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Zorzi M, Urso EDL. Impact of colorectal cancer screening on incidence, mortality and surgery rates: Evidences from programs based on the fecal immunochemical test in Italy. Dig Liver Dis 2023; 55:336-341. [PMID: 35999134 DOI: 10.1016/j.dld.2022.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 12/24/2022]
Abstract
Fecal immunochemical tests (FIT) are among the most commonly used tests for colorectal cancer (CRC) screening programs worldwide. However, no randomised controlled trials have been carried out evaluating the impact of FIT-based screening programs (FIT-progr) on CRC incidence and mortality rates. Italian FIT-progr represent one of the most widespread and established experience worldwide. This paper reviews the evidence on the impact of FIT-progr on CRC incidence, tumor stage at diagnosis, mortality and surgery rates, deriving from Italian routine programs, i.e., outside the research setting. Unfortunately, the application of FIT-progr in Italy can be considered as an unplanned experimental model, due to the differences between Regions, both in health system management and adherence of the target population to the screening programs. The analysis of the manuscripts considered in the review, confirms that FIT-progr are effective in reducing CRC incidence and mortality rates and in improving the rate of endoscopic treatment of early invasive lesions. The review also highlights that FIT-progr are less performing for proximal colon than for distal colon and rectum.
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Affiliation(s)
- Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Passaggio Gaudenzio 1, Padua 35131, Italy
| | - Emanuele Damiano Luca Urso
- Chirurgia Generale 3^, Department of Surgical, Oncological and Gastroenterological, Sciences, University of Padua, Via Giustiniani 2, Padua 35121, Italy.
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2
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Grobbee EJ, Wisse PHA, Schreuders EH, van Roon A, van Dam L, Zauber AG, Lansdorp-Vogelaar I, Bramer W, Berhane S, Deeks JJ, Steyerberg EW, van Leerdam ME, Spaander MC, Kuipers EJ. Guaiac-based faecal occult blood tests versus faecal immunochemical tests for colorectal cancer screening in average-risk individuals. Cochrane Database Syst Rev 2022; 6:CD009276. [PMID: 35665911 PMCID: PMC9169237 DOI: 10.1002/14651858.cd009276.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Worldwide, many countries have adopted colorectal cancer (CRC) screening programmes, often based on faecal occult blood tests (FOBTs). CRC screening aims to detect advanced neoplasia (AN), which is defined as CRC or advanced adenomas. FOBTs fall into two categories based on detection technique and the detected blood component: qualitative guaiac-based FOBTs (gFOBTs) and faecal immunochemical tests (FITs), which can be qualitative and quantitative. Screening with gFOBTs reduces CRC-related mortality. OBJECTIVES To compare the diagnostic test accuracy of gFOBT and FIT screening for detecting advanced colorectal neoplasia in average-risk individuals. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, BIOSIS Citation Index, Science Citation Index Expanded, and Google Scholar. We searched the reference lists and PubMed-related articles of included studies to identify additional studies. SELECTION CRITERIA We included prospective and retrospective studies that provided the number of true positives, false positives, false negatives, and true negatives for gFOBTs, FITs, or both, with colonoscopy as reference standard. We excluded case-control studies. We included studies in which all participants underwent both index test and reference standard ("reference standard: all"), and studies in which only participants with a positive index test underwent the reference standard while participants with a negative test were followed for at least one year for development of interval carcinomas ("reference standard: positive"). The target population consisted of asymptomatic, average-risk individuals undergoing CRC screening. The target conditions were CRC and advanced neoplasia (advanced adenomas and CRC combined). DATA COLLECTION AND ANALYSIS Two review authors independently screened and selected studies for inclusion. In case of disagreement, a third review author made the final decision. We used the Rutter and Gatsonis hierarchical summary receiver operating characteristic model to explore differences between tests and identify potential sources of heterogeneity, and the bivariate hierarchical model to estimate sensitivity and specificity at common thresholds: 10 µg haemoglobin (Hb)/g faeces and 20 µg Hb/g faeces. We performed indirect comparisons of the accuracy of the two tests and direct comparisons when both index tests were evaluated in the same population. MAIN RESULTS We ran the initial search on 25 June 2019, which yielded 63 studies for inclusion. We ran a top-up search on 14 September 2021, which yielded one potentially eligible study, currently awaiting classification. We included a total of 33 "reference standard: all" published articles involving 104,640 participants. Six studies evaluated only gFOBTs, 23 studies evaluated only FITs, and four studies included both gFOBTs and FITs. The cut-off for positivity of FITs varied between 2.4 μg and 50 µg Hb/g faeces. For each Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 domain, we assessed risk of bias as high in less than 20% of studies. The summary curve showed that FITs had a higher discriminative ability than gFOBTs for AN (P < 0.001) and CRC (P = 0.004). For the detection of AN, the summary sensitivity of gFOBTs was 15% (95% confidence interval (CI) 12% to 20%), which was significantly lower than FITs at both 10 μg and 20 μg Hb/g cut-offs with summary sensitivities of 33% (95% CI 27% to 40%; P < 0.001) and 26% (95% CI 21% to 31%, P = 0.002), respectively. Results were simulated in a hypothetical cohort of 10,000 screening participants with 1% CRC prevalence and 10% AN prevalence. Out of 1000 participants with AN, gFOBTs missed 850, while FITs missed 670 (10 μg Hb/g cut-off) and 740 (20 μg Hb/g cut-off). No significant differences in summary specificity for AN detection were found between gFOBTs (94%; 95% CI 92% to 96%), and FITs at 10 μg Hb/g cut-off (93%; 95% CI 90% to 95%) and at 20 μg Hb/g cut-off (97%; 95% CI 95% to 98%). So, among 9000 participants without AN, 540 were offered (unnecessary) colonoscopy with gFOBTs compared to 630 (10 μg Hb/g) and 270 (20 μg Hb/g) with FITs. Similarly, for the detection of CRC, the summary sensitivity of gFOBTs, 39% (95% CI 25% to 55%), was significantly lower than FITs at 10 μg and 20 μg Hb/g cut-offs: 76% (95% CI 57% to 88%: P = 0.001) and 65% (95% CI 46% to 80%; P = 0.035), respectively. So, out of 100 participants with CRC, gFOBTs missed 61, and FITs missed 24 (10 μg Hb/g) and 35 (20 μg Hb/g). No significant differences in summary specificity for CRC were found between gFOBTs (94%; 95% CI 91% to 96%), and FITs at the 10 μg Hb/g cut-off (94%; 95% CI 87% to 97%) and 20 μg Hb/g cut-off (96%; 95% CI 91% to 98%). So, out of 9900 participants without CRC, 594 were offered (unnecessary) colonoscopy with gFOBTs versus 594 (10 μg Hb/g) and 396 (20 μg Hb/g) with FITs. In five studies that compared FITs and gFOBTs in the same population, FITs showed a higher discriminative ability for AN than gFOBTs (P = 0.003). We included a total of 30 "reference standard: positive" studies involving 3,664,934 participants. Of these, eight were gFOBT-only studies, 18 were FIT-only studies, and four studies combined both gFOBTs and FITs. The cut-off for positivity of FITs varied between 5 µg to 250 µg Hb/g faeces. For each QUADAS-2 domain, we assessed risk of bias as high in less than 20% of studies. The summary curve showed that FITs had a higher discriminative ability for detecting CRC than gFOBTs (P < 0.001). The summary sensitivity for CRC of gFOBTs, 59% (95% CI 55% to 64%), was significantly lower than FITs at the 10 μg Hb/g cut-off, 89% (95% CI 80% to 95%; P < 0.001) and the 20 μg Hb/g cut-off, 89% (95% CI 85% to 92%; P < 0.001). So, in the hypothetical cohort with 100 participants with CRC, gFOBTs missed 41, while FITs missed 11 (10 μg Hb/g) and 11 (20 μg Hb/g). The summary specificity of gFOBTs was 98% (95% CI 98% to 99%), which was higher than FITs at both 10 μg and 20 μg Hb/g cut-offs: 94% (95% CI 92% to 95%; P < 0.001) and 95% (95% CI 94% to 96%; P < 0.001), respectively. So, out of 9900 participants without CRC, 198 were offered (unnecessary) colonoscopy with gFOBTs compared to 594 (10 μg Hb/g) and 495 (20 μg Hb/g) with FITs. At a specificity of 90% and 95%, FITs had a higher sensitivity than gFOBTs. AUTHORS' CONCLUSIONS FITs are superior to gFOBTs in detecting AN and CRC in average-risk individuals. Specificity of both tests was similar in "reference standard: all" studies, whereas specificity was significantly higher for gFOBTs than FITs in "reference standard: positive" studies. However, at pre-specified specificities, the sensitivity of FITs was significantly higher than gFOBTs.
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Affiliation(s)
- Esmée J Grobbee
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Pieter HA Wisse
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Eline H Schreuders
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Aafke van Roon
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Leonie van Dam
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Wichor Bramer
- Medical Library , Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sarah Berhane
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Jonathan J Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Manon Cw Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR. Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 325:1978-1998. [PMID: 34003220 DOI: 10.1001/jama.2021.4417] [Citation(s) in RCA: 223] [Impact Index Per Article: 74.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the US. OBJECTIVE To systematically review the effectiveness, test accuracy, and harms of screening for CRC to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2015, to December 4, 2019; surveillance through March 26, 2021. STUDY SELECTION English-language studies conducted in asymptomatic populations at general risk of CRC. DATA EXTRACTION AND SYNTHESIS Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Colorectal cancer incidence and mortality, test accuracy in detecting cancers or adenomas, and serious adverse events. RESULTS The review included 33 studies (n = 10 776 276) on the effectiveness of screening, 59 (n = 3 491 045) on the test performance of screening tests, and 131 (n = 26 987 366) on the harms of screening. In randomized clinical trials (4 trials, n = 458 002), intention to screen with 1- or 2-time flexible sigmoidoscopy vs no screening was associated with a decrease in CRC-specific mortality (incidence rate ratio, 0.74 [95% CI, 0.68-0.80]). Annual or biennial guaiac fecal occult blood test (gFOBT) vs no screening (5 trials, n = 419 966) was associated with a reduction of CRC-specific mortality after 2 to 9 rounds of screening (relative risk at 19.5 years, 0.91 [95% CI, 0.84-0.98]; relative risk at 30 years, 0.78 [95% CI, 0.65-0.93]). In observational studies, receipt of screening colonoscopy (2 studies, n = 436 927) or fecal immunochemical test (FIT) (1 study, n = 5.4 million) vs no screening was associated with lower risk of CRC incidence or mortality. Nine studies (n = 6497) evaluated the test accuracy of screening computed tomography (CT) colonography, 4 of which also reported the test accuracy of colonoscopy; pooled sensitivity to detect adenomas 6 mm or larger was similar between CT colonography with bowel prep (0.86) and colonoscopy (0.89). In pooled values, commonly evaluated FITs (14 studies, n = 45 403) (sensitivity, 0.74; specificity, 0.94) and stool DNA with FIT (4 studies, n = 12 424) (sensitivity, 0.93; specificity, 0.85) performed better than high-sensitivity gFOBT (2 studies, n = 3503) (sensitivity, 0.50-0.75; specificity, 0.96-0.98) to detect cancers. Serious harms of screening colonoscopy included perforations (3.1/10 000 procedures) and major bleeding (14.6/10 000 procedures). CT colonography may have harms resulting from low-dose ionizing radiation. It is unclear if detection of extracolonic findings on CT colonography is a net benefit or harm. CONCLUSIONS AND RELEVANCE There are several options to screen for colorectal cancer, each with a different level of evidence demonstrating its ability to reduce cancer mortality, its ability to detect cancer or precursor lesions, and its risk of harms.
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Affiliation(s)
- Jennifer S Lin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Nora B Henrikson
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Sarah I Bean
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Paula R Blasi
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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4
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Zorzi M, Hassan C, Senore C, Capodaglio G, Turrin A, Narne E, Mussato A, Rizzato S, Chinellato E, Zamberlan S, Repici A, Rugge M. Interval colorectal cancers after negative faecal immunochemical test in a 13-year screening programme. J Med Screen 2020; 28:131-139. [PMID: 32393153 DOI: 10.1177/0969141320918613] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess faecal immunochemical test sensitivity for cancer in a very large population-based cohort followed up for six rounds with biennial faecal immunochemical test repetition. METHODS This study is based on interval colorectal cancers diagnosed in a cohort of subjects aged 50-69 undergoing repeated faecal immunochemical test screening (six rounds) from 2002 to 2015. Test sensitivity was calculated using both the Proportional Interval Cancer Rate and the Interval Cancer Proportion method. RESULTS Among 441,647 faecal immunochemical tests (123,347 individuals), 150 interval colorectal cancers were detected after a negative faecal immunochemical test. Interval colorectal cancer incidence rate was 1.87 per 10,000 person-years (95%CI: 1.60-2.20), and it was higher during the second interval year (rate ratio: 1.78; 95%CI: 1.28-2.47), for proximal locations (rate ratio: 3.00; 95%CI: 1.92-4.68), and among 60-71 year old subjects (rate ratio: 2.37; 95%CI: 1.61-3.50). The Proportional Interval Cancer Rate was 13.1%, with an overall faecal immunochemical test sensitivity of 86.9% (95%CI: 84.7-89.0). Sensitivity was lowest at the first round (81.5%; 95%CI: 75.6-86.2), and increased to 91.9% (95%CI: 83.9-96.5) for subsequent rounds. Applying the Interval Cancer Proportion method, sensitivity was 83.9% (95%CI: 81.3-86.2), and it was highest at the first round (89.0%; 95%CI: 85.7-91.6), ranging between 73% and 83.1% at subsequent rounds. CONCLUSIONS A faecal immunochemical test sensitivity for cancer higher than 80% resulted in a low incidence of interval colorectal cancers, representing an accurate estimate of one of the major limits of screening programmes. Due to intrinsic biases, the Proportional Interval Cancer Rate and the Interval Cancer Proportion methods generated different trends in faecal immunochemical test sensitivity by screening round.
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Affiliation(s)
- Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita, Roma, Italy
| | - Carlo Senore
- Centro Prevenzione Oncologica Regione Piemonte and Azienda Ospedaliero-Universitaria S. Giovanni Battista, Torino, Italy
| | - Giulia Capodaglio
- Screening and Health Impact Assessment Unit, Azienda Zero, Padova, Italy
| | - Anna Turrin
- Screening and Health Impact Assessment Unit, Azienda Zero, Padova, Italy
| | - Elena Narne
- Screening and Health Impact Assessment Unit, Azienda Zero, Padova, Italy
| | - Alessio Mussato
- Pathology Unit, Azienda Ospedaliera di Padova, Padova, Italy
| | | | | | | | | | - Massimo Rugge
- Veneto Tumour Registry, Azienda Zero, Padova, Italy.,Department of Medicine (DIMED), Surgical Pathology & Cytopathology Unit, University of Padova, Padova, Italy
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5
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Mancini S, Bucchi L, Giuliani O, Ravaioli A, Vattiato R, Baldacchini F, Ferretti S, Sassoli de Bianchi P, Mezzetti F, Triossi O, Serafini M, Ricci E, Palazzi M, Imolesi C, Giovanardi M, Canuti D, Voci C, Altini M, Falcini F. Proportional incidence of interval colorectal cancer in a large population-based faecal immunochemical test screening programme. Dig Liver Dis 2020; 52:452-456. [PMID: 32165075 DOI: 10.1016/j.dld.2020.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/23/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The European guidelines for quality assurance in colorectal cancer (CRC) screening recommend that interval cancer rate be expressed as a proportion of background incidence rate. AIM To determine the crude and adjusted proportional incidence of interval CRC in an Italian regional two-yearly faecal immunochemical test (FIT) screening programme. METHODS The programme (year of implementation, 2005) is targeted at over 1,000,000 people aged 50-69 years. The test is a one-sample OC-Sensor (Eiken Chemical Co., Tokyo, Japan). The study covered one-third of the regional area. Excerpts of 434,295 eligible negative FIT records dated 2005-2012 from 193,193 subjects were retrieved from the regional CRC screening data warehouse. By 31 December 2013, the cohort accumulated 198,302 man-years and 235,370 woman-years. Interval CRCs were identified by record-linkage with the local population-based cancer registry. Their number was divided by the expected number, estimated with age-period-cohort models, to obtain the proportional incidence. RESULTS The proportional incidence of interval CRC for men and women was, respectively, 0.06 (95% confidence interval (CI), 0.04-0.09) and 0.17 (95% CI, 0.13-0.23) in the first interval year, and 0.21 (95% CI, 0.16-0.26) and 0.28 (95% CI, 0.22-0.36) in the second year. CONCLUSIONS The results were acceptable and in line with previous studies.
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Affiliation(s)
- Silvia Mancini
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy
| | - Lauro Bucchi
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy.
| | - Orietta Giuliani
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy
| | - Alessandra Ravaioli
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy
| | - Rosa Vattiato
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy
| | - Flavia Baldacchini
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy
| | - Stefano Ferretti
- University of Ferrara and Local Health Authority, Ferrara, Italy
| | | | - Francesca Mezzetti
- Department of Health, Emilia-Romagna Regional Administration, Bologna, Italy
| | - Omero Triossi
- Cancer Screening Unit, Local Health Authority, Ravenna, Italy
| | - Monica Serafini
- Cancer Screening Unit, Local Health Authority, Ravenna, Italy
| | - Enrico Ricci
- Department of Gastroenterology and Digestive Endoscopy, Local Health Authority, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Mauro Palazzi
- Cancer Screening Unit, Local Health Authority, Cesena, Italy
| | - Claudia Imolesi
- Cancer Screening Unit, Local Health Authority, Cesena, Italy
| | | | - Debora Canuti
- Cancer Screening Unit, Local Health Authority, Rimini, Italy
| | - Claudio Voci
- Servizio ICT, Tecnologie e Strutture Sanitarie, Department of Health, Emilia-Romagna Regional Administration, Bologna, Italy
| | - Mattia Altini
- Healthcare Administration, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy
| | - Fabio Falcini
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRST, IRCCS, Meldola, Italy; Cancer Prevention Unit, Local Health Authority, Forlì, Italy
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6
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Senore C, Zappa M, Campari C, Crotta S, Armaroli P, Arrigoni A, Cassoni P, Colla R, Fracchia M, Gili F, Grazzini G, Lolli R, Menozzi P, Orione L, Polizzi S, Rapi S, Riggi E, Rubeca T, Sassatelli R, Visioli C, Segnan N. Faecal haemoglobin concentration among subjects with negative FIT results is associated with the detection rate of neoplasia at subsequent rounds: a prospective study in the context of population based screening programmes in Italy. Gut 2020; 69:523-530. [PMID: 31455608 DOI: 10.1136/gutjnl-2018-318198] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 08/07/2019] [Accepted: 08/11/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To estimate the predictive role of faecal haemoglobin (f-Hb) concentration among subjects with faecal immunochemical test (FIT) results below the positivity cut-off for the subsequent risk of advanced neoplasia (AN: colorectal cancer-CRC-or advanced adenoma). DESIGN Prospective cohort of subjects aged 50-69 years, undergoing their first FIT between 1 January 2004 and 31 December 2010 in four population-based programmes in Italy. METHODS All programmes adopted the same analytical procedure (OC Sensor, Eiken Japan), performed every 2 years, on a single sample, with the same positivity cut-off (20 µg Hb/g faeces). We assessed the AN risk at subsequent exams, the cumulative AN detection rate (DR) over the 4-year period following the second FIT and the interval CRC (IC) risk following two negative FITs by cumulative amount of f-Hb concentration over two consecutive negative FITs, using multivariable logistic regression models and the Kaplan-Meier method. RESULTS The cumulative probability of a positive FIT result over the subsequent two rounds ranged between 7.8% (95% CI 7.5 to 8.2) for subjects with undetectable f-Hb at the initial two tests (50% of the screenees) and 48.4% (95% CI 44.0 to 53.0) among those (0.7% of the screenees) with a cumulative f-Hb concentration ≥20 µg/g faeces. The corresponding figures for cumulative DR were: 1.4% (95% CI 1.3 to 1.6) and 25.5% (95% CI 21.4 to 30.2) for AN; 0.17% (95% CI 0.12 to 0.23) and 4.5% (95% CI 2.8 to 7.1) for CRC. IC risk was also associated with cumulative f-Hb levels. CONCLUSION The association of cumulative f-Hb concentration with subsequent AN and IC risk may allow to design tailored strategies to optimise the utilisation of endoscopy resources: subjects with cumulative f-Hb concentration ≥20 µg/g faeces over two negative tests could be referred immediately for total colonoscopy (TC), while screening interval might be extended for those with undetectable f-Hb.
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Affiliation(s)
- Carlo Senore
- SSD Epidemiologia e screening - CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Marco Zappa
- Clinical Epidemiology Unit, ISPRO, Florence, Italy
| | - Cinzia Campari
- Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Paola Armaroli
- SSD Epidemiologia e screening - CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Arrigo Arrigoni
- University Gastroenterology Unit, Ospedale San Giovanni Antica Sede, Turin, Italy
| | - Paola Cassoni
- Department of Medical Sciences, Universita degli Studi di Torino, Turin, Italy
| | - Rossana Colla
- Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Mario Fracchia
- Gastroenterology Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Fabrizio Gili
- Colorectal Cancer Screening Laboratory, University Hospital Città della Salute e della Scienza, Turin, Italy
| | | | - Roberto Lolli
- Gastroenterology Unit, Regional Hospital, Aosta, Italy
| | | | | | | | | | - Emilia Riggi
- SSD Epidemiologia e screening - CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
| | | | | | | | - Nereo Segnan
- SSD Epidemiologia e screening - CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
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7
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Selby K, Levine EH, Doan C, Gies A, Brenner H, Quesenberry C, Lee JK, Corley DA. Effect of Sex, Age, and Positivity Threshold on Fecal Immunochemical Test Accuracy: A Systematic Review and Meta-analysis. Gastroenterology 2019; 157:1494-1505. [PMID: 31472152 PMCID: PMC6878177 DOI: 10.1053/j.gastro.2019.08.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/18/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Quantitative fecal immunochemical tests (FITs) for hemoglobin are commonly used for colorectal cancer (CRC) screening. We aimed to quantify the change in CRC and advanced adenoma detection and number of positive test results at different positivity thresholds and by sex and age. METHODS We searched MEDLINE and EMBASE, selecting articles of FIT for CRC detection in asymptomatic adults undergoing screening. We calculated sensitivity and specificity, as well as detected number of cancers, advanced adenomas, and positive test results at positivity thresholds ≤10 μg hemoglobin/g feces, 10 to ≤20 μg/g, 20 to ≤30 μg/g, and >30 μg/g. We also analyzed results from stratified by patient sex, age, and reference standard. RESULTS Our meta-analysis comprised 46 studies with 2.4 million participants and 6478 detected cancers. Sensitivity for detection of CRC increased from 69% (95% confidence interval [CI], 63%-75%) at thresholds >10 μg/g and ≤20 μg/g to 80% (95% CI, 76%-83%) at thresholds ≤10 μg/g. At these threshold values, sensitivity for detection of advanced adenomas increased from 21% (95% CI, 18%-25%) to 31% (95% CI, 27%-35%), whereas specificity decreased from 94% (95% CI, 93%-96%) to 91% (95% CI, 89%-93%). In 3 studies stratified by sex, sensitivity of CRC detection was 77% in men (95% CI, 75%-79%) and 81% in women (95% CI, 60%-100%) (P = .68). In 3 studies stratified by age groups, sensitivity of CRC detection was 85% for ages 50-59 years (95% CI, 71%-99%) and 73% for ages 60-69 years (95% CI, 71%-75%) (P = .10). All studies with colonoscopy follow-up had similar sensitivity levels for detection of CRC to studies that analyzed 2-year registry follow-up data (74%; 95% CI, 68%-78% vs 75%; 95% CI, 73%-77%). CONCLUSIONS In a meta-analysis of studies that analyzed detection of CRC and advanced adenomas at different FIT positivity thresholds, we found the sensitivity and specificity of detection to vary with positive cutoff value. It might be possible to decrease positive threshold values for centers with sufficient follow-up colonoscopy resources. More research is needed to precisely establish FIT thresholds for each sex and age subgroup. PROTOCOL PROSPERO CRD42017068760.
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Affiliation(s)
- Kevin Selby
- Kaiser Permanente Division of Research, Oakland, California; Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland.
| | | | - Cecilia Doan
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, California
| | - Anton Gies
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany,Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Hermann Brenner
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | | | - Jeffrey K. Lee
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, California
| | - Douglas A. Corley
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, California
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Zorzi M, Capodaglio G, Rugge M. Interval Cancers in Colorectal Cancer Screening Programs. Gastroenterology 2018; 154:762-763. [PMID: 29353601 DOI: 10.1053/j.gastro.2017.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/17/2017] [Accepted: 09/22/2017] [Indexed: 12/02/2022]
Affiliation(s)
| | | | - Massimo Rugge
- Department of Medicine (DIMED), University of Padua and Veneto Tumor Registry, Veneto Region, Padua, Italy
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9
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Giorgi Rossi P, Carretta E, Mangone L, Baracco S, Serraino D, Zorzi M. Incidence of interval cancers in faecal immunochemical test colorectal screening programmes in Italy. J Med Screen 2017; 25:32-39. [DOI: 10.1177/0969141316686391] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective In Italy, colorectal screening programmes using the faecal immunochemical test from ages 50 to 69 every two years have been in place since 2005. We aimed to measure the incidence of interval cancers in the two years after a negative faecal immunochemical test, and compare this with the pre-screening incidence of colorectal cancer. Methods Using data on colorectal cancers diagnosed in Italy from 2000 to 2008 collected by cancer registries in areas with active screening programmes, we identified cases that occurred within 24 months of negative screening tests. We used the number of tests with a negative result as a denominator, grouped by age and sex. Proportional incidence was calculated for the first and second year after screening. Results Among 579,176 and 226,738 persons with negative test results followed up at 12 and 24 months, respectively, we identified 100 interval cancers in the first year and 70 in the second year. The proportional incidence was 13% (95% confidence interval 10–15) and 23% (95% confidence interval 18–25), respectively. The estimate for the two-year incidence is 18%, which was slightly higher in females (22%; 95% confidence interval 17–26), and for proximal colon (22%; 95% confidence interval 16–28). Conclusion The incidence of interval cancers in the two years after a negative faecal immunochemical test in routine population-based colorectal cancer screening was less than one-fifth of the expected incidence. This is direct evidence that the faecal immunochemical test-based screening programme protocol has high sensitivity for cancers that will become symptomatic.
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Affiliation(s)
- Paolo Giorgi Rossi
- Servizio Interaziendale di Epidemiologia AUSL di Reggio Emilia, Italy
- Arcispedale S. Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Elisa Carretta
- Servizio Interaziendale di Epidemiologia AUSL di Reggio Emilia, Italy
- Arcispedale S. Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Lucia Mangone
- Servizio Interaziendale di Epidemiologia AUSL di Reggio Emilia, Italy
- Arcispedale S. Maria Nuova, IRCCS, Reggio Emilia, Italy
| | | | - Diego Serraino
- SOC Epidemiologia e Biostatistica, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano (PN), Italy
| | - Manuel Zorzi
- Registro Tumori del Veneto, Regione Veneto, Padova, Italy
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Molina R, Marrades RM, Augé JM, Escudero JM, Viñolas N, Reguart N, Ramirez J, Filella X, Molins L, Agustí A. Assessment of a Combined Panel of Six Serum Tumor Markers for Lung Cancer. Am J Respir Crit Care Med 2016; 193:427-37. [DOI: 10.1164/rccm.201404-0603oc] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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11
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Developments in Screening Tests and Strategies for Colorectal Cancer. BIOMED RESEARCH INTERNATIONAL 2015; 2015:326728. [PMID: 26504799 PMCID: PMC4609363 DOI: 10.1155/2015/326728] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/19/2015] [Accepted: 04/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Worldwide, colorectal cancer (CRC) is the third most common cancer in men and second most common in women. It is the fourth most common cause of cancer mortality. In the United States, CRC is the third most common cause of cancer and second most common cause of cancer mortality. Incidence and mortality rates have steadily fallen, primarily due to widespread screening. METHODS We conducted keyword searches on PubMed in four categories of CRC screening: stool, endoscopic, radiologic, and serum, as well as news searches in Medscape and Google News. RESULTS Colonoscopy is the gold standard for CRC screening and the most common method in the United States. Technological improvements continue to be made, including the promising "third-eye retroscope." Fecal occult blood remains widely used, particularly outside the United States. The first at-home screen, a fecal DNA screen, has also recently been approved. Radiological methods are effective but seldom used due to cost and other factors. Serum tests are largely experimental, although at least one is moving closer to market. CONCLUSIONS Colonoscopy is likely to remain the most popular screening modality for the immediate future, although its shortcomings will continue to spur innovation in a variety of modalities.
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Chiang TH, Chuang SL, Chen SLS, Chiu HM, Yen AMF, Chiu SYH, Fann JCY, Chou CK, Lee YC, Wu MS, Chen HH. Difference in performance of fecal immunochemical tests with the same hemoglobin cutoff concentration in a nationwide colorectal cancer screening program. Gastroenterology 2014; 147:1317-26. [PMID: 25200099 DOI: 10.1053/j.gastro.2014.08.043] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/08/2014] [Accepted: 08/27/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS We investigated whether 2 quantitative fecal immunochemical tests (FITs) with the same cutoff concentration of fecal hemoglobin perform equivalently in identifying patients with colorectal cancer (CRC). METHODS A total of 956,005 Taiwanese subjects, 50 to 69 years old, participated in a nationwide CRC screening program to compare results from 2 FITs; 78% were tested using the OC-Sensor (n = 747,076; Eiken Chemical Co, Tokyo, Japan) and 22% were tested using the HM-Jack (n = 208,929; Kyowa Medex Co Ltd, Tokyo, Japan), from 2004 through 2009. The cutoff concentration for a positive finding was 20 μg hemoglobin/g feces, based on a standardized reporting unit system. The tests were compared using short-term and long-term indicators of performance. RESULTS The OC-Sensor test detected CRC in 0.21% of patients, with a positive predictive value of 6.8%. The HM-Jack test detected CRC in 0.17% of patients, with a positive predictive value of 5.2%. The rate of interval cancer rate was 30.7/100,000 person-years among subjects receiving the OC-Sensor test and 40.6/100,000 person-years among those receiving the HM-Jack test; there was significant difference in test sensitivity (80% vs 68%, P = .005) that was related to the detectability of proximal CRC. After adjusting for differences in city/county, age, sex, ambient temperature, and colonoscopy quality, significant differences were observed between the tests in the positive predictive value for cancer detection (adjusted relative risk = 1.29; 95% confidence interval, 1.14-1.46) and the rates of interval cancer (0.75; 95% confidence interval, 0.62-0.92). Although each test was estimated to reduce CRC mortality by approximately 10%, no significant difference in mortality was observed when the 2 groups were compared. CONCLUSIONS Different brands of quantitative FITs, even with the same cutoff hemoglobin concentration, perform differently in mass screening. Population-level data should be gathered to verify the credibility of quantitative laboratory findings.
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Affiliation(s)
- Tsung-Hsien Chiang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Lin Chuang
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Sam Li-Sheng Chen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sherry Yueh-Hsia Chiu
- Department and Graduate Institute of Health Care Management, Chang Gung University, Tao-Yuan, Taiwan
| | | | - Chu-Kuang Chou
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Yi-Chia Lee
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Ming-Shiang Wu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
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Shin A, Choi KS, Jun JK, Noh DK, Suh M, Jung KW, Kim BC, Oh JH, Park EC. Validity of fecal occult blood test in the national cancer screening program, Korea. PLoS One 2013; 8:e79292. [PMID: 24260189 PMCID: PMC3832630 DOI: 10.1371/journal.pone.0079292] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 09/22/2013] [Indexed: 12/12/2022] Open
Abstract
AIM The aims of the current study were to assess the validity of the fecal occult blood test (FOBT) in an organized screening setting in Korea and to determine factors associated with FOBT validity, such as screening round, age group, and anatomical location of the cancer. METHODS Study participants were those who were 50 years and older who received an FOBT through the National Cancer Screening Program between 2004 and 2007. Colorectal cancer diagnoses were ascertained through linkage with the Korean National Cancer Incidence Database. The positivity rate, colorectal cancer detection rate, interval cancer rate, sensitivity, specificity, and positive predictive value of the FOBT were calculated. RESULTS A total of 2,193,093 tests were included in the analysis. Overall, the sensitivity of the FOBT for colorectal cancer was 59.7% for the first round and 56.1% for the subsequent round. Sensitivity was highest for distal colon cancer (65.9%) in the first round, and for rectal cancer (58.4%) for the subsequent round. The sensitivity and positive predictive value of the FOBT generally improved between 2004 and 2008. CONCLUSIONS The FOBT showed reasonable validity in an organized screening setting, and the validity of the FOBT varied by screening round, anatomical location, and screening year.
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Affiliation(s)
- Aesun Shin
- Molecular Epidemiology Branch, Research Institute, National Cancer Center, Goyang-si, Korea
- Cancer Registration & Statistics Branch, National Cancer Control Institute, National Cancer Center, Goyang-si, Korea
| | - Kui Son Choi
- Cancer Early Detection Branch, National Cancer Control Institute, National Cancer Center, Goyang-si, Korea
| | - Jae Kwan Jun
- Cancer Early Detection Branch, National Cancer Control Institute, National Cancer Center, Goyang-si, Korea
| | - Dai Keun Noh
- Cancer Early Detection Branch, National Cancer Control Institute, National Cancer Center, Goyang-si, Korea
| | - Mina Suh
- Cancer Early Detection Branch, National Cancer Control Institute, National Cancer Center, Goyang-si, Korea
| | - Kyu-Won Jung
- Cancer Registration & Statistics Branch, National Cancer Control Institute, National Cancer Center, Goyang-si, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Hospital, National Cancer Center, Goyang-si, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Hospital, National Cancer Center, Goyang-si, Korea
| | - Eun-Cheol Park
- Department of Preventive Medicine & Institute of Health Services Research, Yonsei University, Seoul, Korea
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14
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Raginel T, Puvinel J, Ferrand O, Bouvier V, Levillain R, Ruiz A, Lantieri O, Launoy G, Guittet L. A population-based comparison of immunochemical fecal occult blood tests for colorectal cancer screening. Gastroenterology 2013; 144:918-25. [PMID: 23376426 DOI: 10.1053/j.gastro.2013.01.042] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 01/17/2013] [Accepted: 01/22/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Quantitative fecal immunochemical tests (FITs) identify individuals with colorectal cancer with greater levels of accuracy than guaiac tests. We compared the performances of 2 FITs in a population undergoing screening for colorectal cancer. METHODS We collected fecal samples from 19,797 individuals in France (age, 50-74 y) who participated in a colorectal cancer screening program, from June 2009 through May 2011. Samples were analyzed using the Magstream (Fujirebio Inc, Tokyo, Japan) and OC Sensor (Eiken Chemical Co, Tokyo, Japan) (2 samples each) FITs, as well as the Hemoccult II guaiac test (SKD, Villepinte, France) (3 samples each). Colonoscopies were performed for patients with positive results from all 3 tests. The cut-off values for levels of hemoglobin in buffer and stools were 55 ng/mL and 180 μg/g for the Magstream and 150 ng/mL and 30 μg/g for the OC Sensor, respectively. Results from the FITs were compared with those from the guaiac test for cut-off values for stool samples, positivity rates, and the receiver operating characteristic curve values. The numbers needed to screen and the numbers needed to scope to detect an advanced neoplasia (cancer, adenoma ≥10 mm, or high-grade dysplasia) were calculated. RESULTS A positive test result was found in 1224 participants (6.2%); 1075 (87.8%) underwent a colonoscopy examination. Of these, 334 were found to have advanced neoplasia. Considering the cut-off values associated with the positivity rate of Hemoccult II (1.6%), the numbers needed to screen were 239 for Hemoccult II, 166 for a 1-sample Magstream FIT, and 129 for a 1-sample OC Sensor FIT; the numbers needed to scope were 3.3, 2.3, and 1.8, respectively. For the same false-positive rate as Hemoccult II (0.98%), the true-positive rates for Magstream and OC Sensor FITs were 0.65% and 0.90% respectively, compared with 0.42% for Hemoccult II. The OC Sensor FIT had a greater area under the receiver operating characteristic curve value than the Magstream FIT. CONCLUSIONS Based on results from a large, population-based study, the OC Sensor FIT identifies patients with colorectal cancer with greater accuracy than the Magstream FIT. ClinicalTrials.gov number: NCT01251666.
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Affiliation(s)
- Thibaut Raginel
- Centre Hospitalier Universitaire (CHU) de Caen, Caen, France; Normandie University, Caen, France
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15
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Faivre J, Dancourt V, Lejeune C. Screening for colorectal cancer with immunochemical faecal occult blood tests. Dig Liver Dis 2012; 44:967-73. [PMID: 22898146 DOI: 10.1016/j.dld.2012.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/05/2012] [Indexed: 02/06/2023]
Abstract
Population-based studies have shown that guaiac faecal occult blood testing followed by colonoscopy in case of positivity can reduce colorectal cancer mortality. However these tests have been criticised for their fairly low sensitivity. For this reason attention has been given to alternative tests. The aim of this paper is to review the evidence for screening for colorectal cancer using qualitative immunochemical faecal occult blood tests. For the complete range of tested cut-off values, immunochemical faecal occult blood tests lead to higher diagnostic yield, improved sensitivity and greater participation. The optimal number of samples and the optimal cut-off value has to suit local resources and the acceptability of missed cancers. All economic evaluations, despite some differences between studies, add further arguments to support the opinion that the immunochemical faecal occult blood test is currently the most cost-effective screening test for average-risk populations. These economic evaluations provide strong arguments in favour of the 1-sample strategy. With decreasing the cut-off value similar performances can be achieved with one-compared to two day sampling. Too few data are currently available to accurately compare existing qualitative tests.
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Affiliation(s)
- Jean Faivre
- Burgundy Digestive Cancer Registry, INSERM U866, University of Burgundy, University Hospital of Dijon, Dijon Cedex, France.
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16
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Denters MJ, Deutekom M, Bossuyt PM, Stroobants AK, Fockens P, Dekker E. Lower risk of advanced neoplasia among patients with a previous negative result from a fecal test for colorectal cancer. Gastroenterology 2012; 142:497-504. [PMID: 22108194 DOI: 10.1053/j.gastro.2011.11.024] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 11/06/2011] [Accepted: 11/08/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Consecutive rounds of fecal occult blood tests (FOBTs) are used to screen for colorectal cancer (CRC); they detect precursor lesions and early-stage disease. We assessed whether the positivity rate and the positive predictive values (PPVs) for advanced neoplasia and CRC decrease with repeated testing by using fecal immunochemical tests (FITs). METHODS Data were collected from 2 rounds of screening. In the first round, average-risk persons (50 to 74 years old) were randomly assigned to groups that received the guaiac FOBT or FIT. In the second round, the subjects received only FIT (1594 received FIT after guaiac FOBT and 2022 received FIT after FIT). The positivity rate and PPV for advanced neoplasia and CRC were compared between second-round participants with a previous negative test result (FIT after guaiac FOBT or FIT after FIT) and first-round participants (guaiac FOBT or FIT). RESULTS The rate of positive results from FIT was 7.4% in the FIT-after-FIT group, compared with 8.1% in the first-round FIT group (P = .34). A significant decrease was observed in the PPV for advanced neoplasia between the first and second round from 55% (132/239) to 44% (112/252; P = .017). The PPV for CRC was 8% (20/239) in the first round versus 4% (9/252) in the second round (P = .024). Ten interval cancers were diagnosed. There were no significant differences in stages of cancers detected in the first and second round or the interval cancers. CONCLUSIONS The rate of positive results from FIT does not decrease after repeated CRC screening, but the PPVs of FIT for advanced neoplasia and for CRC are significantly lower among second-round participants who tested negative in the first round.
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Affiliation(s)
- Maaike J Denters
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
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17
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Cost-effectiveness of mass screening for colorectal cancer: choice of fecal occult blood test and screening strategy. Dis Colon Rectum 2011; 54:876-86. [PMID: 21654256 DOI: 10.1007/dcr.0b013e31820fd2bc] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal cancer is a major cause of mortality. This gives high public health priority to mass screening using a noninvasive, fecal occult blood test of asymptomatic individuals. A positive test selects those who should undergo colonoscopy to ensure early detection of colorectal cancer. Guaiac fecal occult blood test has low sensitivity. Automated immunochemical tests that measure the fecal human hemoglobin concentration are more sensitive and can be simplified as a 1- to 3-sample format with optimum cutoff points. OBJECTIVE The aim was to improve the sensitivity of the test by choosing an accurate format (1- to 3-sample and optimum hemoglobin concentration) while maintaining acceptable specificity and avoiding alteration of the screening program in terms of quality of life and economic outputs. METHODS We used a Markov model to estimate the cost-effectiveness of a screening program for a population of 100,000 asymptomatic individuals by use of immunological fecal tests with different cutoffs, leading to different sensitivity/specificity ratios, and to compare its incremental cost-effectiveness ratio compared with the guaiac fecal test program. RESULTS The results suggest that a 3-sample immunological test with 50 ng/mL as a positive cutoff is cost-effective. It provides more asymptomatic cancer detection without significantly increasing normal colonoscopies. CONCLUSION This format should be prospectively evaluated in mass screening.
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Rozen P, Comaneshter D, Levi Z, Hazazi R, Vilkin A, Maoz E, Birkenfeld S, Niv Y. Cumulative evaluation of a quantitative immunochemical fecal occult blood test to determine its optimal clinical use. Cancer 2010; 116:2115-25. [PMID: 20186820 DOI: 10.1002/cncr.25012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Quantified, human hemoglobin (Hb)-specific, immunochemical fecal occult blood test (IFOBT) measurements are now used for colorectal cancer (CRC) screening. The objective was to evaluate sensitivity and specificity for CRC and advanced adenomatous polyps (APs) by the fecal Hb threshold used to determine a positive test and the number of IFOBTs prepared per test, so as to determine the least number of colonoscopies required to detect a neoplasm. METHODS Cumulative data were analyzed from a prospective cross-sectional double-blind study of 1682 consecutive, ambulatory, nonbleeding colonoscopy patients who volunteered for IFOBTs, most of above average risk, from 3 ambulatory-endoscopy centers. Fecal Hb was measured in 3 samples and analyzed by an automated instrument, and the highest result >or=50 ng Hb/mL of buffer was related to findings. RESULTS Colonoscopy identified CRC in 20 patients and advanced APs in 129. Sensitivity for either was best when any of 3 tests had >or=50 ng Hb/mL of buffer; sensitivity was 61.1% (95% confidence interval [CI], 53.2-68.9), and specificity was 87.8% (95% CI, 86.2-89.4). Positive tests identified 100% of CRCs and 55% of advanced APs every 3.1 colonoscopies. Sensitivity of a single test at the commonly used 100-ng Hb/mL threshold was lower at 31.5% (95% CI, 24.1-39.0) (P<.001), but specificity was higher at 96.4% (95% CI, 95.5-97.3) (P<.001). Positive tests identified 65% of CRCs and 26.4% of advanced APs every 2.2 colonoscopies. CONCLUSIONS The fecal Hb cutoff chosen by the screener and the number of samples collected per patient determine sensitivity and specificity for CRC/advanced AP; these factors determine the number of colonoscopies needed for positive tests and neoplasia yield. This information provides guidelines for IFOBT screening. Limitations are 1-time screening and most examinees not being at average risk for CRC.
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Affiliation(s)
- Paul Rozen
- Gastroenterology Department, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.
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Launoy G. [Improvement in screening for colorectal cancer associated with the use of immunochemical faecal occult blood test]. PATHOLOGIE-BIOLOGIE 2009; 57:488-492. [PMID: 18834677 DOI: 10.1016/j.patbio.2008.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 07/03/2008] [Indexed: 05/26/2023]
Abstract
Faecal occult blood tests (FOBT) have been established as the most relevant procedure for colorectal cancer screening in the general average risk population. Immunochemical FOBT consists in monoclonal antibodies reacting with the globin of the haemoglobin. These tests provide higher performances than traditional guaiac tests. They do not need any diet restriction and their analytic sensitivity is higher. An increasing number of papers suggest that their acceptance and clinical performances in the general population are more satisfactory than the guaiac test. The use of automated reading allowed to cut the process price making it similar to the guaiac test. The providing of quantitative measure of haemoglobin allows to choose the positivity threshold associated with the best balance between sensitivity, specificity and positivity rate. Comparative studies conducted in France suggest the use of a positivity threshold allowing an increase in both sensitivity and specificity compared to the guaiac tests.
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Affiliation(s)
- G Launoy
- Cancers & Populations, UFR médecine, CHU de Caen, 14000 Caen, France.
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Guittet L, Bouvier V, Mariotte N, Vallee JP, Levillain R, Tichet J, Launoy G. Performance of immunochemical faecal occult blood test in colorectal cancer screening in average-risk population according to positivity threshold and number of samples. Int J Cancer 2009; 125:1127-33. [PMID: 19431212 DOI: 10.1002/ijc.24407] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Immunochemical faecal occult blood tests (I-FOBT) detect more effectively advanced neoplasia than guaiac tests (G-FOBT). The study aim was to compare the performance of an I-FOBT whilst varying the positivity threshold and considering four analysis modalities: one sample was performed (MG(1)), two samples were performed and at least one sample was positive (MG(2+)), both samples were positive (MG(2++)) or the mean of the two samples' log-transformed haemoglobin contents exceeded the cutoff (MG(2m)). Screening for colorectal cancer using both G-FOBT and two samples' I-FOBT was performed by an average-risk population sample of 20,322 subjects. Among the 1,615 subjects with at least one positive test, 1,277 had a satisfactory colonoscopy result; 43 invasive cancers and 270 high-risk adenomas were detected. The I-FOBT was reinterpreted under each analysis modality (a random selection of one sample led to MG(1)). For all modalities, increasing the positivity threshold decreased sensitivity and increased specificity. The relative ROC curves (in reference to G-FOBT) demonstrated similar performance for MG(1) and MG(2+), and improved performance for MG(2m). MG(2++) sensitivity was limited within the range of positivity thresholds evaluated. For any specificity, MG(2m) provided the highest sensitivity. For any sensitivity, MG(2m) provided the highest specificity. For any positivity rate, MG(2m) provided both the highest sensitivity and specificity. This study suggests the replacement of MG(2+) by MG(1) or, for even better performance, by MG(2m) provided that two samples are performed with similar participation (which should be explored). The targeted positivity rate could then be achieved by choosing the positivity threshold.
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Affiliation(s)
- Lydia Guittet
- Cancers & Populations, ERI INSERM, UFR Médecine, CHU, Caen, France.
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Rozen P, Levi Z, Hazazi R, Waked A, Vilkin A, Maoz E, Birkenfeld S, Leshno M, Niv Y. Identification of colorectal adenomas by a quantitative immunochemical faecal occult blood screening test depends on adenoma characteristics, development threshold used and number of tests performed. Aliment Pharmacol Ther 2009; 29:906-17. [PMID: 19183147 DOI: 10.1111/j.1365-2036.2009.03946.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Faecal occult blood tests (FOBT) are faulted by low sensitivity for advanced adenomatous polyps (AAP). Quantified, immunochemical, haemoglobin (Hb)-specific immunochemical FOBT (I-FOBT) measurements are now used for colorectal screening. AIMS To correlate adenoma characteristics to amount of faecal Hb lost and to evaluate sensitivity and specificity for AAP by faecal Hb development threshold used and number of I-FOBTs collected. METHODS Three daily I-FOBTs were collected and analysed in 1221 patients scheduled for colonoscopy. Faecal Hb was analysed as ngHb/mL of buffer and the highest result related to colonoscopy findings. RESULTS In 1204 patients without cancer, colonoscopy identified adenomas in 294, 99 with AAPs. Adenoma patients had elevated faecal Hb increasing with advanced histology, size, pedunculated shape and multiplicity (P < 0.001 for all). At 50 ngHb/mL threshold, sensitivity and specificity for AAPs were 54.5% (95%CI 44.7, 64.7) and 88.1% (95%CI 86.2, 90.1) for three tests. At higher thresholds, sensitivity decreased, but was significantly higher with more samples collected. Conversely, specificity increased at higher thresholds, but decreased with more samples. CONCLUSIONS Faecal Hb loss from adenomas is significantly associated with size, number and advanced features. Sensitivity and specificity for AAPs are determined by test threshold chosen and number of samples collected; these determine the number of colonoscopies needed for positive tests.
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Affiliation(s)
- P Rozen
- Gastroenterology Department, Rabin Medical Center, Beilinson Hospital, Petach Tikva.
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Guittet L, Bouvier V, Mariotte N, Vallee JP, Levillain R, Tichet J, Launoy G. Comparison of a guaiac and an immunochemical faecal occult blood test for the detection of colonic lesions according to lesion type and location. Br J Cancer 2009; 100:1230-5. [PMID: 19337253 PMCID: PMC2676539 DOI: 10.1038/sj.bjc.6604996] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We investigated variations in sensitivity of an immunochemical (I-FOBT) and a guaiac (G-FOBT) faecal occult blood test according to type and location of lesions in an average-risk 50- to 74-year-old population. Screening for colorectal cancer by both non-rehydrated Haemoccult II G-FOBT and Magstream I-FOBT was proposed to a sample of 20 322 subjects. Of the 1615 subjects with at least one positive test, colonoscopy results were available for 1277. A total of 43 invasive cancers and 270 high-risk adenomas were detected. The gain in sensitivity associated with the I-FOBT was calculated using the ratio of sensitivities (RSN) according to type and location of lesions, and amount of bleeding. The gain in sensitivity by using I-FOBT increased from invasive cancers (RSN=1.48 (1.16–4.59)) to high-risk adenomas (RSN=3.32 (2.70–4.07)), and was inversely related to the amount of bleeding. Among cancers, the gain in sensitivity was confined to rectal cancer (RSN=2.09 (1.36–3.20)) and concerned good prognosis cancers, because they involve less bleeding. Among high-risk adenomas, the gain in sensitivity was similar whatever the location. This study suggests that the gain in sensitivity by using an I-FOBT instead of a G-FOBT greatly depends on the location of lesions and the amount of bleeding. Concerning cancer, the gain seems to be confined to rectal cancer.
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Affiliation(s)
- L Guittet
- Cancers and Populations, ERI3 INSERM, UFR de Médecine, CHU de Caen, Caen, France.
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Grazzini G, Ciatto S, Cislaghi C, Castiglione G, Falcone M, Mantellini P, Zappa M. Cost evaluation in a colorectal cancer screening programme by faecal occult blood test in the District of Florence. J Med Screen 2009; 15:175-81. [PMID: 19106257 DOI: 10.1258/jms.2008.008032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate the direct costs of first and repeat colorectal cancer screening by immunochemical faecal occult blood testing (I-FOBT). METHODS Florence district residents aged 50-70 were invited to undergo one-time I-FOBT every two years. Full colonoscopy was recommended for FOBT-positive subjects. Direct cost analysis was carried out separately for the first and repeat screening. All relevant resources consumed by the programme were calculated. RESULTS Among 25,428 or 62,369 subjects invited to the first or repeat screening, respectively, the corresponding participation rate was 47.8% or 52.3%, and the positivity rate was 4.4% and 3.3%. Corresponding detection rates and positive predictive values for cancer and advanced adenoma were 11.3% or 8.9% and 32.4% or 32.8%, respectively. The assessment phase accounted for the major cost, as compared with recruitment and screening. All cost indicators were slightly higher in the first screening compared with repeat screening. Cost per cancer and advanced adenoma detected was similar in the first or repeat screening. A higher than observed participation rate would have substantially reduced screening cost. CONCLUSION Analysis of I-FOBT-organized population-based screening cost demonstrates lower cost at repeat compared with first screening and provides reference for decision-making in screening implementation.
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Affiliation(s)
- Grazia Grazzini
- ISPO Cancer Prevention and Research Institute Florence, Istituto Tumori Toscano, Viale A. Volta 171, 50131 Firenze, Italy.
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Rozen P, Levi Z, Hazazi R, Waked A, Vilkin A, Maoz E, Birkenfeld S, Niv Y. Quantitative colonoscopic evaluation of relative efficiencies of an immunochemical faecal occult blood test and a sensitive guaiac test for detecting significant colorectal neoplasms. Aliment Pharmacol Ther 2009; 29:450-7. [PMID: 19035980 DOI: 10.1111/j.1365-2036.2008.03898.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The guaiac faecal occult blood test (G-FOBT), HemoccultSENSA, is sensitive for significant neoplasms [colorectal cancer (CRC), advanced adenomatous polyps (AAP)], but faulted by non-specificity for human haemoglobin (Hb). Quantified, Hb- specific, immunochemical faecal occult blood tests (I-FOBT) are now used. AIMS To (i) compare I-FOBT and G-FOBT efficacy in identifying significant neoplasms and colonoscopy needs for positive tests and (ii) examine number of I-FOBTs needed and test threshold to use for equivalent or better sensitivity than G-FOBT and fewest colonoscopies for positive tests. METHODS Three daily G-FOBTs and I-FOBTs were collected and analysed in 330 patients scheduled for colonoscopy. RESULTS Colonoscopy found significant neoplasms in 32 patients, 6 CRC, 26 AAP. G-FOBT, sensitivity and specificity were 53.1% (17 neoplasms) and 59.4%, resulting in 8.1 colonoscopies/neoplasm. One I-FOBT having >or=50 ngHb/mL of buffer provided equivalent sensitivity but 94.0% specificity, resulting in 2.1 colonoscopies/neoplasm. By analysing the higher of two I-FOBTs at 50 ngHb/mL threshold, sensitivity increased to 68.8% (22 neoplasms, P = 0.063), specificity fell to 91.9% (P < 0.001), but still required 2.1 colonoscopies/neoplasm. CONCLUSIONS In this population, quantified I-FOBT had significantly better specificity than G-FOBT for significant neoplasms, reducing the number of colonoscopies needed/neoplasm detected. Results depend on the number of I-FOBTs performed and the chosen development threshold.
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Affiliation(s)
- P Rozen
- Gastroenterology Department, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.
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