Colorectal cancer: referral guidelines

NICE updated their referral guidelines in 2023 to make increased use of Faecal Immunochemical Test (FIT) testing, instead of always doing a colonoscopy first-line.

NICE recommend a FIT is used to guide referral in the following scenarios:

• with an abdominal mass, or
• with a change in bowel habit, or
• with iron-deficiency anaemia, or
• aged 40 and over with unexplained weight loss and abdominal pain, or
• aged under 50 with rectal bleeding and either of the following unexplained symptoms:
  • abdominal pain
  • weight loss, or
• aged 50 and over with any of the following unexplained symptoms:
  • rectal bleeding
  • abdominal pain
  • weight loss, or
• aged 60 and over with anaemia even in the absence of iron deficiency

Important points

• FIT testing should be offered even if the person has previously had a negative FIT result through the NHS bowel cancer screening programme.
• people with a rectal mass, an unexplained anal mass or unexplained anal ulceration do not need to be offered FIT before referral is considered.

Results of FIT test:

• positive: the patient should be referred on the suspected cancer pathway referral
• negative:
  • safety netting
  • NICE recommend referring on suspected cancer pathway if ongoing significant concern (e.g. abdominal mass)
  • whilst not mentioned specifically in the guidance, it is clearly important to continue to investigate the symptoms and reach a definitive diagnosis

NHS screening

The NHS has a national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening

• eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post
• a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb)