Colorectal cancer

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

qFIT testing

  • qFIT tests for occult blood in the stool. It uses antibodies to human haemoglobin so avoids the false positives of the old FOB tests.
  • it is a quantitative test and the risk of significant finding on scope does increase with level
    • qFIT < 10μgHb/g and normal FBC - 0.1% risk colorectal cancer
    • qFIT 10-19μgHb/g and iron deficient anaemia - 1.1% risk of colorectal cancer
    • qFIT 10 - 400 - 20% chance significant finding
    • qFIT > 400 - >50% chance of significant finding >20% colorectal cancer
  • note that the bowel screening programme uses a cut off of 80μgHb/g so a negative bowel screening result does not remove the need for qFIT in a symptomatic patient.
  • qFIT has a better negative predictive value than colonoscopy:
    • the risk of bowel cancer in someone with qFIT<10, normal FBC and normal examination is <0.1%
    • this is lower than the population risk
  • qFIT requires breakdown of blood cells to be positive so is not always positive in fresh rectal bleeding. It is still useful in the investigation of rectal bleeding as a negative qFIT means patients can be assessed by sigmoidoscopy rather than colonoscopy
  • qFIT is specific to lower GI bleeding - the haemoglobin is degraded by upper GI enzymes so will be negative in upper GI bleeding
  • qFIT should not be done in the absence of colorectal symptoms or for an acute change in bowel habit (<4 weeks)

Assessment

Symptoms suggestive of colorectal cancer

  • Abdominal mass
  • Palpable ano-rectal mass or unexplained anorectal ulceration
  • Persistent (more than four weeks) change in bowel habit especially to looser stools - not simple constipation
  • Abdominal pain (4 weeks) with weight loss (5%) (also consider upper GI cancer)
  • Unexplained iron deficiency anaemia (Hb low and ferritin <30mg/L)
  • Repeated ano-rectal bleeding without obvious anorectal cause
  • Any blood mixed with stool

Assessment of patients with symptoms suggestive of colorectal cancer should include:

  • Digital rectal examination - it is important to identify a potentially obstructing low rectal tumour so they are seen in clinic rather than direct to colonoscopy
  • Abdominal examination
  • FBC, U&E, ferritin, LFT
  • qFIT
  • Note qFIT not required for referral of palpable anorectal or abdominal mass or unexplained anorectal ulceration but still helpful to send
  • Do not request CEA or faecal calprotectin

Do not arrange qFIT for patients without symptoms suggestive of colorectal cancer above

Repeat qFIT

For patients with iron deficient anaemia or ongoing symptoms with qFIT < 20μgHb/g

  • Repeat qFIT at 4 weeks
  • If repeat qFIT ≥ 20μgHb/g refer USoC as below
  • If repeat qFIT < 20μgHb/g refer on general colorectal pathway below

Who to refer

There are three referral pathways for patients with suspicion of colorectal cancer:

Direct to test colorectal pathway

This is a direct to test pathway for patients meeting the criteria below. Aim is for referral to test within 10 days.

Mandatory tests

  • qFIT, FBC, U&E, ferritin, LFT, rectal exam
  • Note qFIT is not required prior to referral in patients with palpable abdominal or rectal mass but is still useful to send. You can enter 0 in mandatory qFIT field

Indication

  • qFIT > 20 μg Hb/g and symptoms/signs as above
  • Age under 75 years
  • Fit/suitable for outpatient bowel prep

Exclusions

  • Patients on anticoagulants - i.e. warfarin/DOAC
  • Colonoscopy or CT colon performed in past 12 months
  • Declined or unable to complete a qFIT prior to referral
  • Frail patients

Priority options - Urgent suspicion of cancer(USOC) only

Refer via SCI-Gateway...General Surgery...DG USOC Colorectal

Choose Direct to Colonoscopy from dropdown option

 

Clinic review colorectal pathway

This is a fast track pathway with escalated clinic review and diagnostic test. Aiming for referral to test within 15 days

Mandatory tests

  • qFIT, FBC, U&E, ferritin, LFT, rectal exam
  • If there is a clinical reason why DRE/qFIT cannot be completed, document this in the referral
  • qFIT is not required prior to referral in patients with abdominal or rectal mass but still send one if possible

Indication

  • qFIT > 20μgHb/g and symptoms/signs as above
  • Not suitable for the direct to test pathway, e.g. due to age >75
  • Patients with qFIT < 20μgHb/g but with iron deficient anaemia and meet criteria for USOC referral.

Exclusions

  • Patients who decline qFIT

Priority options - Urgent suspicion of cancer(USOC) only

Refer via SCI-Gateway...General Surgery...DG USOC Colorectal

 

General colorectal pathway

Mandatory tests

  • qFIT, FBC, U&E, ferritin, LFT, rectal exam. Consider second qFIT

Indication

  • qFIT < 20μgHb/g and symptoms/signs as above and significant clinical concern - Refer Urgent
  • Patients with symptoms requiring secondary care management but without significant clinical concern - Refer Routine

Exclusions

  • None

Priority options - Urgent/Routine/Advice

Refer via SCI-Gateway...General Surgery...DG Colorectal

 

Who not to refer

Patients under 40 with low risk symptoms and qFIT < 10μgHb/g

Editorial Information

Last reviewed: 11/02/2026

Next review date: 11/02/2028

Approved By: National cancer pathway

Reviewer name(s): Patrick Collins.