Prioritisation by FIT to mitigate the impact of delays in the 2-week wait colorectal cancer referral pathway during the COVID-19 pandemic: A UK modelling study

Chey Loveday, Amit Sud, Michael E. Jones, John Broggio, Stephen Scott, Firza Gronthound, Beth Torr, Alice Garrett, David L. Nicol, Shaman Jhanji, Stephen A. Boyce, Matthew Williams, Claire Barry, Elio Riboli, Emma Kipps, Ethna Mcferran, David C. Muller, Georgios Lyratzopoulos, Mark Lawler, Muti AbulafiRichard S. Houlston, Clare Turnbull*

*Corresponding author for this work

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    Objective: To evaluate the impact of faecal immunochemical testing (FIT) prioritisation to mitigate the impact of delays in the colorectal cancer (CRC) urgent diagnostic (2-week-wait (2WW)) pathway consequent from the COVID-19 pandemic. 

    Design: We modelled the reduction in CRC survival and life years lost resultant from per-patient delays of 2-6 months in the 2WW pathway. We stratified by age group, individual-level benefit in CRC survival versus age-specific nosocomial COVID-19-related fatality per referred patient undergoing colonoscopy. We modelled mitigation strategies using thresholds of FIT triage of 2, 10 and 150 μg Hb/g to prioritise 2WW referrals for colonoscopy. To construct the underlying models, we employed 10-year net CRC survival for England 2008-2017, 2WW pathway CRC case and referral volumes and per-day-delay HRs generated from observational studies of diagnosis-to-treatment interval. 

    Results: Delay of 2/4/6 months across all 11 266 patients with CRC diagnosed per typical year via the 2WW pathway were estimated to result in 653/1419/2250 attributable deaths and loss of 9214/20 315/32 799 life years. Risk-benefit from urgent investigatory referral is particularly sensitive to nosocomial COVID-19 rates for patients aged >60. Prioritisation out of delay for the 18% of symptomatic referrals with FIT >10 μg Hb/g would avoid 89% of these deaths attributable to presentational/diagnostic delay while reducing immediate requirement for colonoscopy by >80%. 

    Conclusions: Delays in the pathway to CRC diagnosis and treatment have potential to cause significant mortality and loss of life years. FIT triage of symptomatic patients in primary care could streamline access to colonoscopy, reduce delays for true-positive CRC cases and reduce nosocomial COVID-19 mortality in older true-negative 2WW referrals. However, this strategy offers benefit only in short-term rationalisation of limited endoscopy services: the appreciable false-negative rate of FIT in symptomatic patients means most colonoscopies will still be required.

    Original languageEnglish
    Pages (from-to)1053-1060
    Number of pages8
    Issue number6
    Early online date27 Aug 2020
    Publication statusPublished - 7 May 2021

    Bibliographical note

    Funding Information: This study is supported by the Institute for Cancer Research. AS is in receipt of an Academic Clinical Lectureship from National Institute for Health Research (NIHR) and Biomedical Research Centre (BRC) post-doctoral support. MEJ receives funding from Breast Cancer Now (NA). BT and AG are supported by Cancer Research UK award (C61296/A27223). CL and CT receive support from the Movember Foundation (MOV004X). RSH is supported by Cancer Research UK (C1298/A8362) and Bobby Moore Fund for Cancer (NA). GL is supported by a Cancer Research UK Advanced Clinician Scientist Fellowship Award (C18081/A18180) and is Associate Director of the multi-institutional CanTest Collaborative funded by Cancer Research UK (C8640/A23385). DCM is supported by Cancer Research UK (C57955/A24390). ML is supported by a Stratified Medicine in Colorectal Cancer Grant (Medical Research Council/Cancer Research UK) (NA), by Health Data Research UK (HDR-UK)’s DATA-CAN, the UK Health Data Research Hub for Cancer (NIWA1) and by the Queen’s University Belfast Foundation (NA). EM is supported by Cancer Focus Northern Ireland (NA) and by a HDR-UK MRC Rutherford Fellow award (MR/S003789/1). MW is supported by the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre (BRC) (NA).
    The views expressed are those of the authors and not necessarily those of the NHS, NIHR, or the Department of Health. The funding sources had no part in the study design, in the collection of data, in the analysis and interpretation of the data, in the writing of the report or the decision to submit the manuscript. The corresponding author had full access to all the data in the study and had the final decision to submit the manuscript.
    ML has received honoraria from Pfizer, EMD Merck Serono and Roche for speaking honoraria unrelated to this work. ML has received an unrestricted educational grant from Pfizer for research unrelated to this work.

    Open Access: Re-use permitted under CC BY. Published by BMJ.
    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

    Publishers copyright: © Author(s) (or their employer(s)) 2021.

    Citation: Loveday C, Sud A, Jones ME, et al. Prioritisation by FIT to mitigate the impact of delays in the 2-week wait colorectal cancer referral pathway during the COVID-19 pandemic: a UK modelling study. Gut 2021;70:1053-1060.



    • colonoscopy
    • colorectal cancer
    • colorectal cancer screening


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