Colorectal Straight to Test Service

Patients with bowel symptoms will be asked to complete a Faecal Immunochemical Test (FIT), blood tests and examination by a GP or medical professional (please see section below for more information). When bowel cancer is suspected, the GP or a medical professional will make an Urgent Suspected Lower-gastrointestinal Cancer referral to the RCCD Pathway. 

The STT team will assess these referrals and, where bowel cancer is suspected, arrange tests within 14 days (of the referral). Where bowel cancer is not suspected the team will advise the referring GP or medical professional of appropriate alternative pathways. Patients referred may be asked to attend an outpatient clinic appointment, have a telephone assessment by a member of the STT Team to discuss symptoms or, where appropriate, be invited straight-to-testing.

Tests offered on the RCCD pathway (for example colonoscopy, flexible sigmoidoscopy, CT colonography or CT abdomen and pelvis scan) will help to identify whether patients have bowel cancer or not. We may also ask some patients to complete a second FIT.  All patients on the RCCD pathway should receive a diagnosis within 28 days of referral.

Colorectal Nurse Practitioner Team

The Colorectal Nurse Practitioner Team work closely with Colorectal Consultants, Endoscopy and Radiology departments and multidisciplinary teams from other specialities at NUH. We run the Straight-To-Test (STT) Service, Colorectal Nurse-led Clinics and OSCARS lists (see clinic descriptions below).

The team are composed of:

• 7 Senior Colorectal Nurse Practitioners (including 5 Nurse Endoscopists)
• 4 Colorectal Nurse Practitioners
• 3 Patient Pathway Administrators

In the 2024/25 financial year, the nurse practitioner team received approximately 6780 RCCD referrals and 1903 routine/urgent colorectal referrals, giving a total of 8683 referrals.  

Colorectal Nurse-led Clinics

Location: Nottingham Treatment Centre (Entrance on Tram Platform B or near Car Park 4)

Patients referred to the routine or urgent pathway for bowel symptoms will be invited to an outpatient face-to-face or telephone consultation. Patients will see a Senior Colorectal Nurse Practitioner who will provide a holistic clinical assessment of symptoms and perform appropriate tests.

Patients referred to this clinic often have acute or chronic colorectal diseases and require further testing (for example abdominal/ rectal examination, proctoscopy, rigid sigmoidoscopy, haemorrhoid banding). Where necessary, patients may also be referred for tests with other hospital teams (for example blood tests, microbiology tests, endoscopy procedures, scans and minor operations under general or local anaesthesia).

OSCARS: One stop Colonoscopy and Radiological Staging

Nottingham Treatment Centre (Entrance on Tram Platform B or Car Park 4)

Patients with results that indicate a higher risk of bowel cancer will be contacted by the STT Team by telephone and invited to have a test (usually a colonoscopy or flexible sigmoidoscopy). The test may be performed by a doctor, surgeon or a nurse endoscopist, who will inform the patient and relatives about the findings and may organise further tests if necessary (for example CT Chest Abdomen Pelvis / CT Colonography). Patients may be asked to do these tests on the same day as their colonoscopy.

Depending on the patient’s general health, they may be asked to complete other tests (e.g. scans) or attend a clinic appointment to discuss their symptoms (see below) before considering invasive tests. Some patients may be asked to have a CT scan before coming to clinic.

Urgent Suspected Cancer Clinic

Location: Nottingham Treatment Centre (Entrance on Tram Platform B or Car Park 4)

Patients who are unable to have invasive tests to assess their symptoms will be asked to attend an Urgent Suspected Cancer Clinic. The patient will see a Colorectal Consultant, a Colorectal Surgical trainee (Fellow) or a Senior Colorectal Nurse to discuss symptoms and suitable tests.  Some patients may be asked to have a CT scan before coming to clinic.

What is a Faecal Immunochemical Test (FIT)?

FIT is a home test kit which checks for hidden blood in bowel motions (poo). Many things can cause hidden blood in bowel motions, but we know that high levels of hidden blood can indicate a higher risk of serious causes (such as bowel cancer). 

Most people with a high FIT result will still have nothing serious in their large bowel (colon & rectum). The Straight-To-Test (STT) Team will ensure that patients referred with high results have the appropriate tests to rule out anything serious (see STT service above for more information).

Nottingham University Hospitals NHS Trust was the first place in England to make use of FIT in an Urgent Suspected Cancer Pathway. Our results have been shared widely and used to develop new guidelines. FIT helps us to identify those who most need investigation and it helps us to reassure those with very low levels of hidden blood in a patient’s bowel motions.

Faecal Immunochemical Test (FIT)

• Please follow the instructions that come with your test kit (see below). Please note that these instructions will be the same as your bowel screening kit.
• Video instructions are available in English, Arabic, Bengali, Chinese (simplified and traditional), Farsi, Gujarati, Polish, Portuguese, Punjabi, Urdu and British Sign Language on our Vimeo Channel. For other languages please contact your GP.
• Please check that the kit is in date (expiry date down the side of the kit) and that it has your (the patient) name on it.
  If you have a vision impairment please contact the contract your GP for a specially adapted kit.
• Please return the kit as soon as possible. If your sample if over 14 days old, you will need to complete the test again. You will automatically receive a replacement kit if we are unable to process your result.
• Please do not store your kit in hot areas (e.g. above fires/radiators) as you may need to complete the test again. You will automatically receive a replacement kit if we are unable to process your result.
• If you need further support or you are unable to use the test kit for any reason, please contact your GP. 

Test instructions:

When you're ready to do the test (see instructions sent with every kit)

1. Important: Clearly write the date on the sample tube and check that your name is present
2. Use the layers of the toilet paper to catch your poo
3. Twist cap to open sample bottle
4. Collect sample by scraping the green stick along the poo until all the grooves are covered
5. Put the stick back in bottle and click the green cap to close it
6. Wash hands after use
7. Seal the sample bottle inside the return envelope
8. Post envelope without the delay or return it to your GP

The RCCD Pathway uses presenting symptoms and test results provided at the time of referral to prioritise those with the highest risk symptoms for the most urgent investigations and staging. Effective referrals rely on receiving as much information as possible at the time of referral. Where bowel cancer is not indicated based on information provided, the team will advise referring GPs or medical professionals to appropriate alternative pathways.

Tests required for referral

• Faecal Immunochemical Test (FIT) looks for hidden traces of blood in the stool and helps identify which patients are most likely to benefit from urgent investigation (for more information see section above).
• Digital Rectal Examination is mandatory because a ‘negative’ FIT may sometimes miss a palpable rectal mass. Patients with a palpable rectal mass can be referred on the RCCD pathway without a FIT result.
• Blood tests help to identify which patients are most likely to benefit from urgent investigation and assess which type of investigation is appropriate. Patients referred without blood results may delay investigations. Please ensure you book a blood test when making an RCCD referral.

Faecal Immunochemical Test (FIT) Results for GPs

A flow diagram of the RCCD pathway can be found at the end of this section. Please also see the Frequently Asked Questions for GPs in the next section.

FIT less than 4: There is no quantifiable blood in the patient’s bowel motions and the risk of colorectal cancer is less than 1 in 1000 (0.01% detection rate) therefore other referral routes or pathologies should be considered.

Patients under 40-years-old can be referred to the RCCD pathway, with a FIT result of 100 or more. If FIT is less than 100 with abnormal blood results, patients should be referred on the routine colorectal pathway and provided with safety netting in Primary Care.

Patients under 40-years-old, and where Inflammatory Bowel Disease is suspected, should have a faecal calprotectin test. An elevated calprotectin level should have an urgent bowel referral but not to the RCCD Pathway.

Patients over 40-years-old can be referred to the RCCD pathway at the following FIT thresholds (for more information on normal blood threshold see end):

• Rectal bleeding and normal bloods:  ≥ 10
• Rectal bleeding and abnormal bloods:  ≥ 4
• No rectal bleeding and normal bloods: ≥ 20
• No rectal bleeding and abnormal bloods: ≥4

All patients with palpable rectal mass can be referred to the RCCD pathway without a FIT. 

Negative Results and Alternative Pathways

Patients not eligible for the RCCD pathway may be more appropriately referred to other pathways (see below) or can be referred routinely. A repeat FIT is advised if concerns remain about colorectal cancer (see repeat FIT guidance at the end).

Patients with negative FIT and palpable abdominal mass should have ultrasound scan), full blood count, Ca125, glucose and urine dip for haematuria prior to referring onto the following pathways:

• If upper-gastrointestinal (UGI) cancer risk factors/symptoms found: Urgent Suspected UGI Cancer (includes HPB) 
• If raised Ca125 or abnormal pelvic USS or PV bleeding found: Urgent Suspected Gynaecological Cancer
• If haematuria / raised PSA found: Urgent Suspected Urological Cancer
• If vague symptoms/applicable to more than one cancer site are found: Rapid Diagnostic Centre for Urgent Suspected Non-Site Specific Cancer

Patients with negative FIT and unexplained weight loss (>3kg per month) OR Iron Deficiency Anaemia (IDA) should have the following ordered: CXR, FBC, Ca125/ PSA, Glucose, ESR, TFT, UE, LFT, CRP, bone/calcium, myeloma screen, TTG and urine dip for haematuria prior to referring onto the following pathways:

• If IDA and weight loss found or platelets ≥400: Urgent Suspected UGI Cancer
• If abnormal CXR or platelets ≥400 or chest symptoms or lung cancer risk factors found: Urgent Suspected Lung Cancer
• if low abdominal mass or raised Ca125 or abnormal pelvic USS are found: Urgent Suspected Gynaecological Cancer
• If haematuria / raised PSA found: Urgent Suspected Urological Cancer
• If myeloma screen is positive: Urgent Suspected Haematological Cancer
• Where IDA (new or recurrent) but all other tests are normal and patient has not been seen in secondary care in last 3 years: GP should refer the patient to the Gastroenterology team routinely. If IDA persists without an obvious source of blood loss, a repeat FIT is recommended.

Patients with repeated non-return or decline to complete FIT should be referred routinely.

Repeat FIT Guidance

Patients with a FIT less than 20 and normal blood results have a very low but not zero (3 in 1000 or 0.3%) risk of bowel cancer. A repeat FIT may reduce the risk of missed colorectal cancer, if FIT result is between 4 and 19.9 with normal bloods. We are currently evaluating the role of repeat FIT in the pathway.

RCCD definition of abnormal blood results

Abnormal blood results considered in the RCCD pathway:

• HB <130 males/ <120 females
• Platelets ≥400
• Ferritin <25 or ≥350

RCCD Pathway

 

The test results say the kit is spoilt, what should I do?

You do not need to do anything. The Bowel Symptomatic Service (BSS) lab automatically send a replacement FIT kit to any patient who returns a spoilt kit. We will inform you (GP) the reason why the sample has been rejected so you can offer support to your patient. We will notify you after two weeks if the replacement FIT kit has not been returned by your patient.

Do I need to order a replacement FIT kit when I receive a two-week ‘no return’ reminder?

We send a ‘no return’ reminder when your patient has not returned their FIT kit two weeks after the order date to prompt you to follow up with your patient. As FIT is used to guide referral for suspected bowel cancer, we would recommend that patients return their FIT kit as soon as possible. 

However, patients can return their FIT kit after this initial 2-week period as long as sample has been dated and returned to the lab within 14 days of the sample being taken. If the sample is not dated, too old (e.g. delay in returning the sample to the lab) or the test kit itself has expired it cannot be analysed and will be processed as a spoilt kit and a replacement kit will automatically be issued to the patient.

My patient hasn’t received their FIT kit, what should I do?

Check that the patient’s address is up to date and that your patient can receive post securely. You can order a replacement FIT kit to a new address (if required) or alternatively you can order the FIT kit to your GP surgery for patient pick up. Contact the Hub on 0115 849 3217 to arrange this.

My patient is unable to receive the FIT kit at their address, what should I do?

You can order the FIT kit to your GP surgery for patient pick up and they can choose to return the kit via post (postage is paid providing the sample is in the return envelope) or return it to your surgery. Contact the Hub on 0115 849 3217 to arrange this.

My patient is unable to post the FIT kit to the BSS lab, what should I do?

Your patient can return the FIT kit to your GP surgery sealed in the return envelope included in the FIT kit. Samples can be returned to the BSS Lab via the Pathology courier, or the sample can be placed in a bag with the routine blood samples.  

Do I need to order bloods or conduct a DRE if my patient has had a positive FIT?

Yes. Estimated glomerular filtration rate (eGFR) is vital to help determine safety of bowel preparation before investigations. FBC and Ferritin/iron studies are required to access the urgent pathway for FIT<20. A Digital Rectal Examination (DRE) is important to identify/ exclude possible rectal cancers which require different management. Blood tests and DRE are also important for patients invited ‘Straight-to-Test’ as they might not have a face-to-face consultation before their investigation.