Could It Be Colorectal Cancer? General Practitioners' Use of the Faecal Occult Blood Test and Decision Making – A Qualitative Study

Cecilia Högberg; Eva Samuelsson; Mikael Lilja; Eva Fhärm


BMC Fam Pract. 2015;16(153) 

In This Article


Abdominal and bowel complaints are common reasons for contacting general practitioners (GPs) and are mostly caused by benign conditions.[1,2] However, it is important to identify serious diseases such as colorectal cancer (CRC). Worldwide, CRC is the third most common cancer in men and the second most common in women.[3] In Sweden, it is the third most common cancer in both sexes, and approximately two-thirds of the patients who are diagnosed with CRC have initially consulted a primary care physician.[4–6] In spite of this, CRC is a rare diagnosis for the average GP in Sweden, who can expect to encounter fewer than one new case a year.[7]

CRC often presents with vague symptoms, and this can cause a delay in diagnosis, which is probably associated with poorer outcome.[8] It is thus important to identify ways to make an early diagnosis.

Faecal occult blood tests (FOBTs) are used for CRC screening, and many studies have reported on this.[9] They are also used as diagnostic aids,[10–12] but there is little evidence supporting this use. The tests could potentially be helpful,[13,14] but the risk of delayed diagnosis increases with false negative test results.[6,15] It is unclear how the test results are interpreted and applied in everyday clinical practice, and studies have shown that many patients with positive tests are, for unknown reasons, not investigated further.[10,11]

Recommendations for the use of FOBTs in clinical practice vary. Sweden has no national guidelines regarding the use of FOBTs or the investigation of suspected CRC. In Denmark, FOBTs are recommended for use in secondary care for patients with changed bowel habits when the sigmoidoscopy results are normal, and in Ontario, Canada, they are recommended for use in primary care for patients with a low suspicion of CRC and no rectal bleeding.[16,17] In the United Kingdom it is recommended to offer FOBTs in primary care in certain cases in adults without rectal bleeding.[18] New guidelines for suspected CRC recognition and referral were published in the United Kingdom in June 2015, and there is an ongoing discussion about the use of the FOBT as a diagnostic aid in primary care.[19]

As bowel symptoms are common and the symptoms of CRC are often vague, it can be challenging for GPs to decide which patients to refer for further investigation. There are also questions as to the use and usefulness of FOBTs for investigating suspected CRC in primary care. The aim of this study was to explore what makes GPs suspect CRC and to investigate their practices regarding investigation and referral, with special attention on the use of FOBTs.