Faecal immunochemical test for suspected colorectal cancer symptoms: patient survey of usability and acceptability

Summary

To the authors’ knowledge, this is the first study to determine patient perception of FIT in patients with suspected CRC symptoms. In this study, FIT was acceptable to most symptomatic patients who responded; most patients who used FIT felt it was easy to find time to use it and it was hygienic. Despite this, differences in FIT perception were seen between groups; for example, age group differences were seen, with patients aged between 40 and 64 years less likely to find the test straightforward and less likely to prefer FIT over colonoscopy compared with those aged >65 years. The study found some variation by geography and ethnic groups; for example, willingness to use FIT again was stronger in patients from white compared with other non-white groups, and in those outside London. This did not appear to be based on differences in hygiene perception. Patients who used FIT correctly reported finding the test more straightforward than those who did not and were more likely to prefer FIT over colonoscopy.

Strengths and limitations

The study provides an insight into attitudes and perception of over 1000 symptomatic patients who had the opportunity to use FIT, a group whose views should be considered when designing and introducing new FIT pathways. To the authors’ knowledge, the only other study to address this issue was by von Wagner et al who asked public volunteers to imagine they had CRC symptoms, and found 70% would prefer FIT to colonoscopy if the risk of missing cancer was 1%.¹⁵ In the present study of truly symptomatic patients, 78.1% preferred FIT to colonoscopy.

The response rate to the survey was 30.6%, and consent to participation was through questionnaire return; those patients who did not return it were considered as not wishing to participate and were not contacted further. Characteristics of non-responders were only available for the London part of the sample owing to centralised recruitment in London; however, comparison of responders and non-responders showed only minor differences with responders being slightly older. There are many possible reasons for patients choosing not to participate, chief among them could be the voluntary nature of research studies. It would have been useful to include the views of those who did not respond, and this is the subject of a separate study being planned. Similarly, using NICE FIT infrastructure to rapidly disseminate questionnaire packs meant that questionnaires were only able to be sent in English and translation into more languages, which would have allowed a broader range of responses, could not be accommodated. Good acceptability in this study could be explained by different attitudes of the symptomatic population, who would be motivated to use tests to help diagnose their potential CRC symptoms, but also could be explained by those who participated being more likely to give a FIT sample. However, in the nine patients in the study who did not return the FIT sample but completed the questionnaire, eight out of nine patients agreed FIT was straightforward to use, was not unhygienic, and agreed they would use FIT again, consistent with overall study findings. Only a small number of patients, 15 (1.6%), were not able to use the FIT kit successfully and completed the questionnaire; therefore, ORs relating to this variable need to be interpreted with caution. In addition, only 5.4% of patients preferred a non-English language and 12.9% were from a non-white ethnic group.

Questionnaires were sent to patients as they were recruited to the NICE FIT study, therefore questions relating to investigation outcomes were not asked as some patients would not have diagnostic outcomes if they responded promptly. Further studies exploring how colorectal investigation outcomes affect FIT perception would be valuable. In addition, although all patients had urgent 2WW symptoms, the questionnaire did not categorise these symptoms further to determine if specific bowel symptoms affected FIT perception.

Comparison with existing literature

Negative feelings of faecal interaction are a recognised barrier to faecal tests offered as part of screening programmes in asymptomatic people;⁷ this is not necessarily transferable to testing in a diagnostic pathway. However, poor uptake has also been reported in symptomatic patients with chronic conditions, such as inflammatory bowel disease, who were asked to provide a stool sample for faecal calprotectin measurements to monitor disease.¹⁶ Hygiene concerns and embarrassment have previously been reported in patients asked to provide faecal samples by their GP.¹⁷ For this reason, it is important to better understand variation in attitudes to using FIT, patient experience of using FIT, and interaction with the faecal sample. The study has found that faecal aversion was not associated with FIT use by most symptomatic patients who responded.

Differences in perception of faecal tests between patient groups have previously been considered by Orbell et al, who suggest that some ethnic minorities may have lower perceived health vulnerability beliefs that may affect test uptake.¹⁸ While differences were not found in hygiene perception between patient groups, or by deprivation index decile, as might be expected from previous studies,¹⁹ intention to use FIT in the future was greater in those from white compared to other non-white groups. There is no clear explanation for preference for FIT over colonoscopy in older patients and further studies to explore this would be valuable. The study found that previous experience of any faecal test, as would be more likely in older patients, doubled patient intention to use FIT, underlining that faecal aversion was not a barrier to intention to use FIT again.

Implications for research and practice

This study highlights that there is variation in FIT perception between patients offered the test when experiencing suspected CRC symptoms. Incorrect FIT use affected preference for FIT over colonoscopy as an initial test, and addressing barriers to incorrect use, either owing to understanding or physical dexterity, is important at primary care and secondary care levels both to reduce the number of times the test is repeated to avoid diagnosis delay and to retain patient willingness to use FIT. Patient preference for postal test return rather than via primary care should be considered when designing FIT pathways to help deliver patient-centred care. At the same time, in developing these pathways one can be confident that most patients find FIT highly practical and acceptable. Further studies to determine patient decision-making behaviour, particularly in terms of CRC risk perception in relation to FIT result, in the context of FIT pathways, would be valuable. Qualitative studies assessing patient perception of FIT through interviews are also needed to gain greater depth of understanding of differences in patient responses to FIT.

In conclusion, patients presenting with suspected CRC symptoms who used FIT in this study found FIT practical, hygienic, and most would use it again. However, perception differences were seen in patient groups from ethnic minority backgrounds and older compared to younger patients.