Participant uptake of the fecal immunochemical test decreases with the two-sample regimen compared with one-sample FIT

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)

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.

One or two faecal immunochemical tests in an organised population-based colorectal cancer screening programme in Murcia (Spain)

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.

Health plan-based mailed fecal testing for colorectal cancer screening among dual-eligible Medicaid/Medicare enrollees: Outcomes of 2 program models

BACKGROUND

Health insurance plans are increasingly offering mailed fecal immunochemical test (FIT) programs for colorectal cancer (CRC) screening, but few studies have compared the outcomes of different program models (eg, invitation strategies).

METHODS

This study compares the outcomes of 2 health plan-based mailed FIT program models. In the first program (2016), FIT kits were mailed to all eligible enrollees; in the second program (2018), FIT kits were mailed only to enrollees who opted in after an outreach phone call. Participants in this observational study included dual-eligible Medicaid/Medicare enrollees who were aged 50 to 75 years and were due for CRC screening (1799 in 2016 and 1906 in 2018). Six-month FIT completion rates, implementation outcomes (eg, mailed FITs sent and reminders attempted), and program-related health plan costs for each program are described.

RESULTS

All 1799 individuals in 2016 were sent an introductory letter and a FIT kit. In 2018, all 1906 were sent an introductory letter, and 1905 received at least 1 opt-in call attempt, with 410 (21.5%) sent a FIT. The FIT completion rate was 16.2% (292 of 1799 [95% CI, 14.5%-17.9%]) in 2016 and 14.6% (278 of 1906 [95% CI, 13.0%-16.2%]) in 2018 (P = .36). The overall implementation costs were higher in 2016 ($40,156) than 2018 ($34,899), with the cost per completed FIT slightly higher in 2016 ($138) than 2018 ($126).

CONCLUSIONS

An opt-in mailed FIT program achieved FIT completion rates similar to those of a program mailing to all dual-eligible Medicaid/Medicare enrollees.

LAY SUMMARY

Health insurance plans can use different program models to successfully mail fecal test kits for colorectal cancer screening to dual-eligible Medicaid/Medicare enrollees, with nearly 1 in 6 enrollees completing fecal testing.

Quality Improvement of Sample Collection Increases the Diagnostic Accuracy of Quantitative Fecal Immunochemical Test in Colorectal Cancer Screening: A Pilot Study

Objective: The diagnostic efficiency of the quantitative fecal immunochemical test (qFIT) has large variations in colorectal cancer (CRC) screening. We aimed to explore whether the practical sample collection operant training could improve the diagnostic accuracy of the qFIT in CRC screening.

Methods: Moderate-/high-risk individuals aged 50–75 years old were invited to participate in a prospective observational study between July 2020 and March 2021. Participants took a qFIT sample without fecal sample collection operant training in advance and then completed another qFIT sample after the operant training. The primary outcome was the sensitivity and specificity of the qFITs for CRC and advanced colorectal neoplasia (ACRN). The secondary outcome was the difference in the area under the curves (AUCs) and the concentrations of the fecal hemoglobin (Hb) between the qFIT without and after the operant training.

Results: Out of 913 patients, 81 (8.9%) patients had ACRN, including 25 (2.7%) patients with CRC. For CRC, the sensitivities of the qFIT without and after the operant training at 10 μg/g were 80.4 and 100.0%, respectively, and the specificities were 90.1 and 88.4%, respectively. For ACRN, the sensitivities were 49.4 and 69.1% and the specificities were 91.7 and 91.3%, respectively. The AUC of the qFIT after the operant training was significantly higher than that without the operant training for CRC (p = 0.027) and ACRN (p = 0.001). After the operant training, the concentration of the fecal Hb was significantly higher than that without the operant training (p = 0.009) for ACRN, but there was no significant difference for CRC (p = 0.367).

Conclusion: Practical sample collection operant training improves the diagnostic accuracy of the qFIT, which increases the detection of the low concentrations of fecal Hb. Improving the quality of the sample collection could contribute to the diagnostic efficiency of the qFIT in CRC screening.

Impact on healthcare resources of switch from fecal occult blood test to fecal immunochemical test within the English Bowel Cancer Screening Program: a single-center study

BACKGROUND AND AIMS

In July 2019, the fecal immunochemistry test (FIT) replaced the fecal occult blood test (FOBT) in England as the Bowel Cancer Screening Program (BCSP) screening tool. We aimed to assess the impact of this on healthcare resources at our BCSP center.

METHODS

Two 6-month periods were initially analyzed for stool sample return and positivity rates. A subsequent comparative analysis of patient screening episodes assessed utilization of specialist screening practitioner (SSP) time, endoscopy, histology, radiology, surgical, and oncology service usage.

RESULTS

A total of 42,234 patients received FOBT and 42,545 patients received FIT stool kits, with FIT showing higher return (61.8% vs 58.58%, FIT vs FOBT, P < .001) and sample positivity rates (2.41% vs 1.45%, FIT vs FOBT, P < .001). Four hundred patients commenced FOBT and 616 FIT screening episodes, a 54% increase. The FIT group had of a lower mean age (67.5 vs 69.5 years, FIT vs FOBT, P = .0001) with a lower nonattendance rate (.16% vs 1.5%, FIT vs FOBT, P = .01). With higher patient numbers, the FIT group required 69% more endoscopic procedures, 58% increased SSP time, 40% more radiologic tests, and 68% higher surgical procedures. FIT also led to a 109% increase in endoscopy-derived histology samples from an increase in the proportion of patients with polyps with FIT (54.8% vs 47.2%, P = .020) and a greater number of polyps per patient in whom polyps were found (3.00 vs 2.50 polyps, P = .017). This additional service burden equated to additional financial costs of approximately $558,000 per annum.

CONCLUSIONS

The implementation of FIT led to notable increases in SSP time, endoscopy procedures, radiology tests, surgical procedures, and histopathology services, resulting in considerable ongoing financial implications on the organization. Findings can be used to aid workforce and service planning in National Health Service sites delivering BCSP and countries that have already adopted or are considering FIT within their national screening programs.

Evolving perspectives on stool testing for colorectal cancer: a qualitative systematic review

OBJECTIVES

Colorectal cancer is one of the leading causes of cancer-related deaths globally. A multitude of screening methods has been devised for early diagnosis, including the faecal immunochemical test (FIT). This qualitative review aims to discover the barriers and facilitators to the utility of the FIT from the general population's perspective.

METHODS

Authors searched five electronic bases (Medline, Embase, CINAHL, PsycINFO and Web of Science) till December 2019. The search was conducted using key search terms and qualitative and mixed-method studies were included. Two independent reviewers screened articles and conducted quality appraisal. Data were synthesised thematically.

RESULTS

A total of 11 articles that reported users' views on FIT kits were included. Three themes were generated from the included articles: FIT kit factors, patients' perception of colorectal cancer screening, and social health support system. The nature of the test and the supplementary information was found to affect the utilisation of the test. User's awareness and perspectives towards cancer and screening were found to have impacted the adoption of the FIT kit. Social support and local healthcare systems were also found to have influenced the use of FIT.

CONCLUSION

This systematic review focuses on addressing and understanding the perception of FIT from first-hand accounts. Since its inception, FIT screening has increased colorectal cancer screening uptake due to its increased reliability and the simplicity of the test. However, there is a need to increase the uptake of FIT kits through increasing accessibility of the screening process and considering the holistic patient experience.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis

IMPORTANCE

Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused.

OBJECTIVE

To identify interventions associated with increasing CRC screening rates and their effect sizes.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening.

STUDY SELECTION

Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults.

DATA EXTRACTION AND SYNTHESIS

At least 2 investigators independently extracted data and appraised each study's risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention.

MAIN OUTCOMES AND MEASURES

The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs).

RESULTS

The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%).

CONCLUSIONS AND RELEVANCE

Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.

A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population

Introduction

Colorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50–75. Single-component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi-modal approaches may be more effective.

Methods

We designed, implemented, and evaluated the impact of a multi-modal intervention on CRC screening uptake among unscreened patients in a large managed care population. Patient-level components included a mailed letter with education about screening options and pre-colonoscopy telephone counseling. For providers, we facilitated communication of screening test results and work-flow for abnormal results. System-level modifications included establishment of a patient navigator, expedited work-up for abnormal results, and stream-lined colonoscopy scheduling. We measured the rate of screening uptake overall, screening uptake by modality, change in the proportion of the population screened, and positive fecal immunochemical test (FIT) follow-up rates in the 1-year study period.

Results

There were 5093 patients in the intervention cohort. Of these, 33.2% participated in FIT or colonoscopy screening within 1 year of the mailing. A total of 1078 (21.2%) participants completed a FIT and 611 (12.0%) completed a screening colonoscopy. The screening rate in the managed care population increased from 65.1 to 76.6%. Fifty-nine patients (5.5%) had a positive FIT, of which 30 (50.8%) completed a diagnostic colonoscopy.

Conclusion

Multi-modal interventions can result in substantial improvement in CRC screening uptake in large and diverse managed care populations.

Translational Impact

Health systems should shift their focus from single-level to multi-level interventions when addressing barriers to CRC screening.

Balancing Adherence and Expense: The Cost-Effectiveness of Two-Sample vs One-Sample Fecal Immunochemical Test

Colorectal cancer (CRC) causes more than 50,000 deaths each year in the United States but early detection through screening yields survival gains; those diagnosed with early stage disease have a 5-year survival greater than 90%, compared to 12% for those diagnosed with late stage disease. Using data from a large integrated health system, this study evaluates the cost-effectiveness of fecal immunochemical testing (FIT), a common CRC screening tool. A probabilistic decision-analytic model was used to examine the costs and outcomes of positive test results from a 1-FIT regimen compared with a 2-FIT regimen. The authors compared 5 diagnostic cutoffs of hemoglobin concentration for each test (for a total of 10 screening options). The principal outcome from the analysis was the cost per additional advanced neoplasia (AN) detected. The authors also estimated the number of cancers detected and life-years gained from detecting AN. The following costs were included: program management of the screening program, patient identification, FIT kits and their processing, and diagnostic colonoscopy following a positive FIT. Per-person costs ranged from $33 (1-FIT at 150ng/ml) to $92 (2-FIT at 50ng/ml) across screening options. Depending on willingness to pay, the 1-FIT 50 ng/ml and the 2-FIT 50 ng/ml are the dominant strategies with cost-effectiveness of $11,198 and $28,389, respectively, for an additional AN detected. The estimates of cancers avoided per 1000 screens ranged from 1.46 to 4.86, depending on the strategy and the assumptions of AN to cancer progression.

Performance of a quantitative fecal immunochemical test for detecting advanced colorectal neoplasia: a prospective cohort study

BACKGROUND

The fecal immunochemical test (FIT) is easier to use and more sensitive than the guaiac fecal occult blood test, but it is unclear how to optimize FIT performance. We compared the sensitivity and specificity for detecting advanced colorectal neoplasia between single-sample (1-FIT) and two-sample (2-FIT) FIT protocols at a range of hemoglobin concentration cutoffs for a positive test.

METHODS

We recruited 2,761 average-risk men and women ages 49-75 referred for colonoscopy within a large nonprofit, group-model health maintenance organization (HMO), and asked them to complete two separate single-sample FITs. We generated receiver-operating characteristic (ROC) curves to compare sensitivity and specificity estimates for 1-FIT and 2-FIT protocols among those who completed both FIT kits and colonoscopy. We similarly compared sensitivity and specificity between hemoglobin concentration cutoffs for a single-sample FIT.

RESULTS

Differences in sensitivity and specificity between the 1-FIT and 2-FIT protocols were not statistically significant at any of the pre-specified hemoglobin concentration cutoffs (10, 15, 20, 25, and 30 μg/g). There was a significant difference in test performance of the one-sample FIT between 50 ng/ml (10 μg/g) and each of the higher pre-specified cutoffs. Disease prevalence was low.

CONCLUSIONS

A two-sample FIT is not superior to a one-sample FIT in detection of advanced adenomas; the one-sample FIT at a hemoglobin concentration cutoff of 50 ng/ml (10 μg/g) is significantly more sensitive for advanced adenomas than at higher cutoffs. These findings apply to a population of younger, average-risk patients in a U.S. integrated care system with high rates of prior screening.

Blood free-circulating DNA testing by highly sensitive methylation assay to diagnose colorectal neoplasias

Although methylated TWIST1 is a biomarker of colorectal neoplasia, its detection from serum samples is very difficult by conventional bisulfite-based methylation assays. Therefore, we have developed a new methylation assay that enables counting of even one copy of a methylated gene in a small DNA sample amount without DNA bisulfite treatment. We performed this study to evaluate the sensitivity and specificity of serum DNA testing by the new methylation assay in combination with and without the fecal immunochemical test for hemoglobin for the detection of colorectal neoplasia. This study comprised 113 patients with colorectal neoplasia and 25 control individuals. For the new methylation assay, DNA was treated in two stages with methylation-sensitive restriction enzymes, followed by measurement of copy numbers of hTERT and methylated TWIST1 by multiplex droplet digital PCR. The fecal immunochemical test had a sensitivity of 8.0% for non-advanced adenoma, 24.3% for advanced adenoma, and 44.4% for colorectal cancer, and a specificity of 88.0%. The new assay had a sensitivity of 36.0% for non-advanced adenoma, 30.0% for advanced adenoma, and 44.4% for colorectal cancer, and a specificity of 92.0%. Combination of the both tests increased the sensitivity to 40.0%, 45.7%, and 72.2% for the detection of non-advanced adenoma, advanced adenoma, and colorectal cancer, respectively, and resulted in a specificity of 84.0%. Combination of both tests may provide an alternative screening strategy for colorectal neoplasia including potentially precancerous lesions and colorectal cancer.

Highly sensitive faecal DNA testing of TWIST1 methylation in combination with faecal immunochemical test for haemoglobin is a promising marker for detection of colorectal neoplasia

Background

As TWIST1 methylation is specific to colorectal neoplasia, detection of TWIST1 methylation from faeces samples might be useful for colorectal neoplasia screening. However, because the content of human DNA in faeces is very small, it is very difficult to detect TWIST1 methylation by conventional bisulphite-based methylation assays. Therefore, we developed a new methylation assay without bisulphite treatment, the combined restriction digital PCR assay, and evaluated its sensitivity and specificity in combination with and without the faecal immunochemical test for haemoglobin for colorectal neoplasia detection from faeces samples.

Methods

For the combined restriction digital PCR assay, DNA was treated with three methylation-sensitive restriction enzymes and an exonuclease, followed by measurement of TWIST1 methylation level by droplet digital PCR. Faecal DNA testing and faecal immunochemical test for haemoglobin were performed on 109 patients with colorectal neoplasia and 10 control individuals.

Results

Basic performance testing showed that the combined restriction digital PCR assay enabled detection of 0.14% of the TWIST1 methylation level for the lymphocyte DNA. The combined restriction digital PCR assay from faeces samples had a sensitivity of 22.2% (95% confidence interval, 2.8–60.0%) for non-advanced adenoma, 47.1% (95% confidence interval, 23.0–72.2%) for advanced adenoma, and 33.7% (95% confidence interval, 23.7–45.0%) for colorectal cancer, and a specificity of 100.0%. Combination of faecal immunochemical test for haemoglobin and faecal combined restriction digital PCR assay increased sensitivity to 82.4% (95% confidence interval, 56.6–96.2%) for the detection of advanced adenoma.

Conclusions

We developed the combined restriction digital PCR assay, a possible highly sensitive methylation assay. Combination of faecal combined restriction digital PCR assay with faecal immunochemical test for haemoglobin may provide an alternative screening strategy for colorectal neoplasia, especially for potentially precancerous lesions.