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Tibbs RE, Benton SC. A service evaluation of the use of faecal immunochemical tests in symptomatic patients aged under 50 years presenting to primary care. Ann Clin Biochem 2024; 61:48-54. [PMID: 37414413 DOI: 10.1177/00045632231189386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Most colorectal cancers (CRCs) occur in individuals aged over 50 years; however, the incidence in younger age groups is increasing. Diagnosis in younger patients is frequently delayed due to non-specific symptoms and the relative frequency of benign disease. There is a need to identify patients who warrant further investigation for CRC. This study reviewed whether a faecal haemoglobin (f-Hb) ≥10 μg Hb/g faeces measured by the faecal immunochemical test for f-Hb (FIT) was associated with CRC in a local primary care population aged under 50 years. METHODS f-Hb results from symptomatic patients aged 18-49 years presenting to primary care during a 17-month period were extracted from local laboratory information systems. Colonoscopy lists were obtained from three local trusts. The Somerset Cancer Registry was searched to identify CRCs. f-Hb and outcomes were matched using NHS numbers. RESULTS A total of 3119 patients were included (median age 41 years); 313 of 2682 patients with f-Hb <10 μg/g (11.7%) and 305 of 437 patients with f-Hb ≥10 μg/g (69.8%) underwent colonoscopy. Twelve CRCs were detected. At a cut-off of 10 μg/g, the positivity rate was 14.0%, sensitivity was 100% (75.8-100%), specificity was 86.3% (85.1-87.5%), positive predictive value (PPV) was 2.7% (2.5-3.0%) and negative predictive value (NPV) was 100%. At a cut-off of 150 μg/g, sensitivity was 83.3% (55.2-95.3%), specificity was 95.2% (94.4-95.9%), PPV was 6.2% (4.7-8.2%) and NPV was 99.9% (99.8-100%). CONCLUSION Our data supports the use of FIT to triage patients aged under 50 years presenting to primary care with symptoms suggestive of CRCs.
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Affiliation(s)
- Rebecca E Tibbs
- Department of Clinical Biochemistry, Berkshire and Surrey Pathology Services, Royal Surrey County Hospital, Guildford, UK
- NHS Bowel Cancer Screening Programme Southern Hub, Surrey Research Park, Guildford, UK
| | - Sally C Benton
- Department of Clinical Biochemistry, Berkshire and Surrey Pathology Services, Royal Surrey County Hospital, Guildford, UK
- NHS Bowel Cancer Screening Programme Southern Hub, Surrey Research Park, Guildford, UK
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2
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Hampton JS, Kenny RP, Rees CJ, Hamilton W, Eastaugh C, Richmond C, Sharp L. The performance of FIT-based and other risk prediction models for colorectal neoplasia in symptomatic patients: a systematic review. EClinicalMedicine 2023; 64:102204. [PMID: 37781155 PMCID: PMC10541467 DOI: 10.1016/j.eclinm.2023.102204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
Background Colorectal cancer (CRC) incidence and mortality are increasing internationally. Endoscopy services are under significant pressure with many overwhelmed. Faecal immunochemical testing (FIT) has been advocated to identify a high-risk population of symptomatic patients requiring definitive investigation by colonoscopy. Combining FIT with other factors in a risk prediction model could further improve performance in identifying those requiring investigation most urgently. We systematically reviewed performance of models predicting risk of CRC and/or advanced colorectal polyps (ACP) in symptomatic patients, with a particular focus on those models including FIT. Methods The review protocol was published on PROSPERO (CRD42022314710). Searches were conducted from database inception to April 2023 in MEDLINE, EMBASE, Cochrane libraries, SCOPUS and CINAHL. Risk of bias of each study was assessed using The Prediction study Risk Of Bias Assessment Tool. A narrative synthesis based on the guidelines for Synthesis Without Meta-Analysis was performed due to study heterogeneity. Findings We included 62 studies; 23 included FIT (n = 22) or guaiac Faecal Occult Blood Testing (n = 1) combined with one or more other variables. Twenty-one studies were conducted solely in primary care. Generally, prediction models including FIT consistently had good discriminatory ability for CRC/ACP (i.e. AUC >0.8) and performed better than models without FIT although some models without FIT also performed well. However, many studies did not present calibration and internal and external validation were limited. Two studies were rated as low risk of bias; neither model included FIT. Interpretation Risk prediction models, including and not including FIT, show promise for identifying those most at risk of colorectal neoplasia. Substantial limitations in evidence remain, including heterogeneity, high risk of bias, and lack of external validation. Further evaluation in studies adhering to gold standard methodology, in appropriate populations, is required before widespread adoption in clinical practice. Funding National Institute for Health and Care Research (NIHR) [Health Technology Assessment Programme (HTA) Programme (Project number 133852).
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Affiliation(s)
- James S. Hampton
- Population Health Sciences Institute, Newcastle University, United Kingdom
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, United Kingdom
| | - Ryan P.W. Kenny
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
| | - Colin J. Rees
- Population Health Sciences Institute, Newcastle University, United Kingdom
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, United Kingdom
| | - William Hamilton
- College of Medicine and Health, University of Exeter, United Kingdom
| | - Claire Eastaugh
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
| | - Catherine Richmond
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, United Kingdom
| | - COLOFIT Research Team
- Population Health Sciences Institute, Newcastle University, United Kingdom
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, United Kingdom
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
- College of Medicine and Health, University of Exeter, United Kingdom
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3
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Gerrard AD, Maeda Y, Miller J, Gunn F, Theodoratou E, Noble C, Porteous L, Glancy S, MacLean P, Pattenden R, Dunlop MG, Din FVN. Double faecal immunochemical testing in patients with symptoms suspicious of colorectal cancer. Br J Surg 2023; 110:471-480. [PMID: 36785496 PMCID: PMC10364540 DOI: 10.1093/bjs/znad016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Faecal immunochemical test (FIT)-directed pathways based on a single test have been implemented for symptomatic patients. However, with a single test, the sensitivity is 87 per cent at 10 µg haemoglobin (Hb) per g faeces. This aims of this study were to define the diagnostic performance of a single FIT, compared with double FIT in symptomatic populations. METHODS Two sequential prospective patient cohorts referred with symptoms from primary care were studied. Patients in cohort 1 were sent a single FIT, and those in cohort 2 received two tests in succession before investigation. All patients were investigated, regardless of having a positive or negative test (threshold 10 µg Hb per g). RESULTS In cohort 1, 2260 patients completed one FIT and investigation. The sensitivity of single FIT was 84.1 (95 per cent c.i. 73.3 to 91.8) per cent for colorectal cancer and 67.4 (61.0 to 73.4) per cent for significant bowel pathology. In cohort 2, 3426 patients completed at least one FIT, and 2637 completed both FITs and investigation. The sensitivity of double FIT was 96.6 (90.4 to 99.3) per cent for colorectal cancer and 83.0 (77.4 to 87.8) per cent for significant bowel pathology. The second FIT resulted in a 50.0 per cent reduction in cancers missed by the first FIT, and 30.0 per cent for significant bowel pathology. Correlation between faecal Hb level was only modest (rs = 0.58), and 16.8 per cent of double tests were discordant, 11.4 per cent in patients with colorectal cancer and 18.3 per cent in those with significant bowel pathology. CONCLUSION FIT in patients with high-risk symptoms twice in succession reduces missed significant colorectal pathology and has an acceptable workload impact.
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Affiliation(s)
- A D Gerrard
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
| | - Y Maeda
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Department of Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - J Miller
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
| | - F Gunn
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
| | - E Theodoratou
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - C Noble
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - L Porteous
- Lead GP for Cancer and Palliative Care, NHS Lothian, Edinburgh, UK
| | - S Glancy
- Department of Radiology, Western General Hospital, Edinburgh, UK
| | - P MacLean
- Department of Radiology, Western General Hospital, Edinburgh, UK
| | - R Pattenden
- Department of Biochemistry, Western General Hospital, Edinburgh, UK
| | - M G Dunlop
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- UK Colon Cancer Genetics Group, Medical Research Council Human Genetics Unit, Medical Research Council Institute of Genetics & Cancer, Western General Hospital, The University of Edinburgh, Edinburgh, UK
| | - F V N Din
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
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4
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Hijos-Mallada G, Saura N, Lué A, Velamazan R, Nieto R, Navarro M, Arechavaleta S, Chueca E, Gomollon F, Lanas A, Sostres C. A Point-of-Care Faecal Test Combining Four Biomarkers Allows Avoidance of Normal Colonoscopies and Prioritizes Symptomatic Patients with a High Risk of Colorectal Cancer. Cancers (Basel) 2023; 15:cancers15030721. [PMID: 36765678 PMCID: PMC9913693 DOI: 10.3390/cancers15030721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 01/26/2023] Open
Abstract
Most colonoscopies performed to evaluate gastrointestinal symptoms detect only non-relevant pathologies. We aimed to evaluate the diagnostic accuracy of a qualitative point-of-care (POC) test combining four biomarkers (haemoglobin, transferrin, calprotectin, and lactoferrin), a quantitative faecal immunochemical test (FIT) for haemoglobin, and a quantitative faecal calprotectin (FC) test in symptomatic patients prospectively recruited. Colorectal cancer (CRC), adenoma requiring surveillance, inflammatory bowel disease (IBD), microscopic colitis, and angiodysplasia were considered significant pathologies. A total of 571 patients were included. Significant pathology was diagnosed in 118 (20.7%), including 30 CRC cases (5.3%). The POC test yielded the highest negative predictive values: 94.8% for a significant pathology and 100% for CRC or IBD if the four markers turned negative (36.8% of the patients). Negative predictive values of FIT, FC, and its combination for diagnosis of a significant pathology were 88.4%, 87.6%, and 90.8%, respectively. Moreover, the positive predictive value using the POC test was 82.3% for significant pathology when all biomarkers tested positive (6% of the patients), with 70.6% of these patients diagnosed with CRC or IBD. The AUC of the POC test was 0.801 (95%CI 0.754-0.848) for the diagnosis of a significant pathology. Therefore, this POC faecal test allows the avoidance of unnecessary colonoscopies and prioritizes high risk symptomatic patients.
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Affiliation(s)
- Gonzalo Hijos-Mallada
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
- Correspondence:
| | - Nuria Saura
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
| | - Alberto Lué
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
| | - Raúl Velamazan
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
| | - Rocío Nieto
- Departamento de Medicina, Universidad de Zaragoza, 50009 Zaragoza, Spain
| | - Mercedes Navarro
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
| | | | - Eduardo Chueca
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
| | - Fernando Gomollon
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
- Departamento de Medicina, Universidad de Zaragoza, 50009 Zaragoza, Spain
- CIBER Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
- Departamento de Medicina, Universidad de Zaragoza, 50009 Zaragoza, Spain
- CIBER Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Carlos Sostres
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain
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5
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Farkas NG, Fraser CG, Maclean W, Jourdan I, Rockall T, Benton SC. Replicate and repeat faecal immunochemical tests in symptomatic patients: A systematic review. Ann Clin Biochem 2023; 60:27-36. [PMID: 35394384 DOI: 10.1177/00045632221096036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Faecal Immunochemical tests (FITs) in the assessment of patients presenting with symptoms have generally used a single sample. Little evidence pertains to the use of replicate, where a number of tests are done prior to decision-making or repeat FIT, where additional FIT are performed following clinical decision-making. Overwhelmingly, research has focussed on FIT to help identify colorectal cancer (CRC). The aim of this review is to assess the available literature concerning replicate and repeat FIT in symptomatic patients to help generate consensus and guide future research. METHODS The terms 'faecal immunochemical test' or 'FIT' were combined with 'multiple' or 'repeat'. EMBASE, Medline and PubMed database and other searches were conducted. All papers published in English were included with no exclusion date limits until November 2021. RESULTS Of the 161 initial papers screened, seven were included for review. Qualitative and quantitative FIT outcomes were assessed in the studies. The primary aims of most related to whether replicate FIT increased diagnostic yield of CRC, with colonoscopy used as the reference standard. One publication assessed the impact of a new COVID-adapted pathway on CRC detection. No consensus on replicate FIT was apparent. Some concluded that FITs may help minimise missed CRC diagnoses: others showed no increase in diagnostic yield of CRC. CONCLUSIONS Current evidence on replicate and repeat FIT is both minimal and conflicting. FIT is a superb clinical tool, but significant gaps surrounding application remain. Further studies relating to replicate and repeat FIT are required.
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Affiliation(s)
- Nicholas G Farkas
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Callum G Fraser
- Centre for Research Into Cancer Prevention and Screening, Population Health and Genomics, School of Medicine, 85326University of Dundee, Scotland, UK
| | - William Maclean
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Iain Jourdan
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Tim Rockall
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sally C Benton
- Department of Clinical Biochemistry, Royal Surrey County Hospital, Berkshire and Surrey Pathology Services, Guildford, UK.,NHS Bowel Cancer Screening South of England Hub, Berkshire and Surrey Pathology Services, Royal Surrey County Hospital, Guildford, UK
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6
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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: 34] [Impact Index Per Article: 17.0] [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.
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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
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7
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One or two faecal immunochemical tests in an organised population-based colorectal cancer screening programme in Murcia (Spain). J Med Screen 2022; 29:231-240. [PMID: 35578555 DOI: 10.1177/09691413221094919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Roll-out of population-based colorectal cancer (CRC) screening with faecal immunochemical test (FIT) is limited by availability of further investigations, particularly colonoscopy and examination of excised lesions. Our objective was to assess whether variation in number of faecal samples and threshold adjustment can optimise resource utilisation and CRC detection rate. METHODS Three different screening strategies were compared for the same FIT threshold using a quantitative FIT system: one FIT, positive when >20 µg Hb/g faeces; two FIT, positive when either was >20 µg Hb/g faeces; and two FIT, positive when the mean was >20 µg Hb/g faeces. We calculated changes in the size of population the provider could invite to screening for an equal number of screening positive results, and CRC and adenoma detected. RESULTS In our setting, Region of Murcia, south of Spain (not fully rolled out screening programme), changing the usual strategy of two FIT, positive when either to positive when the mean was >20 µg Hb/g faeces, would increase population invited by 37.81% with the same number of positive results (which would generate a CRC detection rate of 19.2%). In a fully rolled out programme, changing the strategy from one to two FIT (positive when the mean is >20 µg Hb/g faeces), would increase CRC detection rate by 4.64% with an increase of only 13.34% in positive FIT. CONCLUSIONS In a population-based CRC screening programme, smart use of number of FITs and positivity threshold can increase population invited and CRC detection without increasing the number of colonoscopies and pathological examinations needed.
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8
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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.
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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
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Abstract
INTRODUCTION Colorectal cancer (CRC) is the second leading cause of cancer-related deaths globally. Nonetheless, with early detection of CRC or its precancerous lesions, mortality, and CRC incidence can be reduced. Although colonoscopy is currently the gold standard for CRC screening and diagnosis, its invasive nature, and troublesome bowel preparation deter patient participation. Therefore, there is a need to expand the use of noninvasive or minimally invasive methods to increase patient compliance. AREAS COVERED This review summarizes advances in different methods for CRC screening, including stool bacterial and metagenomic markers, fecal proteins, genetic and epigenetic markers in blood and stools, and imaging modalities. The cost-effectiveness of these methods is also discussed. FIT is more cost-effective compared to virtual colonoscopy, mSEPT9 test, and Multitarget Stool DNA test, while the cost-effectiveness of other noninvasive methods requires further evaluation. EXPERT OPINION Recent evidence has well demonstrated the usefulness of gut microbiome and certain fecal bacterial markers in the noninvasive diagnosis of CRC and its precancerous lesions. Many of the fecal biomarkers, from host cells or the gut environment, show better diagnostic sensitivity than FIT. New screening tests based on these fecal biomarkers can be expected to replace FIT with higher cost-effectiveness in the near future.
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Affiliation(s)
- Sarah Cheuk Hei Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Jessie Qiaoyi Liang
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, Cuhk Shenzhen Research Institute, the Chinese University of Hong Kong, Shatin, Hong Kong, China
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10
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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: 7] [Impact Index Per Article: 3.5] [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.
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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
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11
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Ross FA, Park JH, Mansouri D, Combet E, Horgan PG, McMillan DC, Roxburgh CSD. The role of faecal calprotectin in diagnosis and staging of colorectal neoplasia: a systematic review and meta-analysis. BMC Gastroenterol 2022; 22:176. [PMID: 35397505 PMCID: PMC8994317 DOI: 10.1186/s12876-022-02220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The presence of inflammation is a key hallmark of cancer and, plays an important role in disease progression and survival in colorectal cancer (CRC). Calprotectin detected in the faeces is a sensitive measure of colonic inflammation. The role of FC as a diagnostic test that may categorise patients by risk of neoplasia is poorly defined. This systematic review and meta-analysis aims to characterise the relationship between elevations of FC and colorectal neoplasia. Methods A systematic review was performed using the keywords (MESH terms) and a statistical and meta-analysis was performed. Results A total of 35 studies are included in this review. CRC patients are more likely than controls to have an elevated FC OR 5.19, 95% CI 3.12–8.62, p < 0.001 with a heterogeneity (I2 = 27%). No tumour characteristics significantly correlated with FC, only stage of CRC shows signs that it may potentially correlate with FC. Conclusion FC levels are significantly higher in CRC, with high sensitivity. Its low specificity prevents it from being used to diagnose or screen for CRC. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02220-1.
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12
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Bradley C, Hee SW, Andronis L, Persaud K, Hull MA, Todd J, Taylor-Phillips S, Smith S, Constable R, Waugh N, Arasaradnam RP. REducing Colonoscopies in patients without significant bowEl DiseasE: the RECEDE Study - protocol for a prospective diagnostic accuracy study. BMJ Open 2022; 12:e058559. [PMID: 35354626 PMCID: PMC8968545 DOI: 10.1136/bmjopen-2021-058559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Demand for colonoscopies and CT colonography (CTC) is exceeding capacity in National Health Service Trusts. In many patients colonoscopies and CTCs show no significant bowel disease (SBD). Faecal Immunochemical Testing (FIT) is being introduced to prioritise patients for colonoscopies but is insufficient to identify non-SBD patients meaning colonoscopy and CTC demand remains high. The REducing Colonoscopies in patients without significant bowEl DiseasE (RECEDE) study aims to test urine volatile organic compound (VOC) analysis alongside FIT to improve detection of SBD and to reduce the number of colonoscopies and CTCs. METHODS AND ANALYSIS This is a multicentre, prospective diagnostic accuracy study evaluating whether stool FIT plus urine VOC compared with stool FIT alone improves detection of SBD in patients referred for colonoscopy or CTC due to persistent lower gastrointestinal symptoms. To ensure SBD is not missed, the dual test requires a high sensitivity, set at 97% with 95% CI width of 5%. Our assumption is that to achieve this sensitivity requires 200 participants with SBD. Further assuming 19% of all participants will have SBD and 55% of all participants will return both stool and urine samples we will recruit 1915 participants. The thresholds for FIT and VOC results diagnosing SBD have been pre-set. If either FIT or VOC exceeds the respective threshold, the participant will be classed as having suspected SBD. As an exploratory analysis we will be testing different thresholds. The reference comparator will be a complete colonoscopy or CTC. Secondary outcomes will look at optimising the FIT and VOC thresholds for SBD detection. An economic evaluation, using a denovo decision analytic model, will be carried out determine the costs, benefits and overall cost-effectiveness of FIT +VOC vs FIT followed by colonoscopy. ETHICS AND DISSEMINATION Ethical approval was obtained by Liverpool Central Research Ethics Committee (20/NW/0346). TRIAL REGISTRATION NUMBER RECEDE is registered on Clinicaltrials.gov NCT04516785 & ISRCTN14982373. This protocol was written and published before results of the trial were available.
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Affiliation(s)
- Christopher Bradley
- Research & Development, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Siew Wan Hee
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Lazaros Andronis
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Krishna Persaud
- Department of Chemical Engineering, The University of Manchester, Manchester, UK
| | - Mark A Hull
- School of Medicine, University of Leeds, Leeds, UK
| | - John Todd
- Research & Development, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Steve Smith
- Research & Development, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Bowel Cancer Screening Hub, NW Bowel Cancer Screening Hub, Hospital of St. Cross, Rugby, UK
| | - Rachel Constable
- Research & Development, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Norman Waugh
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Ramesh P Arasaradnam
- Research & Development, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
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13
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Withrow DR, Shine B, Oke J, Tamm A, James T, Morris E, Davies J, Harris S, East JE, Nicholson BD. Combining faecal immunochemical testing with blood test results for colorectal cancer risk stratification: a consecutive cohort of 16,604 patients presenting to primary care. BMC Med 2022; 20:116. [PMID: 35287679 PMCID: PMC8920746 DOI: 10.1186/s12916-022-02272-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/24/2022] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Faecal immunochemical tests (FITs) are used to triage primary care patients with symptoms that could be caused by colorectal cancer for referral to colonoscopy. The aim of this study was to determine whether combining FIT with routine blood test results could improve the performance of FIT in the primary care setting. METHODS Results of all consecutive FITs requested by primary care providers between March 2017 and December 2020 were retrieved from the Oxford University Hospitals NHS Foundation Trust. Demographic factors (age, sex), reason for referral, and results of blood tests within 90 days were also retrieved. Patients were followed up for incident colorectal cancer in linked hospital records. The sensitivity, specificity, positive and negative predictive values of FIT alone, FIT paired with blood test results, and several multivariable FIT models, were compared. RESULTS One hundred thirty-nine colorectal cancers were diagnosed (0.8%). Sensitivity and specificity of FIT alone at a threshold of 10 μg Hb/g were 92.1 and 91.5% respectively. Compared to FIT alone, blood test results did not improve the performance of FIT. Pairing blood test results with FIT increased specificity but decreased sensitivity. Multivariable models including blood tests performed similarly to FIT alone. CONCLUSIONS FIT is a highly sensitive tool for identifying higher risk individuals presenting to primary care with lower risk symptoms. Combining blood test results with FIT does not appear to lead to better discrimination for colorectal cancer than using FIT alone.
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Affiliation(s)
- Diana R Withrow
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - Brian Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation, Oxford, UK
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - Andres Tamm
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Tim James
- Department of Computer Science, Big Data Institute, University of Oxford, Oxford, UK
| | - Eva Morris
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Jim Davies
- Department of Computer Science, Big Data Institute, University of Oxford, Oxford, UK
| | - Steve Harris
- Oxford BRC Informatics Theme, Big Data Institute, University of Oxford, Oxford, UK
| | - James E East
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
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14
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Comparison of faecal protein biomarkers' diagnostic accuracy for colorectal advanced neoplasms: a systematic review and meta-analysis. Sci Rep 2022; 12:2623. [PMID: 35173276 PMCID: PMC8850428 DOI: 10.1038/s41598-022-06689-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 02/03/2022] [Indexed: 11/16/2022] Open
Abstract
Early diagnosis of colorectal advanced neoplasms (ANs), including colorectal cancer (CRC) and advanced adenoma (AA), has a positive effect on the survival rate. As a first attempt, the aim of this meta-analysis was to compare the diagnostic accuracy of faecal protein biomarkers for the detection of colorectal neoplasms with consideration of a wide range of covariates. A systematic literature search was performed up to Jun 10, 2021 on Web of Sciences, Scopus and PubMed. The diagnostic accuracies were calculated using the bivariate/hierarchical random effect model. Biomarkers were determined to be clinically applicable (CA) if they had areas under the curve > 0.70 and positive and negative likelihood ratios > 2 and < 0.5, respectively. A total of 47,059 test results were extracted from 16 immunochemical faecal occult blood test (iFOBT), 26 pyruvate kinase-M2 (PK-M2) and 23 faecal calprotectin (FC) studies. Only iFOBT, PK-M2 and FC for CRC plus iFOBT and PK-M2 for AN were CA. iFOBT had significantly superior accuracy (P = 0.02 versus PK-M2 and P < 0.01 versus FC for CRC; P < 0.01 versus PK-M2 for AN). Regarding covariates, the lateral flow method of PK-M2 measurement increased its accuracy for CRC detection compared to the enzyme-linked immunosorbent assay (P < 0.01). iFOBT is recommended as the most accurate faecal biomarker for CRC and AN diagnosis.
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15
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Faecal immunochemical test for patients with 'high-risk' bowel symptoms: a large prospective cohort study and updated literature review. Br J Cancer 2021; 126:736-743. [PMID: 34903843 PMCID: PMC8888593 DOI: 10.1038/s41416-021-01653-x] [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: 05/18/2021] [Revised: 10/21/2021] [Accepted: 11/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background We evaluated whether faecal immunochemical testing (FIT) can rule out colorectal cancer (CRC) among patients presenting with ‘high-risk’ symptoms requiring definitive investigation. Methods Three thousand five hundred and ninety-six symptomatic patients referred to the standard urgent CRC pathway were recruited in a multi-centre observational study. They completed FIT in addition to standard investigations. CRC miss rate (percentage of CRC cases with low quantitative faecal haemoglobin [f-Hb] measurement) and specificity (percentage of patients without cancer with low f-Hb) were calculated. We also provided an updated literature review. Results Ninety patients had CRC. At f-Hb < 10 µg/g, the miss rate was 16.7% (specificity 80.1%). At f-Hb < 4 µg/g, the miss rate was 12.2% (specificity 73%), which became 3.3% if low FIT plus the absence of anaemia and abdominal pain were considered (specificity 51%). Within meta-analyses of 9 UK studies, the pooled miss rate was 7.2% (specificity 74%) for f-Hb < 4 µg/g. Discussion FIT alone as a triage tool would miss an estimated 1 in 8 cases in our study (1 in 14 from meta-analysis), while many people without CRC could avoid investigations. FIT can focus secondary care diagnostic capacity on patients most at risk of CRC, but more work on safety netting is required before incorporating FIT triage into the urgent diagnostic pathway.
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16
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Turvill JL, Turnock D, Cottingham D, Haritakis M, Jeffery L, Girdwood A, Hearfield T, Mitchell A, Keding A. The Fast Track FIT study: diagnostic accuracy of faecal immunochemical test for haemoglobin in patients with suspected colorectal cancer. Br J Gen Pract 2021; 71:e643-e651. [PMID: 33798091 PMCID: PMC8279659 DOI: 10.3399/bjgp.2020.1098] [Citation(s) in RCA: 18] [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: 12/09/2020] [Accepted: 03/24/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The faecal immunochemical test (FIT) is now available to support clinicians in the assessment of patients at low risk of colorectal cancer (CRC) and within the bowel cancer screening programme. AIM To determine the diagnostic accuracy of FIT for CRC and clinically significant disease in patients referred as they were judged by their GP to fulfil National Institute for Health and Care Excellence guideline 12 (NG12) criteria for suspected CRC. DESIGN AND SETTING Patients referred from primary care with suspected CRC, meeting NG12 criteria, to 12 secondary care providers in Yorkshire and Humber were asked to complete a FIT before investigation. METHOD The diagnostic accuracy of FIT based on final diagnosis was evaluated using receiver operating characteristics analysis. This permitted a statistically optimal cut-off value for FIT to be determined based on the maximisation of sensitivity and specificity. Clinicians and patients were blinded to the FIT results. RESULTS In total, 5040 patients were fully evaluated and CRC was detected in 151 (3.0%). An optimal cut-off value of 19 µg Hb/g faeces for CRC was determined, giving a sensitivity of 85.4% (95% confidence interval [CI] = 78.8% to 90.6%) and specificity of 85.2% (95% CI = 84.1% to 86.2%). The negative predictive value at this cut-off value was 99.5% (95% CI = 99.2% to 99.7%) and the positive predictive value 15.1% (95% CI = 12.8% to 17.7%). Sensitivity and specificity of FIT for CRC and significant premalignant polyps at this cut-off value were 62.9% (95% CI = 57.5% to 68.0%) and 86.4% (95% CI = 85.4% to 87.4%), respectively; and when including all organic enteric disease were 35.7% (95% CI = 32.9% to 38.5%) and 88.6% (95% CI = 87.5% to 89.6%), respectively. CONCLUSION FIT used in patients fulfilling NG12 criteria should allow for a more personalised CRC risk assessment. FIT should permit effective, patient-centred decision-making to inform the need for, type, and timing of further investigation.
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Affiliation(s)
- James L Turvill
- Department of Gastroenterology, York and Scarborough Teaching Hospitals NHS Foundation Trust, York
| | - Daniel Turnock
- Department of Gastroenterology, York and Scarborough Teaching Hospitals NHS Foundation Trust, York
| | - Dan Cottingham
- Macmillan GP Cancer and End of Life lead, Vale of York Clinical Commissioning Group, West Offices Station Rise, York
| | - Monica Haritakis
- Department of Research and Development, York and Scarborough Teaching Hospitals NHS Foundation Trust, York
| | - Laura Jeffery
- Department of Research and Development, York and Scarborough Teaching Hospitals NHS Foundation Trust, York
| | - Annabelle Girdwood
- Department of Research and Development, York and Scarborough Teaching Hospitals NHS Foundation Trust, York
| | - Tom Hearfield
- Department of Research and Development, York and Scarborough Teaching Hospitals NHS Foundation Trust, York
| | - Alex Mitchell
- Department of Health Sciences, Faculty of Sciences, University of York, York
| | - Ada Keding
- Department of Health Sciences, Faculty of Sciences, University of York, York
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17
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Li H, Vanarsa K, Zhang T, Soomro S, Cicalese PA, Duran V, Dasari S, Lee KH, Pedroza C, Kisiel JB, Qin H, Bresalier RS, Chia N, Mohan C. Comprehensive aptamer-based screen of 1317 proteins uncovers improved stool protein markers of colorectal cancer. J Gastroenterol 2021; 56:659-672. [PMID: 34117903 DOI: 10.1007/s00535-021-01795-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/19/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND To screen and validate novel stool protein biomarkers of colorectal cancer (CRC). METHODS A novel aptamer-based screen of 1317 proteins was used to uncover elevated proteins in the stool of patients with CRC, as compared to healthy controls (HCs) in a discovery cohort. Selected biomarker candidates from the discovery cohort were ELISA validated in three independent cross-sectional cohorts comprises 76 CRC patients, 15 adenoma patients, and 63 healthy controls, from two different ethnicities. The expression of the potential stool biomarkers within CRC tissue was evaluated using single-cell RNA-seq datasets. RESULTS A total of 92 proteins were significantly elevated in CRC samples as compared to HCs in the discovery cohort. Among Caucasians, the 5 most discriminatory proteins among the 16 selected proteins, ordered by their ability to distinguish CRC from adenoma and healthy controls, were MMP9, haptoglobin, myeloperoxidase, fibrinogen, and adiponectin. Except myeloperoxidase, the others were significantly associated with depth of tumor invasion. The 8 stool proteins with the highest AUC values were also discriminatory in a second cohort of Indian CRC patients. Several of the stool biomarkers elevated in CRC were also expressed within CRC tissue, based on the single-cell RNA-seq analysis. CONCLUSIONS Stool MMP9, fibrinogen, myeloperoxidase, and haptoglobin emerged as promising CRC stool biomarkers, outperforming stool Hemoglobin. Longitudinal studies are warranted to assess the clinical utility of these novel biomarkers in early diagnosis of CRC.
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Affiliation(s)
- Hao Li
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Biomedical Engineering, University of Houston, Houston, USA
| | - Kamala Vanarsa
- Department of Biomedical Engineering, University of Houston, Houston, USA
| | - Ting Zhang
- Department of Biomedical Engineering, University of Houston, Houston, USA
| | - Sanam Soomro
- Department of Biomedical Engineering, University of Houston, Houston, USA
| | | | - Valeria Duran
- Department of Biomedical Engineering, University of Houston, Houston, USA
| | - Shobha Dasari
- Department of Biomedical Engineering, University of Houston, Houston, USA
| | - Kyung Hyun Lee
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School, UT Health Science Center At Houston, Houston, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School, UT Health Science Center At Houston, Houston, USA
| | - John B Kisiel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA
| | - Huanlong Qin
- Department of General Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Robert S Bresalier
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Nicholas Chia
- Department of Surgical Research, Mayo Clinic, Rochester, USA
| | - Chandra Mohan
- Department of Biomedical Engineering, University of Houston, Houston, USA.
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18
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James T, Nicholson BD, Marr R, Paddon M, East JE, Justice S, Oke JL, Shine B. Faecal immunochemical testing (FIT): sources of result variation based on three years of routine testing of symptomatic patients in English primary care. Br J Biomed Sci 2021; 78:211-217. [PMID: 33627037 DOI: 10.1080/09674845.2021.1896204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: We aimed to determine the analytical capabilities of a commonly used faecal immunochemical test (FIT) to detect faecal haemoglobin (Hb) in symptomatic people attending primary care in the context of the English NICE DG30 guidance.Materials and Methods: Data obtained from independent verification studies and clinical testing of the HM-JACKarc FIT method in routine primary care practice were analysed to derive performance characteristics.Results: Detection capabilities for the FIT method were 0.5 µg/g (limit of blank), 1.3 µg/g (limit of detection) and 3.0 µg/g (limit of quantitation). Of 33 non-homogenized specimens, 31 (93.9%) analysed in triplicate were consistently categorized relative to 10 µg/g, compared to all 33 (100%) homogenized specimens. Imprecision was higher (median 27.8%, (range 20.5% to 48.6%)) in non-homogenized specimens than in homogenized specimens (10.2%, (7.0 to 13.5%)). Considerable variation was observed in sequential clinical specimens from individual patients but no positive or negative trend in specimen degradation was observed over time (p = 0.26).Discussion: The FIT immunoassay evaluated is capable of detecting faecal Hb at concentrations well below the DG30 threshold of 10 µg/g and is suitable for application in this context. The greatest practical challenge to FIT performance is reproducible sampling, the pre-analytical step associated with most variability. Further research should focus on reducing sampling variability, particularly as post-COVID-19 guidance recommends greater FIT utilization.
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Affiliation(s)
- T James
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
| | - B D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - R Marr
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
| | - M Paddon
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
| | - J E East
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - S Justice
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
| | - J L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - B Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
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19
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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 .
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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
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20
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Iron deficiency: a modern primer to diagnosis and management. Curr Opin Gastroenterol 2021; 37:121-127. [PMID: 33315792 DOI: 10.1097/mog.0000000000000702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Iron deficiency with anemia (IDA) and without anemia remain a diagnostic and management challenge. Iron deficiency has a broad spectrum of causes, including gastrointestinal malignancy. The purpose of this review is to summarize the value and limitations of current methods to diagnose iron deficiency and underline the relevance of contemporaneous evidence to guide the pretest probability of gastrointestinal disease. RECENT FINDINGS A number of biomarkers for iron deficiency exist, and all have their caveats. Serum ferritin remains the most pragmatic means of diagnosing iron deficiency. Hepcidin holds future promise as a marker of iron status during inflammatory states. Men and postmenopausal women with IDA have the highest overall prevalence of gastrointestinal malignancy (∼11%), while premenopausal women with IDA (<1.5%) and those with iron deficiency without anemia (<0.5%) have a very low risk. Noninvasive investigation with fecal immunochemical test and fecal calprotectin hold promise to guide further investigations in lower risk groups. SUMMARY Confirmation of iron deficiency remains a challenge. Appropriate risk stratification is the key to guiding judicious gastrointestinal investigation. Use of noninvasive tests may play an important role in lower risk groups. Risk prediction tools applicable to relevant populations are required.
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Högberg C, Gunnarsson U, Jansson S, Thulesius H, Cronberg O, Lilja M. Diagnosing colorectal cancer in primary care: cohort study in Sweden of qualitative faecal immunochemical tests, haemoglobin levels, and platelet counts. Br J Gen Pract 2020; 70:e843-e851. [PMID: 33139332 PMCID: PMC7643823 DOI: 10.3399/bjgp20x713465] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/13/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) diagnostics are challenging in primary care and reliable diagnostic aids are desired. Qualitative faecal immunochemical tests (FITs) have been used for suspected CRC in Sweden since the mid-2000s, but evidence regarding their effectiveness is scarce. Anaemia and thrombocytosis are both associated with CRC. AIM To evaluate the usefulness of qualitative FITs requested for symptomatic patients in primary care, alone and combined with findings of anaemia and thrombocytosis, in the diagnosis of CRC. DESIGN AND SETTING A population-based cohort study using electronic health records and data from the Swedish Cancer Register, covering five Swedish regions. METHOD Patients aged ≥18 years in the five regions who had provided FITs requested by primary care practitioners from 1 January 2015 to 31 December 2015 were identified. FIT and blood-count data were registered and all CRC diagnoses made within 2 years were retrieved. Diagnostic measurements were calculated. RESULTS In total, 15 789 patients provided FITs (four different brands); of these patients, 304 were later diagnosed with CRC. Haemoglobin levels were available for 13 863 patients, and platelet counts for 10 973 patients. Calculated for the different FIT brands only, the sensitivities for CRC were 81.6%-100%; specificities 65.7%-79.5%; positive predictive values 4.7%-8.1%; and negative predictive values 99.5%-100%. Calculated for the finding of either a positive FIT or anaemia, the sensitivities increased to 88.9-100%. Adding thrombocytosis did not further increase the diagnostic performance. CONCLUSION Qualitative FITs requested in primary care seem to be useful as rule-in tests for referral when CRC is suspected. A negative FIT and no anaemia indicate a low risk of CRC.
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Affiliation(s)
| | - Ulf Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå
| | - Stefan Jansson
- University Health Care Research Centre, Örebro University, Örebro
| | - Hans Thulesius
- Department of Clinical Sciences, Lund University, Malmö; professor of primary care, Department of Medicine and Optometry, Linnaeus University, Kalmar
| | - Olof Cronberg
- Department of Clinical Sciences, Lund University, Malmö
| | - Mikael Lilja
- Department of Public Health and Clinical Medicine
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Benton SC, Fraser CG. Faecal immunochemical tests in the COVID-19 pandemic; safety-netting of patients with symptoms and low faecal haemoglobin concentration - can a repeat test be used? Ann Clin Biochem 2020; 58:163-165. [PMID: 33016079 DOI: 10.1177/0004563220967569] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sally C Benton
- Clinical Biochemistry, Royal Surrey County Hospital/ NHS Bowel Cancer Screening South of England Hub, Berkshire and Surrey Pathology Services, Guildford, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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Marín-Gabriel JC, de Santiago ER. AEG-SEED position paper for the resumption of endoscopic activity after the peak phase of the COVID-19 pandemic. GASTROENTEROLOGÍA Y HEPATOLOGÍA (ENGLISH EDITION) 2020. [PMCID: PMC7351450 DOI: 10.1016/j.gastre.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction The COVID-19 pandemic has led to the suspension of programmed activity in most of the Endoscopy Units in our environment. The aim of this document is to facilitate the resumption of elective endoscopic activity in an efficient and safe manner. Material and methods A series of questions considered to be of clinical and logistical relevance were formulated. In order to elaborate the answers, a structured bibliographic search was carried out in the main databases and the recommendations of the main Public Health and Digestive Endoscopy institutions were reviewed. The final recommendations were agreed upon through telematic means. Results A total of 33 recommendations were made. The main aspects discussed are: 1) Reassessment and prioritization of the indication, 2) Restructuring of spaces, schedules and health personnel, 3) Screening for infection, 4) Hygiene measures and personal protective equipment. Conclusion The AEG and SEED recommend restarting endoscopic activity in a phased, safe manner, adapted to local resources and the epidemiological situation of SARS-CoV-2 infection.
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Affiliation(s)
- José Carlos Marín-Gabriel
- Servicio de Medicina del Aparato Digestivo, Unidad de Endoscopias, Consulta de Alto Riesgo, Hospital Universitario 12 de Octubre, Instituto de Investigación «i + 12», Madrid, Spain
- Corresponding author.
| | - Enrique Rodríguez de Santiago
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
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Marín-Gabriel JC, Santiago ERD. AEG-SEED position paper for the resumption of endoscopic activity after the peak phase of the COVID-19 pandemic. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:389-407. [PMID: 32561216 PMCID: PMC7250749 DOI: 10.1016/j.gastrohep.2020.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
Introducción La pandemia por COVID-19 ha conllevado la suspensión de la actividad programada en la mayoría de las Unidades de Endoscopia de nuestro medio. El objetivo del presente documento es facilitar el reinicio de la actividad endoscópica electiva de forma eficiente y segura. Material y métodos Se formuló una serie de preguntas consideradas de relevancia clínica y logística. Para la elaboración de las respuestas, se realizó una búsqueda bibliográfica estructurada en las principales bases de datos y se revisaron las recomendaciones de las principales instituciones de Salud Pública y de endoscopia digestiva. Las recomendaciones finales se consensuaron por vía telemática. Resultados Se han elaborado un total de 33 recomendaciones. Los principales aspectos que se discuten son: 1) la reevaluación y priorización de la indicación; 2) la restructuración de espacios, agendas y del personal sanitario; 3) el cribado de la infección, y 4) las medidas de higiene y los equipos de protección individual. Conclusión La AEG y la SEED recomiendan reiniciar la actividad endoscópica de forma escalonada, segura, adaptada a los recursos locales y a la situación epidemiológica de la infección por SARS-CoV-2.
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Affiliation(s)
- José Carlos Marín-Gabriel
- Servicio de Medicina del Aparato Digestivo, Unidad de Endoscopias, Consulta de Alto Riesgo, Hospital Universitario 12 de Octubre, Instituto de Investigación «i+12», Madrid, España.
| | - Enrique Rodríguez de Santiago
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, España
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Tsapournas G, Hellström PM, Cao Y, Olsson LI. Diagnostic accuracy of a quantitative faecal immunochemical test vs. symptoms suspected for colorectal cancer in patients referred for colonoscopy. Scand J Gastroenterol 2020; 55:184-192. [PMID: 31906738 DOI: 10.1080/00365521.2019.1708965] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: Determine diagnostic accuracy of a quantitative faecal immunochemical haemoglobin test (QuikRead go® FIT, Orion Diagnostica Oy) in symptomatic patients referred for colonoscopy, at various cut-offs and for one or two tests.Methods: Patients referred to four endoscopy units in mid-Sweden between 2013 and 2017 provided information on lower abdominal symptoms and faecal samples from two separate days prior to colonoscopy.Results: In all, 5.4% (13/242) patients had colorectal cancer (CRC). For one FIT at cut-off 10 µg Hb/g faeces, sensitivity for CRC was 92% (95% CI 78-100%) and specificity 77% (95% CI 72-83%); equal to 74%; 95% CI 68-80 (178/242) colonoscopies potentially avoidable and one CRC missed. Based on the maximal outcome of two FITs, sensitivity was 100%, specificity 71% (66-77%) and 68%; 95% CI 62-74 (160/237) colonoscopies potentially avoidable. Among 17% (42/242) patients with one FIT of >200 µg Hb/g faeces, 85% (11/13) had CRC. Positive predictive values of FIT varied 16.9-26.2% depending on cut-off and one or two FITs, whereas NPVs were 99% and above in all scenarios.In 60 patients reporting rectal bleeding, one FIT at cut-off 10 µg Hb/g discriminated well between CRC and other conditions (p = .001). In regression models, FIT was more important than age, sex and all symptoms.Conclusion: One or two FITs in symptomatic patients referred for colonoscopy imply powerful risk stratification abilities for CRC, even among patients reporting rectal bleeding. Larger studies in various settings will clarify how to make the best use of this opportunity. Trial registration: Clinicaltrails.gov NCT02491593.
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Affiliation(s)
| | - Per M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Sweden
| | - Louise I Olsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Camtö, Örebro University Hospital, Örebro, Sweden
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Qualitative faecal immunochemical tests (FITs) for diagnosing colorectal cancer in patients with histories of rectal bleeding in primary care: a cohort study. Int J Colorectal Dis 2020; 35:2035-2040. [PMID: 32602056 PMCID: PMC7541370 DOI: 10.1007/s00384-020-03672-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rectal bleeding is considered an alarm symptom for colorectal cancer (CRC) but it is common and mostly caused by benign conditions. Qualitative faecal immunochemical tests (FITs) for occult blood have been used as diagnostic aids for many years in Sweden when CRC is suspected. The study aimed to evaluate the usefulness of FITs requested by primary care physicians for patients with and without histories of rectal bleeding, in the diagnosis of CRC. METHODS Results of all FITs requested in primary care for symptomatic patients in the Örebro region during 2015 were retrieved. Data on each patient's history of rectal bleeding was gathered from electronic health records. Patients diagnosed with CRC within 2 years were identified from the Swedish Cancer Register. The analysis focused on three-sample FITs, the customary FIT in Sweden. RESULTS A total of 4232 patients provided three-sample FITs. Information about the presence/absence of rectal bleeding was available for 2027 patients, of which 59 were diagnosed with CRC. For 606 patients with the presence of rectal bleeding, the FIT showed sensitivity 96.2%, specificity 60.2%, positive predictive value 9.8% (95% CI 6.1-13.4) and negative predictive value 99.7% (95% CI 99.2-100) for CRC. For 1421 patients without rectal bleeding, the corresponding figures were 100%, 73.6%, 8.3% (95% CI 5.6-10.9) and 100% (95% CI 99.6-100). CONCLUSION The diagnostic performance of a qualitative three-sample FIT provided by symptomatic patients in primary care was similar for those with and without a history of rectal bleeding. FITs seem useful for prioritising patients also with rectal bleeding for further investigation.
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Abstract
Population screening and endoscopic surveillance are used widely to prevent the development of and death from colorectal cancer (CRC). However, CRC remains a major cause of cancer mortality and the increasing burden of endoscopic investigations threatens to overwhelm some health services. This Perspective describes the rationale for and approach to improved risk stratification and decision-making for CRC prevention and diagnosis. Limitations of current approaches will be discussed using the UK as an example of the challenges faced by a particular health-care system, followed by discussion of novel risk biomarker utilization. We explore how risk stratification will be advantageous to current health-care providers and users, enabling more efficient use of limited colonoscopy resources. We discuss risk stratification in the setting of population screening as well as the surveillance of high-risk groups and investigation of symptomatic patients. We also address challenges in the development and validation of risk stratification tools and identify key research priorities.
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Chuter C, Keding A, Holmes H, Turnock D, Turvill J. Getting the best out of faecal immunochemical tests and faecal calprotectin. Frontline Gastroenterol 2019; 11:414-416. [PMID: 32884634 PMCID: PMC7447280 DOI: 10.1136/flgastro-2019-101381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/09/2019] [Accepted: 12/13/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Charlotte Chuter
- Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, North Yorkshire, UK
| | - Ada Keding
- Health Sciences, University of York, York, North Yorkshire, UK
| | - Hayden Holmes
- York Health Economics Consortium, York, North Yorkshire, UK
| | - Daniel Turnock
- Biochemistry, York Teaching Hospital NHS Foundation Trust, York, North Yorkshire, UK
| | - James Turvill
- Gastroenterology, York Teaching Hospital NHS Foundation Trust, York, North Yorkshire, UK
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Chen ZR, Liu G. Fecal calprotectin and colorectal cancer. Shijie Huaren Xiaohua Zazhi 2019; 27:1436-1440. [DOI: 10.11569/wcjd.v27.i23.1436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fecal calprotectin (FC) is a bioactive protein secreted by inflammatory cells in the intestine, having anti-microbial and anti-infection activities. The content of FC reflects the inflammatory state of the intestine, and its role in inflammatory bowel disease has been translated into clinical practice. In recent years, the application of FC in colorectal cancer (CRC) has been increasing. Previous research results show that FC can be used to screen colorectal cancer and differentiate it from other intestinal diseases, and the concentration of FC may be related to the stage, location, and resectability of CRC. However, its role still needs to be further clarified through high-quality, large-sample research. This paper reviews the application of FC in colorectal cancer.
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Affiliation(s)
- Zong-Ran Chen
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Gang Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
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D'Souza N, Hicks G, Benton SC, Abulafi M. The diagnostic accuracy of the faecal immunochemical test for colorectal cancer in risk-stratified symptomatic patients. Ann R Coll Surg Engl 2019; 102:174-179. [PMID: 31697171 DOI: 10.1308/rcsann.2019.0144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The faecal immunochemical test detects blood in the faeces, reporting faecal haemoglobin quantitatively in micrograms of haemoglobin per gram of faeces. The aim of this pilot study was to determine the feasibility of using the faecal immunochemical test as a rule-out test in symptomatic patients at low and high risk of colorectal cancer. MATERIAL AND METHODS Between November 2016 and October 2017, consecutive symptomatic patients within a multicultural part of London were recruited to perform a faecal immunochemical test prior to colonoscopy. Analysis was performed on the HM-JACKarc analyser. RESULTS Faecal immunochemical test samples were returned by 298 patients who underwent colonoscopy. There was no significant variation in faecal haemoglobin levels by age, sex, ethnicity or deprivation. The overall detection rate for colorectal cancer was 100% at 2 µg/g and 92% at 10 µg/g. If a faecal haemoglobin threshold for investigation of 2 µg/g (ie detectable) or 10 µg/g had been employed, the number of colonoscopies would have been reduced by 70% and 84%, respectively, in all symptomatic patients. For low-risk patients, the sensitivity of the faecal immunochemical test for colorectal cancer at both thresholds of 2 µg/g or 10 µg/g remained 100%, with the number of colonoscopies reduced by 80% and 91%, respectively. CONCLUSION This study shows that the faecal immunochemical test is a promising technology that detected colorectal cancer in all high- or low-risk symptomatic patients in our cohort at a threshold of detectable faecal haemoglobin. Data from adequately powered cohort studies will elucidate the true diagnostic accuracy of the test and the rate and patterns of undetected colorectal cancer.
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Affiliation(s)
- N D'Souza
- Croydon University Hospital, Croydon, UK
| | - G Hicks
- Croydon University Hospital, Croydon, UK
| | - S C Benton
- Royal Surrey County Hospital, Guildford, UK.,Royal Surrey County Hospital NHS Trust, Guildford, UK
| | - M Abulafi
- Croydon University Hospital, Croydon, UK
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Navarro M, Hijos G, Ramirez T, Omella I, Carrera-Lasfuentes P, Lanas Á. Fecal Hemoglobin Concentration, a Good Predictor of Risk of Advanced Colorectal Neoplasia in Symptomatic and Asymptomatic Patients. Front Med (Lausanne) 2019; 6:91. [PMID: 31131279 PMCID: PMC6510055 DOI: 10.3389/fmed.2019.00091] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 04/12/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Periodical fecal immunochemical testing (FIT) is a cost-effective strategy in colon cancer screening programmes. FIT is also used as a diagnostic test in symptomatic patients, but data, are scarce. Aim: To determine the association between FIT-Hb concentration and the risk of advanced neoplasia (AN) detected in colonoscopy in two different populations. Methods: The outcomes of colonoscopies performed after a positive FIT (>117 ng/ml) (Sentinel Gold test) result were analyzed in patients included within a population-based CRC screening programme (screening group) and, as diagnostic evaluation in symptomatic patients (symptomatic group). The study was performed between January 1st, 2014 and October 31, 2016. Data are reported as medians with interquartile ranges or frequencies and percentages. Positive predictive value (PPV) at arbitrary fecal hemoglobin concentrations were also reported calculated for AN. Results: We recruited 2742 patients who underwent a colonoscopy procedure, 1515 (53.5%) of them within the CRC screening programme. Patients in the screening group were younger (65.0 ± 3.3 vs. 66.2 ± 13.4 years, p < 0.001) and more frequently male (p < 0.001) vs. the symptomatic group. Colonoscopy found more frequently neoplastic lesions in the screening compared to the symptomatic group (61.9 vs. 44.8% p < 0.001). Hb concentration in FIT was significantly higher in patients with AN compared with patients without AN in both groups (p < 0.001). The age-adjusted risk of AN increased significantly in both groups according to FIT Hb concentration in the Quartile 3 [OR (95% CI): 2.94 (2.33–3.71)] and Quartile 4 [OR: 5.52 (4.36–6.99)]. Males, in both groups showed a higher probability of presenting AN. FIT values were higher for left- than for right-sided AN in the screening, but not in the symptomatic group. Positive predictive values for AN were higher in the screening group in positive FIT tests (range 43.9–70.5%; 117 to >1,000 ng/ml) compared to those in the symptomatic group (36.3–52.5%). Similar trends were observed for cancer diagnosis alone. Conclusions: Male gender, age, and FIT Hb concentration are predictors of risk of advanced adenoma and colorectal cancer and can be used to prioritize colonoscopy in patients with suspected advanced neoplasia, both in screening and in symptomatic patients.
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Affiliation(s)
- Mercedes Navarro
- Service of Digestive Diseases, University Clinic Hospital, Zaragoza, Spain
| | - Gonzalo Hijos
- Service of Digestive Diseases, University Clinic Hospital, Zaragoza, Spain
| | - Teresa Ramirez
- Service of Pathology, University Clinic Hospital, Zaragoza, Spain
| | | | | | - Ángel Lanas
- Service of Digestive Diseases, University Clinic Hospital, Zaragoza, Spain.,University of Zaragoza, Zaragoza, Spain.,CIBERehd, Madrid, Spain.,IIS Aragón, Zaragoza, Spain
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