Dear all,
Callum Fraser has asked me to post an differing view on the use of FIT in primary care on his behalf. Please find his response below.
Many thanks,
Emma
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FIT for GP - An Alternative View
I am sorry but I have to disagree with my old friend and many times excellent collaborator, Stephen Halloran, on the use of FIT by GP.
Stephen is right when he says that NICE, BSG, SIGN and many others tell that FOBT are of little value in assessment of those with symptoms and those with iron deficiency anaemia. But, in my view, the authors of these guidelines are actually referring to guaiac faecal occult blood tests (gFOBT) and not to the more modern faecal immunochemical tests for haemoglobin (FIT).
FIT have many advantages and these are outlined in many papers and reviews, including my Personal View in Ann Clin Biochem 2012;49:518-26. Most of the plethora of studies on FIT published to date are indeed concerned with screening the asymptomatic. However, the references in the Personal View include a meta-analysis by Jellema P, et al. BMJ. 2010 Mar 31;340:c1269. doi: 10.1136/bmj.c1269 which states: ..... combinations of symptom and results of immunochemical faeces tests showed good diagnostic performance for colorectal cancer .....
Since then, studies have been published showing that FIT are very good tests, with very high negative predictive value (rather like calprotectin in the IBD/IBS dilemma situation), for exclusion of significant lower bowel disease in patients with symptoms:
Kok L, et al. Clin Chem 2012;58:69–98.
McDonald, PJ, et al. Colorectal Dis 2013;15:e151-9.
Kaul A, et al. Int J Surg 2013;11:329-31.
Other studies are in progress. I can provide pdf of these three papers if anyone is interested - [log in to unmask]
I admit that it is early days, but the evidence is surely growing that use of FIT by GP - at a faecal Hb concentration of 10 ug haemoglobin/g faeces - would be an ideal tool to cut down the huge demands for colonoscopy, noting that lower abdominal symptoms are very common but serious colorectal disease is not.
Again I urge clinical biochemists and other professionals in laboratory medicine to try as hard as possible to eliminate use of gFOBT everywhere and in all clinical settings, but have open and receptive minds to the fact that FIT are useful in assessment of the symptomatic. with the caveat correctly documented by Stephen, that not all FIT are the same and careful selection of the right FIT is required.
Professor Callum G Fraser
Consultant, Scottish Bowel Screening Research Unit
Honorary Consultant Clinical Biochemist, NHS Tayside
Honorary Professor, Centre for Research into Cancer Prevention and Screening
Centre for Research into Cancer Prevention and Screening
University of Dundee
Ninewells Hospital and Medical School
Dundee DD1 9SY
Scotland
Phone +44 [0] 1382 553799
FAX +44 [0] 1382 425679
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