GI tract

No priority for NBCSP: all patients with positive FIT need access to colonoscopy

Patients with a positive faecal immunochemical test (FIT) should be prioritised for colonoscopy regardless of whether they were tested within the National Bowel Cancer Screening Program (NBCSP) or outside the program, Australian researchers say.

A study of 2,365 patients referred to the Newcastle Direct Access Colonoscopy Service between 2014 and 2018 found bowel pathology rates were similar in the NBCSP participants compared to those whose FIT was initiated in the community by the patient themselves or their GP.

The study evaluated 11 colonoscopy outcome measures and found only “high risk adenomas (3 or 4) or any adenomas ≥10mm” was statistically more common in the NBCSP group than the community-initiated group (22.9% v 17.2%).

All other measures including multiple adenomas (2.4% v 2.1%), high risk sessile adenomas (3.7% v 3.2%), and adenocarcinomas (2.7% v 4.0%) were not statistically different between the two groups.

“The large population in our study means that it provides colonoscopy providers strong evidence that evaluation should be performed equally promptly for patients with positive results from NBSCP and community-initiated FITs,” the researchers concluded.

Senior investigator Dr Peter Pockney, a colorectal surgeon from the John Hunter Hospital and University of Newcastle, told the limbic that many services around the country were struggling to find a way to deal with the demand for colonoscopy.

“We’ve been running this service since 2014 and during that period when we were reporting at meetings etc … just about the main question we were asked was: ‘Are you only doing NBCSP patients or the ones the GP or the patient has organised themselves and what is the difference in the pathology?’” he said.

“Because some services, when they are grappling with the volume of patients being referred in have been discussing at least, prioritising only the NBCSP patients and not the community-initiated patients.”

Dr Pockney said the study clearly showed that the patient’s route to referral was not an appropriate way of filtering patients.

“If someone has a positive stool test in the age groups 50-74 years, which is how we trimmed this group to match the NBCSP, then they have a high probability – going on for 50% – of having some significant pathology and they need to be investigated.”

“We’ve reported that there isn’t a difference in pathology and yes, you should be prioritising a positive stool test regardless of the route. You need to provide a service to both groups of patients,” he said.

He said the study was an “utterly real-world, pragmatic description of what happens” including the fact that patients sometimes received poor advice that delayed their referral for diagnostic investigations.

“It is absolutely the case that we have a very significant number of community-initiated patients where the patient has been to the GP with overt rectal bleeding and they get told to go away and do the test [FIT] which is for invisible rectal bleeding.”

He noted there was more than enough capacity in the system to prioritise patients with a positive FIT by not scoping those that were not well indicated.

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