOWEL CANCER SCREENING AGE  

In England and Wales, a drop in the age people are first invited to participate in bowel screening, from 60 years of age to 56 and 58 years of age respectively, has taken place over the last two years (Public Health Wales, 2021; NHS, 2022). Further widening of the eligibility criteria — moving to an age range of 50–74 years of age — will occur in the coming two to three years, bringing England and Wales in line with the criteria adopted by Scotland (NHS Inform, 2022).  

Alongside this widening of access, there are also plans for the sensitivity of FIT to be improved with a reduced threshold of 80μg of blood per gram of faeces, again bringing Wales in line with practice in Scotland. In Northern Ireland, a long-awaited cancer strategy published in March 2022 committed to optimisation of their bowel screening programme and planning is underway to make that a reality.  

CAN FIT FIND EVEN MORE CANCERS?  

The UK National Screening Committee recommends a FIT threshold of 20μg/g, so there remains work to be done across the UK to fully optimise bowel screening, but the signs are positive that bowel screening will be strengthened, and this may prevent some people from developing bowel cancer in the first place.  

With only eight to 10% of bowel cancer diagnoses resulting from bowel screening in England and Wales (Cancer Research UK, 2022b), it is important not only to see optimisation of these programmes, but also increased rates of informed participation across all demographics for those eligible to take part.  

HOW CAN WE WORK TOGETHER TO REACH MORE PEOPLE AND SAVE MORE LIVES?  

Since the onset of the pandemic and the introduction of FIT, there has been an uplift in bowel screening participation. The rate of uptake has increased to record highs in Scotland, Wales and England, ranging from 65 to 67% respectively among those invited in the last year (data for uptake in Northern Ireland for the last year is not yet available) (Office for Health Improvement and Disparities, 2022; Public Health Scotland, 2022). Participation must increase further as too many people are still missing out on the potential for early detection of bowel cancer, or the identification of pre-cancerous polyps that can be removed. This is of particular importance when considering inequalities in accessing health care.  

Figures published by the Scottish Government in February 2022 show that while participation in 2021 reached 65%, there was a 20% point gap between uptake in the most and least affluent communities (73 to 53%) (Public Health Scotland, 2022). A strategy to address inequality in accessing screening programmes in Scotland is forecast to be published by the end of this year, and Bowel Cancer UK is part of a coalition of charities undertaking research to understand the data landscape of inequalities across the cancer pathway. 

The challenges faced by the NHS, because of increasing demand for bowel cancer diagnostic services require several solutions. Ongoing optimisation of bowel screening programmes and universal access to qFIT for symptomatic patients in primary care are just two ways we can deliver a much-needed shift to early diagnosis of bowel cancer and save more lives.