1
|
Monroy-Iglesias MJ, Martin S, Cargaleiro C, Jones G, Steward L, Murtagh C, Bruno F, Millwaters J, Schizas A, Watson H, Haire A, Haire K, Moss CL, Russell B, Srirajaskanthan R, Van Hemelrijck M, Dolly S. Real-world data evaluating Guy's rapid diagnostic clinic as an alternate pathway for patients with FIT levels below 10. BMJ Open 2024; 14:e080285. [PMID: 38626962 PMCID: PMC11029265 DOI: 10.1136/bmjopen-2023-080285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/13/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE To analyse the effectiveness of rapid diagnostic clinics (RDCs) as an alternative pathway for patients with concerning symptoms and a faecal immunochemical test (FIT) result <10. Our primary endpoint was rate of colorectal cancer (CRC) detection. Second endpoints were rates of other cancers and gastrointestinal (GI) serious benign conditions. Finally, we analysed the specific pathway followed by FIT <10 patients with cancer at Guy's and St Thomas NHS Foundation Trust (GSTT) RDC. DESIGN A retrospective and prospective cohort study. SETTING GSTT RDC, one of England's largest single-centre RDCs. Sociodemographic and clinical characteristics of FIT <10 patients were analysed descriptively. PARTICIPANTS Patients with an FIT result <10, seen at GSTT RDC between 1 January 2020 and 5 May 2023. RESULTS A total of 1299 patients with an FIT<10 were seen at GSTT RDC between January 2020 and May 2023. Of these, 66% (n=861) reported weight loss, 62% (n=805) pain, 37% (n=481) fatigue, 34% (n=444) were anaemic and 23% (n=301) had nausea and vomiting. Among these patients, 7% (n=88) received a cancer diagnosis, 36% (n=462) were identified as having a serious benign condition. Within the patients with cancer, 9% (n=8) were diagnosed with CRC. Among patients with serious benign conditions, 7% (n=31) were referred to colorectal, hepatopancreatobiliary, or upper GI specialists. CONCLUSION This study demonstrates the effectiveness of RDCs as an alternate pathway for FIT <10 patients with ongoing clinical concerns. These results contribute to enhancing patient care and optimising resource allocation within the healthcare system.
Collapse
Affiliation(s)
| | - Sabine Martin
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Carlos Cargaleiro
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Geraint Jones
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
- Southeast London Cancer Alliance, London, UK
| | - Lindsay Steward
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Colette Murtagh
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Flaminia Bruno
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Juliet Millwaters
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Alexis Schizas
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Harriet Watson
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anna Haire
- Translational Oncology and Urology Research, King's College London, London, UK
| | - Kate Haire
- Southeast London Cancer Alliance, London, UK
| | | | - Beth Russell
- Translational Oncology and Urology Research, King's College London, London, UK
| | | | | | - Saoirse Dolly
- Medical Oncology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| |
Collapse
|
2
|
Rahman F, Trivedy M, Rao C, Akinlade F, Mansuri A, Aggarwal A, Laskaratos FM, Rajendran N, Banerjee S. Faecal Immunochemical Testing to Detect Colorectal Cancer in Symptomatic Patients: A Diagnostic Accuracy Study. Diagnostics (Basel) 2023; 13:2332. [PMID: 37510076 PMCID: PMC10378039 DOI: 10.3390/diagnostics13142332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/19/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: NHS England recommended faecal immunochemical testing (FIT) for symptomatic patients in June 2020 to rationalise limited diagnostic services during COVID-19. (2) Aim: to investigate the diagnostic performance of FIT, analysing the proportion of FIT-negative colorectal cancers (CRC) missed in symptomatic patients and how this risk could be mitigated. (3) Design and Setting: a retrospective study of biochemistry and cancer databases involving patients referred from primary healthcare with suspected CRC to a single secondary care trust in North East London. (4) Methods: a retrospective cohort diagnostic accuracy study was undertaken to determine the performance of FIT for detecting CRC at 10 µgHb/g. (5) Results: between January and December 2020, 7653 patients provided a stool sample for FIT analysis; 1679 (22%) samples were excluded due to inadequate or incorrect specimens; 48% of suspected CRC referrals completed FIT before evaluation; 86 FIT tested patients were diagnosed with histologically proven CRC. At 10 µgHb/g, FIT performance was comparable with the existing literature with a sensitivity of 0.8140 (95% CI 0.7189-0.8821), a specificity of 0.7704 (95% CI 0.7595-0.7809), a positive predictive value (PPV) of 0.04923 (95% CI 0.03915-0.06174), a negative predictive value (NPV) of 0.9965 (95% CI 0.9943-0.9978), and a likelihood ratio (LR) of 3.545; 16 patients with CRC had an FIT of ≤10 µgHb/g (18.6% 95% CI 11.0-28.4%). (6) Conclusions: this study raises concerns about compliance with FIT testing and the incidence of FIT-negative CRC at the NICE recommended threshold and how this risk can be mitigated without colonic imaging. Whilst FIT may have facilitated prioritisation during COVID-19, we must be cautious about using FIT alone to determine which patients are referred to secondary care or receive further investigation.
Collapse
Affiliation(s)
- Farzana Rahman
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0A, UK
| | - Mihir Trivedy
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0A, UK
- Barts Health NHS Trust, Whipps Cross Hospital, London E11 1NR, UK
| | - Christopher Rao
- Department of Surgery and Cancer, Imperial College London, London SW7 2BX, UK
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle CA2 7HY, UK
| | - Funmi Akinlade
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0A, UK
| | - Ahmer Mansuri
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0A, UK
| | - Atul Aggarwal
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0A, UK
| | | | - Nirooshun Rajendran
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0A, UK
| | - Saswata Banerjee
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0A, UK
| |
Collapse
|
3
|
Booth R, Carten R, D'Souza N, Westwood M, Kleijnen J, Abulafi M. Role of the faecal immunochemical test in patients with risk-stratified suspected colorectal cancer symptoms: A systematic review and meta-analysis to inform the ACPGBI/BSG guidelines. THE LANCET REGIONAL HEALTH. EUROPE 2022; 23:100518. [PMID: 36212984 PMCID: PMC9535300 DOI: 10.1016/j.lanepe.2022.100518] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background The UK National Institute for Health and Care Excellence (NICE), recommended in 2017 the use of the faecal immunochemical test (FIT) to guide investigations in patients presenting with NICE-defined low-risk symptoms suspicious for colorectal cancer (CRC). At that time, NICE did not recommend FIT use for high-risk symptoms. This is the first systematic review to evaluate the diagnostic accuracy of FIT in NICE-defined high and low-risk symptoms and was designed to inform the joint ACPGBI/BSG guidelines. Methods We performed a systematic literature review and meta-analysis. PROSPERO registration number CRD42021224674. Medline and EMBASE databases were searched from inception to 31st March 2022. We included studies recruiting adult patients presenting with suspected CRC symptoms in whom FIT was performed and diagnostic accuracy data for CRC detection could be derived at a limit of detection (LoD) and/or 10 µg haemoglobin/gram faeces threshold in four commonly used analysers. FIT performance was assessed for high-risk, low-risk and individual symptoms where possible. Bivariate meta-analysis was performed where study numbers allowed. Findings Thirty-one studies (79566 patients) met inclusion criteria. At 10 µg/g, for "all symptoms" (n = 35,945) sensitivity and specificity were 91.0% (95% CI: 88.9, 92.7) and 75.2% (95% CI: 69.6, 80.1); for "high-risk" symptoms (n = 18,264), 88.7% (95% CI: 84.4, 92.0) and 78.5% (95% CI: 73.0, 83.2); and for "low-risk" symptoms (n = 2161), 88.7% (95% CI: 78.1, 95.3) and 88.5% (95% CI: 87.1, 89.9), respectively. At LoD, for "all symptoms" (n = 26,056) sensitivity and specificity were 94.7% (95% CI: 90.5, 97.1) and 66.5% (95% CI: 58.7, 73.6); for "high-risk" symptoms (n = 16,768), 92.8% (95% CI: 86.4, 96.3) and 70.3% (95% CI: 66.5, 73.8); and for "low-risk" symptoms (n = 2082), 94.7% (95% CI: 85.4, 98.9) and 71.9% (95% CI: 69.9, 73.9), respectively. Summary estimates were similar across different analysers. Interpretation FIT sensitivity for CRC detection is maximised at the LoD; its performance is similar in high and low-risk symptoms, and across different analysers where a common threshold is used. FIT performance for CRC detection is adequate and transferrable to clinical diagnostic pathways. Funding This review was part-funded by NHS England awarded to RM Partners. RB and RC were funded by research fellowships awarded by Croydon University Hospital.
Collapse
|
4
|
Lööv A, Högberg C, Lilja M, Theodorsson E, Hellström P, Metsini A, Olsson L. Diagnostic accuracy for colorectal cancer of a quantitative faecal immunochemical test in symptomatic primary care patients: a study protocol. Diagn Progn Res 2022; 6:16. [PMID: 35978403 PMCID: PMC9386911 DOI: 10.1186/s41512-022-00129-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/21/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There is increasing evidence supporting the use of faecal immunochemical tests (FIT) in patients reporting symptoms associated with colorectal cancer (CRC), but most studies until now have focused on selected subjects already referred for investigation. We therefore set out to determine the accuracy and predictive values of FIT in a primary care population. METHOD A prospective, multicentre, single-gated comparative diagnostic study on quantitative FIT in patients aged 40 years and above presenting in primary care with symptoms associated with CRC will be conducted. Patients representing the whole spectrum of severity of such symptoms met with in primary care will be eligible and identified by GPs. Participants will answer a short form on symptoms during the last month. They will provide two faecal samples from two separate days. Analyses will be performed within 5 days (QuikRead go®, Aidian Oy). The analytical working range is 10-200 μg Hb/g faeces. Reference test will be linked to the Swedish Colorectal Cancer Registry up to 2 years after inclusion. Accuracy, area under ROC curves, and predictive values will be calculated for one FIT compared to the highest value of two FIT and at cutoff < 10, 10-14.9, 15-19.9 and ≥ 20 μg Hb/g faeces. Subgroup analyses will be conducted for patients with anaemia and those reporting rectal bleeding. A model-based cost-effectiveness analysis based on the clinical accuracy study will be performed. Based on previous literature, we hypothesized that the sensitivity of the highest value of two FIT at cutoff 10 μg Hb/g faeces will be 95% (95% CI + / - 15%). The prevalence of CRC in the study population was estimated to be 2%, and the rate of non-responders to be 1/6. In all, 3000 patients will be invited at 30 primary care centres. DISCUSSION This study will generate important clinical real-life structured data on accuracy and predictive values of FIT in the most critical population for work-up of CRC, i.e. patients presenting with at times ambiguous symptoms in primary care. It will help establish the role of FIT in this large group. TRIAL REGISTRATION NCT05156307 . Registered on 14 December 2021-retrospectively registered.
Collapse
Affiliation(s)
- Anna Lööv
- Department of Medical Sciences, Örebro University, Örebro, Sweden.
- Skebäck Primary Care Centre, Region Örebro län, Örebro, Sweden.
| | - Cecilia Högberg
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development Östersund, Umeå University, Umeå, Sweden
| | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development Östersund, Umeå University, Umeå, Sweden
| | - Elvar Theodorsson
- Department of Biomedical and Clinical Science; Clinical Chemistry, Linköping University, Linköping, Sweden
| | - Per Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Alexandra Metsini
- Department of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Knowledge Management and Patient Safety Unit, Region Värmland, Karlstad, Sweden
| | - Louise Olsson
- Department of Medical Sciences, Örebro University, Örebro, Sweden
- Centre for Assessment of Medical Technology, Örebro University Hospital, Örebro, Sweden
| |
Collapse
|
5
|
Monahan KJ, Davies MM, Abulafi M, Banerjea A, Nicholson BD, Arasaradnam R, Barker N, Benton S, Booth R, Burling D, Carten RV, D'Souza N, East JE, Kleijnen J, Machesney M, Pettman M, Pipe J, Saker L, Sharp L, Stephenson J, Steele RJ. Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG). Gut 2022; 71:gutjnl-2022-327985. [PMID: 35820780 PMCID: PMC9484376 DOI: 10.1136/gutjnl-2022-327985] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/01/2022] [Indexed: 12/12/2022]
Abstract
Faecal immunochemical testing (FIT) has a high sensitivity for the detection of colorectal cancer (CRC). In a symptomatic population FIT may identify those patients who require colorectal investigation with the highest priority. FIT offers considerable advantages over the use of symptoms alone, as an objective measure of risk with a vastly superior positive predictive value for CRC, while conversely identifying a truly low risk cohort of patients. The aim of this guideline was to provide a clear strategy for the use of FIT in the diagnostic pathway of people with signs or symptoms of a suspected diagnosis of CRC. The guideline was jointly developed by the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology, specifically by a 21-member multidisciplinary guideline development group (GDG). A systematic review of 13 535 publications was undertaken to develop 23 evidence and expert opinion-based recommendations for the triage of people with symptoms of a suspected CRC diagnosis in primary care. In order to achieve consensus among a broad group of key stakeholders, we completed an extended Delphi of the GDG, and also 61 other individuals across the UK and Ireland, including by members of the public, charities and primary and secondary care. Seventeen research recommendations were also prioritised to inform clinical management.
Collapse
Affiliation(s)
- Kevin J Monahan
- The Wolfson Endoscopy Unit, Gastroenterology Department, St Mark's Hospital and Academic Institute, Harrow, London, UK
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, UK
| | - Michael M Davies
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - Muti Abulafi
- Colorectal Surgery, Croydon Health Services NHS Trust, Croydon, Greater London, UK
| | - Ayan Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Brian D Nicholson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ramesh Arasaradnam
- University of Warwick, Clinical Sciences Research Institute, Coventry, UK
- Gastroenterology Department, University Hospital Coventry, Coventry, UK
| | | | - Sally Benton
- Hub Director, NHS Bowel Cancer Screening South of England Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Richard Booth
- Colorectal Surgery, Croydon University Hospital, Croydon, UK
| | - David Burling
- Radiology, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | | | | | - James Edward East
- Translational Gastroenterology Unit, Univerity of Oxford Nuffield Department of Medicine, Oxford, UK
- Gastroenterology, Mayo Clinic Healthcare, London, UK
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, North Yorkshire, UK
| | - Michael Machesney
- Colorectal Surgery, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Maria Pettman
- Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Lance Saker
- General Practice, Oak Lodge Medical Centre, London, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Robert Jc Steele
- Surgery and Oncology Department, University of Dundee, Dundee, UK
| |
Collapse
|
6
|
Forse CL, Petkiewicz S, Teo I, Purgina B, Klaric KA, Ramsay T, Wasserman JK. Negative Impact of COVID-19 Associated Health System Shutdown on Patients Diagnosed With Colorectal Cancer: A Retrospective Study From a Large Tertiary Center in Ontario, Canada. J Can Assoc Gastroenterol 2022; 5:137-142. [PMID: 35664369 PMCID: PMC8754725 DOI: 10.1093/jcag/gwab044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background In March 2020, a directive to halt all elective and non-urgent procedures was issued in Ontario, Canada because of COVID-19. The directive caused a temporary slowdown of screening programs including surveillance colonoscopies for colorectal cancer (CRC). Our goal was to determine if there was a difference in patient and tumour characteristics between CRC patients treated surgically prior to the COVID-19 directive compared to CRC patients treated after the slowdown. Methods CRC resections collected within the Champlain catchment area of eastern Ontario in the 6 months prior to COVID-19 (August 1, 2019-January 31, 2020) were compared to CRC resections collected in the 6 months post-COVID-19 slowdown (August 1, 2020-January 31, 2021). Clinical (e.g., gender, patient age, tumour site, and clinical presentation) and pathological (tumour size, tumour stage, nodal stage, and lymphovascular invasion) features were evaluated using chi-square tests, T-tests, and Mann-Whitney tests where appropriate. Results Three hundred and thirty-eight CRC specimens were identified (173 pre-COVID-19, 165 post-COVID-19 slowdown). CRC patients treated surgically post-COVID-19 slowdown had larger tumours (44 mm vs. 35 mm; P = 0.0048) and were more likely to have presented emergently (24% vs. 10%; P < 0.001). Although there was a trend towards higher tumour stage, nodal stage, and clinical stage, these differences did not reach statistical significance. Other demographic and pathologic variables including patient gender, age, and tumour site were similar between the two cohorts. Interpretation The COVID-19 slowdown resulted in a shift in the severity of disease experienced by CRC patients in Ontario. Pandemic planning in the future should consider the long-term consequences to cancer diagnosis and management.
Collapse
Affiliation(s)
- Catherine L Forse
- Department of Pathology and Laboratory Medicine, Division of Anatomical Pathology, The Ottawa Hospital, Eastern Ontario Regional Laboratory Association, and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephanie Petkiewicz
- Department of Pathology and Laboratory Medicine, Division of Anatomical Pathology, The Ottawa Hospital, Eastern Ontario Regional Laboratory Association, and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Iris Teo
- Department of Pathology and Laboratory Medicine, Division of Anatomical Pathology, The Ottawa Hospital, Eastern Ontario Regional Laboratory Association, and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Bibianna Purgina
- Department of Pathology and Laboratory Medicine, Division of Anatomical Pathology, The Ottawa Hospital, Eastern Ontario Regional Laboratory Association, and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kristina-Ana Klaric
- Department of Pathology and Laboratory Medicine, Division of Anatomical Pathology, The Ottawa Hospital, Eastern Ontario Regional Laboratory Association, and University of Ottawa, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jason K Wasserman
- Department of Pathology and Laboratory Medicine, Division of Anatomical Pathology, The Ottawa Hospital, Eastern Ontario Regional Laboratory Association, and University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| |
Collapse
|
7
|
Pin-Vieito N, Tejido-Sandoval C, de Vicente-Bielza N, Sánchez-Gómez C, Cubiella J. Faecal immunochemical tests safely enhance rational use of resources during the assessment of suspected symptomatic colorectal cancer in primary care: systematic review and meta-analysis. Gut 2022; 71:950-960. [PMID: 34108236 DOI: 10.1136/gutjnl-2021-324856] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/02/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Implementation of faecal immunochemical tests (FIT) as a triage test in primary healthcare may improve the efficiency of referrals without missing cases of colorectal cancer (CRC). We aim to summarise the performance characteristics of FITs for CRC in symptomatic patients presenting to primary healthcare. DESIGN We performed a systematic literature review of Medline and EMBASE databases from May 2018 to November 2020. Previous related systematic searches were also adapted to this aim and completed with reference screening. We identified studies performed on adult patients consulting for abdominal symptoms in primary care which reported data such that the FIT diagnostic performance parameters for CRC could be obtained. Bivariate models were used to synthesise available evidence. Meta-regression analysis was performed to evaluate the causes of heterogeneity. RESULTS Twenty-three studies (69 536 participants) were included (CRC prevalence 0.3%-6.2%). Six studies (n=34 691) assessed FIT as rule in test (threshold of ≥150 µg Hb/g faeces) showing a sensitivity of 64.1% (95% CI 57.8% to 69.9%) and a specificity of 95.0% (95% CI 91.2% to 97.2%). A threshold of 10 µg/g (15 studies; n=48 872) resulted in a sensitivity of 87.2% (95% CI 81.0% to 91.6%) and a specificity of 84.4% (95% CI 79.4% to 88.3%) for CRC. At a 20 µg Hb/g faeces threshold (five studies; n=24 187) less than one additional CRC would be missed per 1000 patients investigated compared with 10 µg Hb/g faeces threshold (CRC prevalence 2%). CONCLUSION FIT is the test of choice to evaluate patients with new-onset lower gastrointestinal symptoms in primary healthcare.
Collapse
Affiliation(s)
- Noel Pin-Vieito
- Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain.,Instituto de Investigacíon Sanitaria Galicia Sur, Ourense, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Ourense, Spain.,Biochemistry, Genetics and Immunology, Faculty of Biology, University of Vigo, Vigo, Spain
| | | | | | | | - Joaquín Cubiella
- Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain .,Instituto de Investigacíon Sanitaria Galicia Sur, Ourense, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Ourense, Spain
| |
Collapse
|
8
|
Hunt N, Rao C, Logan R, Chandrabalan V, Oakey J, Ainsworth C, Smith N, Banerjee S, Myers M. A cohort study of duplicate faecal immunochemical testing in patients at risk of colorectal cancer from North-West England. BMJ Open 2022; 12:e059940. [PMID: 35418441 PMCID: PMC9014104 DOI: 10.1136/bmjopen-2021-059940] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES We sought to investigate if duplicate faecal immunochemical testing (FIT) sampling improves the negative and positive predictive value of patients thought to be at risk of colorectal cancer (CRC). Specifically, we aimed to investigate whether the proportion of FIT-negative CRC missed by a single FIT test in symptomatic patients could be reduced by duplicate FIT testing. DESIGN A retrospective service evaluation cohort study of the diagnostic accuracy of duplicate FIT testing. SETTING Patients referred from primary care with suspected CRC to four secondary care trusts in North-West England. PARTICIPANTS 28 622 patients over 18-years-old with lower gastrointestinal symptoms suggestive of CRC who completed two FIT samples. PRIMARY AND SECONDARY OUTCOME MEASURES The performance of duplicate FIT for detecting CRC at a threshold of 10 µgHb/g. RESULTS The sensitivity if either test was >10 µgHb/g was 0.978 (0.955-0.989), specificity was 0.662 (0.657-0.668), positive predictive value 0.031 (0.028-0.035) and negative predictive value 1.00 (0.999-1.00). Despite two-thirds of patients (18952) being negative following two tests, at this threshold only seven CRC were missed over a 26-month period. All seven patients had other high-risk features which should have prompted investigation. CONCLUSIONS This study suggests that in routine NHS practice, a duplicate FIT sample strategy together with clinical evaluation for evidence of anaemia and weight loss is superior to a single FIT sample alone and would allow symptomatic patients to be managed in primary care without the need for urgent referral to secondary care for urgent colonic imaging.
Collapse
Affiliation(s)
- Natalie Hunt
- Department of Clinical Biochemistry, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Christopher Rao
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - Robert Logan
- Department of Gastroenterology, King's College London, London, UK
| | - Vishnu Chandrabalan
- Department of Colorectal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Jane Oakey
- Clinical Biochemistry, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | | | - Neil Smith
- NHS Blackburn with Darwen CCG, Blackburn, UK
| | | | - Martin Myers
- Department of Clinical Biochemistry, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| |
Collapse
|
9
|
Snook J, Bhala N, Beales ILP, Cannings D, Kightley C, Logan RP, Pritchard DM, Sidhu R, Surgenor S, Thomas W, Verma AM, Goddard AF. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut 2021; 70:2030-2051. [PMID: 34497146 PMCID: PMC8515119 DOI: 10.1136/gutjnl-2021-325210] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA-for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease- with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.
Collapse
Affiliation(s)
- Jonathon Snook
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Neeraj Bhala
- Gastroenterology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust and Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ian L P Beales
- Gastroenterology, University of East Anglia, Norwich, UK
| | - David Cannings
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Chris Kightley
- Digestive Diseases, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | | | - D Mark Pritchard
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool and Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Reena Sidhu
- Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Sue Surgenor
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Wayne Thomas
- Haematology, Plymouth Hospitals NHS Foundation Trust, Plymouth, Plymouth, UK
| | - Ajay M Verma
- Digestive Diseases, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | | |
Collapse
|
10
|
Almilaji O, Parry SD, Docherty S, Snook J. Colorectal cancer and the blood loss paradox. Frontline Gastroenterol 2021; 13:381-385. [PMID: 36051962 PMCID: PMC9380756 DOI: 10.1136/flgastro-2021-101959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/12/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Faecal occult blood (FOB) positivity and iron deficiency anaemia (IDA) are common manifestations of colorectal cancer (CRC) and both potentially facilitate diagnosis at an earlier, more treatable stage. It has been assumed that both are the consequence of low-grade blood loss from the tumour bed. METHOD A retrospective analysis of 1121 cases of CRC diagnosed at a single centre between 2010 and 2016, comparing cases presenting via FOB-based Bowel Cancer Screening Programme (BCSP) and IDA pathways for a series of variables including age, sex, tumour location and prevalence of anaemia. RESULTS The BCSP and IDA pathways each accounted for about 15% of the total case load. There were significant differences between the BCSP and IDA sub-groups in median age (68 vs 78 years: p<0.001), median haemoglobin (138 vs 89 g/L: p<0.001) and proportion of lesions in right colon (31.1% vs 82.5%: p<0.001). The major disparity in the prevalence of anaemia (overall 20.0% vs 98.2%: p<0.001) persisted when controlled for tumour location. CONCLUSION Paradoxically, CRC screening through the detection of FOB positivity and IDA identifies distinctly different sub-populations of cases. The theoretical implication is that an additional mechanism may be required to explain the development of IDA in CRC. The practical implication is that detection of IDA may have a complementary role to the BCSP in population screening for CRC.
Collapse
Affiliation(s)
- Orouba Almilaji
- Department of Gastroenterology, Poole Hospital, UHD Foundation Trust, Poole, UK,Department of Medical Science and Public Health, Bournemouth University, Bournemouth, UK
| | - Sally D Parry
- Department of Gastroenterology, Poole Hospital, UHD Foundation Trust, Poole, UK
| | - Sharon Docherty
- Department of Medical Science and Public Health, Bournemouth University, Bournemouth, UK
| | - Jonathon Snook
- Department of Gastroenterology, Poole Hospital, UHD Foundation Trust, Poole, UK
| |
Collapse
|
11
|
Bailey JA, Weller J, Chapman CJ, Ford A, Hardy K, Oliver S, Morling JR, Simpson JA, Humes DJ, Banerjea A. Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation. BJS Open 2021; 5:6162967. [PMID: 33693553 PMCID: PMC7947575 DOI: 10.1093/bjsopen/zraa056] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A novel pathway incorporating faecal immunochemical testing (FIT) for rapid colorectal cancer diagnosis (RCCD) was introduced in 2017. This paper reports on the service evaluation after 2 years of pathway implementation. METHODS The RCCD protocol was based on FIT, blood results and symptoms to stratify adult patients in primary care. Two-week-wait (2WW) investigation was indicated for patients with rectal bleeding, rectal mass and faecal haemoglobin (fHb) level of 10 µg Hb/g faeces or above or 4 µg Hb/g faeces or more in the presence of anaemia, low ferritin or thrombocytosis, in all other symptom groups. Patients with 100 µg Hb/g faeces or above had expedited investigation . A retrospective audit of colorectal cancer detected between 2017 and 2019 was conducted, fHb thresholds were reviewed and critically assessed for cancer diagnoses. RESULTS In 2 years, 14788 FIT tests were dispatched with 13361 (90.4 per cent) completed returns. Overall, fHb was less than 4 µg Hb/g faeces in 9208 results (68.9 per cent), 4-9.9 µg Hb/g in 1583 (11.8 per cent), 10-99.9 µg Hb/g in 1850 (13.8 per cent) and 100 µg Hb/g faeces or above in 720 (5.4 per cent). During follow-up (median 10.4 months), 227 colorectal cancers were diagnosed. The cancer detection rate was 0.1 per cent in patients with fHb below 4 µg Hb/g faeces, 0.6 per cent in those with fHb 4-9.9 µg Hb/g faeces, 3.3 per cent for fHb 10-99.9 µg Hb/g faeces and 20.7 per cent for fHb 100 µg Hb/g faeces or above. The detection rate in the cohort with 10-19.9 µg Hb/g faeces was 1.4 per cent, below the National Institute for Health and Care Excellence threshold for urgent referral. The colorectal cancer rate in patients with fHb below 20 µg Hb/g faeces was less than 0.3 per cent. CONCLUSION Use of FIT to "rule out" urgent referral from primary care misses a small number of cases. The threshold for referral may be adjusted with blood results to improve stratification .
Collapse
Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Weller
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C J Chapman
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Ford
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Hardy
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Oliver
- Nottingham City Clinical Commissioning Group, Nottingham,UK
| | - J R Morling
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - J A Simpson
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK,National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK,Correspondence to: Nottingham Colorectal Service, E Floor West Block, Queen’s Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK (e-mail: )
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
12
|
Nunoo-Mensah JW, Giordano P, Chung-Faye G. COVID-19: An Opportunity to Reimagine Colorectal Cancer Diagnostic Testing-A New Paradigm Shift. Clin Colorectal Cancer 2020; 19:227-230. [PMID: 32921580 PMCID: PMC7395219 DOI: 10.1016/j.clcc.2020.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Joseph W Nunoo-Mensah
- Department of Colorectal Surgery, King's College Hospital Foundation NHS Trust, London, UK; Cleveland Clinic London, London, UK.
| | - Pasquale Giordano
- Department of Colorectal Surgery, Whipps Cross University Hospital, London, UK
| | - Guy Chung-Faye
- Department of Gastroenterology, King's College Hospital Foundation NHS Trust, London, UK
| |
Collapse
|
13
|
Nunoo-Mensah JW, Rizk M, Caushaj PF, Giordano P, Fortunato R, Dulskas A, Bugra D, da Costa Pereira JM, Escalante R, Koda K, Samalavicius NE, Maeda K, Chun HK. COVID-19 and the Global Impact on Colorectal Practice and Surgery. Clin Colorectal Cancer 2020; 19:178-190.e1. [PMID: 32653470 PMCID: PMC7276135 DOI: 10.1016/j.clcc.2020.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The novel severe acute respiratory syndrome coronavirus 2 virus that emerged in December 2019 causing coronavirus disease 2019 (COVID-19) has led to the sudden national reorganization of health care systems and changes in the delivery of health care globally. The purpose of our study was to use a survey to assess the global effects of COVID-19 on colorectal practice and surgery. MATERIALS AND METHODS A panel of International Society of University Colon and Rectal Surgeons (ISUCRS) selected 22 questions, which were included in the questionnaire. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in the ISUCRS database and was advertised on social media sites. The questionnaire remained open from April 16 to 28, 2020. RESULTS A total of 287 surgeons completed the survey. Of the 287 respondents, 90% were colorectal specialists or general surgeons with an interest in colorectal disease. COVID-19 had affected the practice of 96% of the surgeons, and 52% were now using telemedicine. Also, 66% reported that elective colorectal cancer surgery could proceed but with perioperative precautions. Of the 287 respondents, 19.5% reported that the use of personal protective equipment was the most important perioperative precaution. However, personal protective equipment was only provided by 9.1% of hospitals. In addition, 64% of surgeons were offering minimally invasive surgery. However, 44% reported that enough information was not available regarding the safety of the loss of intra-abdominal carbon dioxide gas during the COVID-19 pandemic. Finally, 61% of the surgeons were prepared to defer elective colorectal cancer surgery, with 29% willing to defer for ≤ 8 weeks. CONCLUSION The results from our survey have demonstrated that, globally, COVID-19 has affected the ability of colorectal surgeons to offer care to their patients. We have also discussed suggestions for various practical adaptation strategies for use during the recovery period.
Collapse
Affiliation(s)
- Joseph W Nunoo-Mensah
- Department of Colorectal Surgery, King's College Hospital Foundation NHS Trust, London, United Kingdom.
| | - Mariam Rizk
- Department of Colorectal Surgery, King's College Hospital Foundation NHS Trust, London, United Kingdom
| | | | - Pasquale Giordano
- Department of Colorectal Surgery, Whipps Cross University Hospital, London, United Kingdom
| | - Richard Fortunato
- Department of Colorectal Surgery, Allegheny General Hospital, Pittsburgh, PA
| | - Audrius Dulskas
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - Dursun Bugra
- Department of Surgery, Koç University, Istanbul, Turkey
| | | | | | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | | | - Kotaro Maeda
- Department of Surgery, International Medical Center, Fujita Health University Hospital, Toyoake, Japan
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Seoul, South Korea
| | -
- ISUCRS, 109 Partin Street, Chapel Hill, NC 27514, USA
| |
Collapse
|