Yield of Colonoscopy After a Positive Result From a Fecal Immunochemical Test OC-Light

SIED-GISCOR recommendations for colonoscopy in screening programs: Part I - Diagnostic

The implementation of FIT programs reduces incidence and mortality from CRC in the screened subjects. The ultimate efficacy for CRC morbidity and mortality prevention in a FIT program depends on the colonoscopy in FIT+ subjects that has the task of detecting and removing these advanced lesions. Recently, there has been growing evidence on factors that influence the quality of colonoscopy specifically withing organized FIT programs, prompting to dedicated interventions in order to maximize the benefit/harm ratio of post-FIT colonoscopy. This document focuses on the diagnostic phase of colonoscopy, providing indications on how to standardise colonoscopy in FIT+ subjects, regarding timing of examination, management of antithrombotic therapy, bowel preparation, competence and sedation.

Electronic Coding for Abnormal Fecal Immunochemical Test Is Associated With Increased Colonoscopy Completion

INTRODUCTION

We examined the utility of the International Classification of Disease, Tenth Revision (ICD-10) code, R19.5, for a positive or abnormal fecal immunochemical test (FIT) and its association with colonoscopy completion.

METHODS

We identified all patients in a safety-net health system who underwent FITs from January 1, 2020, to August 31, 2021, and extracted the FIT date, FIT result, and ICD-10 code (R19.5) and colonoscopy procedures for each patient.

RESULTS

FIT-positive patients who had an R19.5 designation within 90 days (n = 383) were significantly more likely than all other FIT-positive patients (n = 273) to complete a colonoscopy within 6 months (40.9% vs 16.8%, P <0.001).

DISCUSSION

We found that less than two-thirds of patients had an ICD-10 code designated in their chart within 30 days of an abnormal FIT. When coding occurred in a timely manner, patients were more likely to complete their colonoscopy within 6 months.

Performance of OC-Auto Micro 80 Fecal Immunochemical Test in an Integrated Academic-Community Health System

GOALS

We aimed to determine the performance of the OC-Auto Micro 80 fecal immunochemical test (FIT) in an average-risk population receiving care in an integrated, academic-community health system.

BACKGROUND

The FIT is the most used colorectal cancer (CRC) screening test worldwide. However, many Food and Drug Administration-cleared FIT products have not been evaluated in clinical settings.

STUDY

We performed a retrospective cohort study of patients (50 to 75 y old) in the University of Washington Medicine health care system who were screened for CRC by OC-Auto Micro 80 FIT between March 2016 and September 2021. We used electronic health records to extract patient-level and clinic-level factors, FIT use, colonoscopy, and pathology findings. The primary outcomes were the FIT positivity rate and neoplasms detected at colonoscopy. Secondary outcomes were FIT positivity by sex and safety-net versus non-safety-net clinical settings.

RESULTS

We identified 39,984 FITs completed by 26,384 patients; 2411 (6.0%) had a positive FIT result (>100 ng/mL of hemoglobin in buffer), and 1246 (51.7%) completed a follow-up colonoscopy. The FIT positive rate was 7.0% in men and 5.2% in women ( P <0.01). Among those who completed a colonoscopy after an abnormal FIT result, the positive predictive value for CRC, advanced adenoma, and advanced neoplasia was 3.0%, 20.9%, and 23.9%, respectively.

CONCLUSIONS

In a retrospective analysis of a large heterogeneous population, the OC-Auto Micro 80 FIT for CRC screening demonstrated a positivity rate of 6.0% and a positive predictive value for CRC of 3.0%.

Blood-based tests for multicancer early detection (PATHFINDER): a prospective cohort study

BACKGROUND

Multicancer early detection (MCED) blood tests can detect a cancer signal from circulating cell-free DNA (cfDNA). PATHFINDER was a prospective cohort study investigating the feasibility of MCED testing for cancer screening.

METHODS

In this prospective cohort study done in oncology and primary care outpatient clinics at seven US health networks, a convenience sample of adults aged 50 years or older without signs or symptoms of cancer consented to MCED testing. We collected blood, analysed cfDNA, and returned results to participants' doctors. If a methylation signature indicative of cancer was detected, predicted cancer signal origin(s) informed diagnostic assessment. The primary outcome was time to, and extent of, diagnostic testing required to confirm the presence or absence of cancer. This trial is registered at ClinicalTrials.gov, NCT04241796, and is completed.

FINDINGS

Between Dec 12, 2019, and Dec 4, 2020, we recruited 6662 participants. 4204 (63·5%) of 6621 participants with analysable results were women, 2417 (36·5%) were men, and 6071 (91·7%) were White. A cancer signal was detected in 92 (1·4%) of 6621 participants with analysable results. 35 (38%) participants were diagnosed with cancer (true positives) and 57 (62%) had no cancer diagnosis (false positives). Excluding two participants whose diagnostic assessments began before MCED test results were reported, median time to diagnostic resolution was 79 days (IQR 37-219): 57 days (33-143) in true-positive and 162 days (44-248) in false-positive participants. Most participants had both laboratory tests (26 [79%] of 33 with true-positive results and 50 [88%] of 57 with false-positive results) and imaging (30 [91%] of 33 with true-positive results and 53 [93%] of 57 with false-positive results). Fewer procedures were done in participants with false-positive results (17 [30%] of 57) than true-positive results (27 [82%] of 33) and few had surgery (one with a false-positive result and three with a true-positive result).

INTERPRETATION

This study supports the feasibility of MCED screening for cancer and underscores the need for further research investigating the test's clinical utility.

FUNDING

GRAIL.

Adenoma Detection Rate and Colorectal Cancer Risk in Fecal Immunochemical Test Screening Programs : An Observational Cohort Study

BACKGROUND

Colorectal cancer (CRC) screening programs based on fecal immunochemical tests (FITs) represent the standard of care for population-based interventions. Their benefit depends on the identification of neoplasia at colonoscopy after FIT positivity. Colonoscopy quality measured by adenoma detection rate (ADR) may affect screening program effectiveness.

OBJECTIVE

To examine the association between ADR and postcolonoscopy CRC (PCCRC) risk in a FIT-based screening program.

DESIGN

Retrospective population-based cohort study.

SETTING

Fecal immunochemical test-based CRC screening program between 2003 and 2021 in northeastern Italy.

PATIENTS

All patients with a positive FIT result who had a colonoscopy were included.

MEASUREMENTS

The regional cancer registry supplied information on any PCCRC diagnosed between 6 months and 10 years after colonoscopy. Endoscopists' ADR was categorized into 5 groups (20% to 39.9%, 40% to 44.9%, 45% to 49.9%, 50% to 54.9%, and 55% to 70%). To examine the association of ADR with PCCRC incidence risk, Cox regression models were fitted to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

Of the 110 109 initial colonoscopies, 49 626 colonoscopies done by 113 endoscopists between 2012 and 2017 were included. After 328 778 person-years follow-up, 277 cases of PCCRC were diagnosed. Mean ADR was 48.3% (range, 23% and 70%). Incidence rates of PCCRC from lowest to highest ADR group were 13.13, 10.61, 7.60, 6.01, and 5.78 per 10 000 person-years. There was a significant inverse association between ADR and PCCRC incidence risk, with a 2.35-fold risk increase (95% CI, 1.63 to 3.38) in the lowest group compared with the highest. The adjusted HR for PCCRC associated with 1% increase in ADR was 0.96 (CI, 0.95 to 0.98).

LIMITATION

Adenoma detection rate is partly determined by FIT positivity cutoff; exact values may vary in different settings.

CONCLUSION

In a FIT-based screening program, ADR is inversely associated with PCCRC incidence risk, mandating appropriate colonoscopy quality monitoring in this setting. Increasing endoscopists' ADR may significantly reduce PCCRC risk.

PRIMARY FUNDING SOURCE

None.

Evaluation of Colonoscopy and Sigmoidoscopy Utilization for Colorectal Cancer Screening in Georgia, USA

Colorectal cancer (CRC) is the third most prevalent cancer, and the second most common cancer-related cause of death in the United States (USA). Timely screening reduces both CRC incidence and mortality. Understanding population behaviors and factors that influence CRC screening is important for directing interventions targeted at reducing CRC rates. The 1997-2018 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed for trends in colonoscopy and sigmoidoscopy utilization for CRC screening among adults in Georgia, USA. Overall, in Georgia, there has been an increase in the prevalence of colonoscopy and sigmoidoscopy utilization from 48.1% in 1997 to 71.2% in 2018 (AAPC = 2.30, p < 0.001). Compared nationally, this increase was less pronounced (from 41.0% in 1997 to 73.7% in 2018 (AAPC = 2.90, p < 0.001) overall for USA). Logistic regression analysis of the 2018 BRFSS data, adjusting for sociodemographic factors, shows that sex (female vs. male [aOR = 1.20, C.I. = 1.05, 1.38]); marital status (couple vs. single [aOR = 1.20, C.I. = 1.04, 1.39]); healthcare coverage (yes vs. no [aOR = 3.86, C.I. = 3.05, 4.88]); age (60-69 years [aOR = 2.38, C.I. = 2.02, 2.80], 70-79 [aOR = 2.88, C.I. = 2.38, 3.48] vs. 50-59 years); education (high school [aOR = 1.32, C.I. = 1.05, 1.65], some post high school [aOR= 1.63, C.I. = 1.29, 2.06], college graduate [aOR = 2.08, C.I. = 1.64, 2.63] vs. less than high school); and income ($25,000-$49,999 [aOR = 1.24, C.I. = 1.01, 1.51], $50,000+ [aOR = 1.56, C.I. = 1.27, 1.91] vs. <$25,000) were all significantly associated with colonoscopy and sigmoidoscopy utilization. In Georgia, a significant increase over time in colonoscopy and sigmoidoscopy utilization for CRC screening was observed pertaining to the associated sociodemographic factors. The findings from this study may help guide tailored programs for promoting screening among underserved populations.

Improving Fecal Immunochemical Test Return Rates: A Colorectal Cancer Screening Quality Improvement Project in a Multisite Federally Qualified Health Center

The goal of this quality improvement project was to improve colorectal cancer (CRC) screening rates in a multicenter federally qualified health center (FQHC) within the Central Appalachian region of rural, southwestern Virginia. Guided by the Plan-Do-Study-Act (PDSA) cycle, the objectives were to (1) evaluate implementation processes and effectiveness of an automated electronic medical record patient reminder system to promote fecal immunochemical test (FIT) completion, compared with live telephone reminders delivered by a care coordinator (i.e., usual care), and (2) explore staff perceptions related to improving CRC screening rates. In total, 119 FITs were distributed with 59 assigned to usual care and 60 to the automated groups. In the usual care group, 79% patients with completed protocol returned their FIT; 9% were positive. In the automated reminder group, 76% patients with completed protocol returned their FIT; 10% were positive. There was no significant difference in the number of contacts per patients between the usual care (2.0, SD = 0.82 contacts/patient) and automated (1.8, SD = 0.98 contacts/patient) groups (p = .248). In total, the usual care and automated groups required 56 and 17 live calls, respectively. Overall, FQHC system-wide CRC screening rates increase from 30.5% to 47.3%. Ten staff interviews revealed perceptions of CRC screening, the QI project, and organizational change processes that may inform future cancer control projects. Researcher and practitioners should consider PDSA quality improvement projects as an initial step to build capacity and improve CRC screening rates, especially when working in FQHC with limited resources to engage in large complex research projects.

Adaptation of colorectal cancer screening tailored navigation content for American Indian communities and early results using the intervention

BACKGROUND

American Indians (AI) experience major colorectal cancer (CRC) screening disparities with commensurate inequity in CRC mortality and other outcomes. The purpose of this report is to describe the methods and early results of adapting a previously successful intervention for the AI community.

METHODS

The educational content and delivery strategy of the parent intervention were adapted for AIs guided by an adaptation framework and cultural consultations with the community and clinicians. As part of the environmental scanning, we identified the need to substantively revise our data entry, collection, and tracking system and develop a REDCap database for this purpose. In this study, we staggered the implementation of the intervention in each facility to inform the process from one clinic to the next, and assess both the clinical outcomes of the tailored intervention and the implementation processes across two clinic settings, Facilities A and B.

RESULTS

The REDCap database is an indispensable asset, and without it we would not have been able to obtain reliable aggregate screening data while improvements to facility electronic health records are in progress. Approximately 8% (n = 678) of screening-eligible patients have been exposed to the navigator intervention. Of those exposed to the navigator intervention, 37% completed screening.

CONCLUSIONS

With the small numbers of patients exposed so far to the intervention, it would be premature to draw any broad conclusions yet about intervention effects. However, early screening completion rates are substantial advances on existing rates, and we have demonstrated that a tailored navigator intervention for facilitating CRC screening was readily adapted with provider and community input for application to AIs. A REDCap database for tracking of CRC screening by navigators using tablets or laptops on- or offline is easy to use and allows for generation of aggregate, anonymized screening data.

TRIAL REGISTRATION

There was no health intervention meeting the criteria of a clinical trial. The University of Arizona Institutional Review Board granted exemption from obtaining informed consent from patients undergoing CRC screening after administration of the tailored navigation intervention as usual care.

PPV and Detection Rate of mt-sDNA Testing, FIT, and CT Colonography for Advanced Neoplasia: A Hierarchic Bayesian Meta-Analysis of the Noninvasive Colorectal Screening Tests

BACKGROUND. Noninvasive tests for colorectal cancer (CRC) screening and prevention limit the need for invasive colonoscopy to follow up positive test results. However, the relative performance characteristics of available noninvasive tests have not yet been adequately compared. OBJECTIVE. We performed a systematic review and meta-analysis to compare the diagnostic performance of the available noninvasive CRC screening tests, including multitarget stool DNA (mt-sDNA) testing, fecal immunochemical testing (FIT), and CT colonography (CTC), with an emphasis on comparison of PPV and detection rate (DR) for advanced neoplasia (AN; encompassing cases of advanced adenomas and CRC). EVIDENCE ACQUISITION. After systematic searches of MEDLINE and Google Scholar databases, 10 mt-sDNA, 27 CTC, and 88 FIT published screening studies involving 25,132, 33,493, and 2,355,958 asymptomatic adults, respectively, were included. Meta-analysis with hierarchic Bayesian modeling was conducted in accordance with Cochrane Collaboration and PRISMA guidelines to determine test positivity rates (TPRs) leading to optical colonoscopy, as well as PPVs and DRs for both AN and CRC. Different positivity thresholds were considered for FIT and CTC. EVIDENCE SYNTHESIS. Point estimates (with 95% credible intervals) from pooled Bayesian meta-analysis combining all thresholds for FIT and stratifying CTC results by a polyp size threshold of 6 mm or larger (CTC6) and 10 mm or larger (CTC10) were calculated. TPR was 13.5% (10.9-16.6%) for mt-sDNA testing, 6.4% (5.8-7.2%) for FIT, 13.4% (11.4-15.6%) for CTC6, and 6.6% (5.2-7.7%) for CTC10. AN PPV was 26.9% (95% credible interval, 21.8-33.2%) for mt-sDNA testing, 31.8% (29.3-34.5%) for FIT, 34.4% (27.2-41.0%) for CTC6, and 61.0% (54.0-70.0%) for CTC10. CRC PPV was 2.4% (1.5-3.9%) for mt-sDNA testing, 4.9% (4.3-5.3%) for FIT, 3.5% (2.5-4.8%) for CTC6, and 6.0% (4.3-8.0%) for CTC10. The DR for AN was 3.4% (95% credible interval, 2.5-4.8%) for mt-SDNA, 2.0% (1.8-2.3%) for FIT, 4.8% (4.0-6.5%) for CTC6, and 4.0% (3.0-4.6%) for CTC10. When FIT is restricted to a lower threshold (< 10 μg Hb/g feces), its performance profile is similar to that of mt-sDNA testing, although available data are limited. AN PPV odds ratios (relative to CTC10 as the reference) were 0.24 (95% credible interval, 0.17-0.33) for mt-sDNA testing, 0.30 (0.24-0.45) for FIT, and 0.33 (0.25-0.47) for CTC6. CONCLUSION. Among noninvasive CRC screening tests, CTC with a polyp size threshold of 10 mm or larger most effectively targets AN, preserving detection while also decreasing unnecessary colonoscopies compared with mt-sDNA testing and FIT. CLINICAL IMPACT. CTC performed with a polyp size threshold for colonoscopy referral set at 10 mm or larger represents the most effective and efficient noninvasive screening test for CRC prevention and detection.

"ASKing" the Right Questions About Screening for Celiac Disease

Make a distinction between investigating symptoms and screening for disease. Understand the performance characteristics of a test for those with symptoms and for screening those without symptoms, whether at elevated risk or average risk of disease. Positive test results require patient education and follow-up. Importantly, screening should be advantageous to an individual, and disease treatment should be in their interest. The practical application of these principles in relation to population-based Celiac disease screening may be difficult, as a large Colorado study has found.

Effectiveness of a mailed fecal immunochemical test outreach: a Medicare Advantage pilot study

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach effectively increases colorectal cancer (CRC) screening but is underutilized. This pilot aimed to determine the use of FIT for CRC screening among Medicare Advantage enrollees when offered via mailed outreach and the factors associated with FIT return.

METHODS

Our pilot study included Medicare Advantage enrollees who were 50-75-years old, not up to date with CRC screening, and had a billable primary care encounter in the prior 3 years. Eligible patients received a letter containing information about CRC screening and a FIT kit, screening status by FIT was then assessed using the electronic health record.

RESULTS

Of the 1142 patients identified, 945 were eligible for outreach. On 12-month follow up, 29% of patients (n = 276) completed CRC screening via FIT, with a median return time of 140 days [interquartile range (IQR) 52-257]; 6% (n = 17) of the completed tests were positive, and 53% (n = 9) of patients have completed a diagnostic colonoscopy. Patients with primary encounter <12 months prior to mailed outreach were most likely to complete a FIT. Over the 12-month study period, CRC screening rates increased by 5% (63-68%).

CONCLUSIONS

Mailed FIT outreach in a Medicare Advantage population was feasible and led to a 5% increase in CRC screening completion. Our pilot revealed rare incorrect patient addresses and high lab discard rate; both important factors that were addressed prior to larger-scale implementation of a mailed FIT program. Further research is needed to understand the potential impact of multilevel interventions on CRC screening in this healthcare system.