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Hassanlouei B, Ostovar A, Motevalian SA, Ghanbari Motlagh A, Moradi Y, Salehi M, Asadi Lari M. Colorectal Cancer Screening Program Results in Iran. Med J Islam Repub Iran 2022; 36:118. [PMID: 36447540 PMCID: PMC9700411 DOI: 10.47176/mjiri.36.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Indexed: 01/25/2023] Open
Abstract
Background: Colorectal cancer (CRC) accounts for a large proportion of the global burden of cancer and is the fourth leading cause of cancer-related mortality worldwide. Fecal Immunochemical Testing (FIT) can be used for CRC screening programs due to its high accuracy and compliance. The present study reports the preliminary results of the CRC screening program in Iran among all people aged 50 to 69 years. Methods: This cross-sectional study was carried out on 2,669,625 participants referred to health centers in Iran for CRC screening programs in 2018 and 2019. The data required for this study was taken from the CRC screening program. Relevant information for all individuals aged 50 to 69 referred to the health system that was called for colorectal cancer screening was extracted from the Integrated Electronic Health Records (SIB) database. Finally, the standards indices were calculated for all provinces. Gender, history of inflammatory bowel disease (IBD) (Crohn's disease or ulcerative colitis), history of colon cancer or adenoma in a first-degree family (father, mother, siblings or children), history of colon cancer in a second-degree family if occurred under the age of fifty (aunt, uncle, grandparents), lower gastrointestinal bleeding in a prior month, constipation in the prior month (with or without diarrhea, abdominal pain and feeling of fullness in the colon after defecation), more than ten percent weight loss in the last six months and FIT were assessed. Results: Among a total number of over 2.6 million, 56.3% were female, and the number of people evaluated by health care providers for CRC screening programs in 2018 and 2019 were 1,365,248 (14.23%) and 1,304,377 (12.89%), respectively. The number of people with positive FIT evaluated for the CRC screening program in 2018 and 2019 was 33,299 (3.09%) and 33,583 (2.57%), respectively. Bushehr province (0.59%) and Isfahan province (7.35%) had the lowest and highest positive FIT rate in 2018, respectively. Also, the correlation between the above-mentioned variables and the number of people with a positive FIT across gender was statistically significant (p<0.05). The study of the relationship between the number of positive FIT cases and the variables examined by Behvarz and community health worker showed that the number of people with a family history of colon cancer in second-degree relatives under the age of 50 and also the number of people with an individual history of inflammatory bowel disease had a significant association with the number of positive FIT cases (p<0.05) (β=-0.718, 95% CI; -2.557-14.992, β=0.388, 95% CI; 0.322-16.737, respectively). The relationship between the number of positive FIT cases and effective variables was not statistically significant (p>0.05). Conclusion: Positive cases should be referred for further evaluation and colonoscopy. Before performing a screening program, the conditions for performing colonoscopy for these people must be assessed and prepared. The FIT for CRC screening program can be easily promoted in Iran.
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Affiliation(s)
- Babak Hassanlouei
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Afshin Ostovar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Abbas Motevalian
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Ghanbari Motlagh
- Department of Radiotherapy, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yousef Moradi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Masoud Salehi
- Health Management and Economics Research Center and Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Asadi Lari
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran,Corresponding author: Dr Mohsen Asadi Lari,
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Grobbee EJ, Wisse PHA, Schreuders EH, van Roon A, van Dam L, Zauber AG, Lansdorp-Vogelaar I, Bramer W, Berhane S, Deeks JJ, Steyerberg EW, van Leerdam ME, Spaander MC, Kuipers EJ. Guaiac-based faecal occult blood tests versus faecal immunochemical tests for colorectal cancer screening in average-risk individuals. Cochrane Database Syst Rev 2022; 6:CD009276. [PMID: 35665911 PMCID: PMC9169237 DOI: 10.1002/14651858.cd009276.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Worldwide, many countries have adopted colorectal cancer (CRC) screening programmes, often based on faecal occult blood tests (FOBTs). CRC screening aims to detect advanced neoplasia (AN), which is defined as CRC or advanced adenomas. FOBTs fall into two categories based on detection technique and the detected blood component: qualitative guaiac-based FOBTs (gFOBTs) and faecal immunochemical tests (FITs), which can be qualitative and quantitative. Screening with gFOBTs reduces CRC-related mortality. OBJECTIVES To compare the diagnostic test accuracy of gFOBT and FIT screening for detecting advanced colorectal neoplasia in average-risk individuals. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, BIOSIS Citation Index, Science Citation Index Expanded, and Google Scholar. We searched the reference lists and PubMed-related articles of included studies to identify additional studies. SELECTION CRITERIA We included prospective and retrospective studies that provided the number of true positives, false positives, false negatives, and true negatives for gFOBTs, FITs, or both, with colonoscopy as reference standard. We excluded case-control studies. We included studies in which all participants underwent both index test and reference standard ("reference standard: all"), and studies in which only participants with a positive index test underwent the reference standard while participants with a negative test were followed for at least one year for development of interval carcinomas ("reference standard: positive"). The target population consisted of asymptomatic, average-risk individuals undergoing CRC screening. The target conditions were CRC and advanced neoplasia (advanced adenomas and CRC combined). DATA COLLECTION AND ANALYSIS Two review authors independently screened and selected studies for inclusion. In case of disagreement, a third review author made the final decision. We used the Rutter and Gatsonis hierarchical summary receiver operating characteristic model to explore differences between tests and identify potential sources of heterogeneity, and the bivariate hierarchical model to estimate sensitivity and specificity at common thresholds: 10 µg haemoglobin (Hb)/g faeces and 20 µg Hb/g faeces. We performed indirect comparisons of the accuracy of the two tests and direct comparisons when both index tests were evaluated in the same population. MAIN RESULTS We ran the initial search on 25 June 2019, which yielded 63 studies for inclusion. We ran a top-up search on 14 September 2021, which yielded one potentially eligible study, currently awaiting classification. We included a total of 33 "reference standard: all" published articles involving 104,640 participants. Six studies evaluated only gFOBTs, 23 studies evaluated only FITs, and four studies included both gFOBTs and FITs. The cut-off for positivity of FITs varied between 2.4 μg and 50 µg Hb/g faeces. For each Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 domain, we assessed risk of bias as high in less than 20% of studies. The summary curve showed that FITs had a higher discriminative ability than gFOBTs for AN (P < 0.001) and CRC (P = 0.004). For the detection of AN, the summary sensitivity of gFOBTs was 15% (95% confidence interval (CI) 12% to 20%), which was significantly lower than FITs at both 10 μg and 20 μg Hb/g cut-offs with summary sensitivities of 33% (95% CI 27% to 40%; P < 0.001) and 26% (95% CI 21% to 31%, P = 0.002), respectively. Results were simulated in a hypothetical cohort of 10,000 screening participants with 1% CRC prevalence and 10% AN prevalence. Out of 1000 participants with AN, gFOBTs missed 850, while FITs missed 670 (10 μg Hb/g cut-off) and 740 (20 μg Hb/g cut-off). No significant differences in summary specificity for AN detection were found between gFOBTs (94%; 95% CI 92% to 96%), and FITs at 10 μg Hb/g cut-off (93%; 95% CI 90% to 95%) and at 20 μg Hb/g cut-off (97%; 95% CI 95% to 98%). So, among 9000 participants without AN, 540 were offered (unnecessary) colonoscopy with gFOBTs compared to 630 (10 μg Hb/g) and 270 (20 μg Hb/g) with FITs. Similarly, for the detection of CRC, the summary sensitivity of gFOBTs, 39% (95% CI 25% to 55%), was significantly lower than FITs at 10 μg and 20 μg Hb/g cut-offs: 76% (95% CI 57% to 88%: P = 0.001) and 65% (95% CI 46% to 80%; P = 0.035), respectively. So, out of 100 participants with CRC, gFOBTs missed 61, and FITs missed 24 (10 μg Hb/g) and 35 (20 μg Hb/g). No significant differences in summary specificity for CRC were found between gFOBTs (94%; 95% CI 91% to 96%), and FITs at the 10 μg Hb/g cut-off (94%; 95% CI 87% to 97%) and 20 μg Hb/g cut-off (96%; 95% CI 91% to 98%). So, out of 9900 participants without CRC, 594 were offered (unnecessary) colonoscopy with gFOBTs versus 594 (10 μg Hb/g) and 396 (20 μg Hb/g) with FITs. In five studies that compared FITs and gFOBTs in the same population, FITs showed a higher discriminative ability for AN than gFOBTs (P = 0.003). We included a total of 30 "reference standard: positive" studies involving 3,664,934 participants. Of these, eight were gFOBT-only studies, 18 were FIT-only studies, and four studies combined both gFOBTs and FITs. The cut-off for positivity of FITs varied between 5 µg to 250 µg Hb/g faeces. For each QUADAS-2 domain, we assessed risk of bias as high in less than 20% of studies. The summary curve showed that FITs had a higher discriminative ability for detecting CRC than gFOBTs (P < 0.001). The summary sensitivity for CRC of gFOBTs, 59% (95% CI 55% to 64%), was significantly lower than FITs at the 10 μg Hb/g cut-off, 89% (95% CI 80% to 95%; P < 0.001) and the 20 μg Hb/g cut-off, 89% (95% CI 85% to 92%; P < 0.001). So, in the hypothetical cohort with 100 participants with CRC, gFOBTs missed 41, while FITs missed 11 (10 μg Hb/g) and 11 (20 μg Hb/g). The summary specificity of gFOBTs was 98% (95% CI 98% to 99%), which was higher than FITs at both 10 μg and 20 μg Hb/g cut-offs: 94% (95% CI 92% to 95%; P < 0.001) and 95% (95% CI 94% to 96%; P < 0.001), respectively. So, out of 9900 participants without CRC, 198 were offered (unnecessary) colonoscopy with gFOBTs compared to 594 (10 μg Hb/g) and 495 (20 μg Hb/g) with FITs. At a specificity of 90% and 95%, FITs had a higher sensitivity than gFOBTs. AUTHORS' CONCLUSIONS FITs are superior to gFOBTs in detecting AN and CRC in average-risk individuals. Specificity of both tests was similar in "reference standard: all" studies, whereas specificity was significantly higher for gFOBTs than FITs in "reference standard: positive" studies. However, at pre-specified specificities, the sensitivity of FITs was significantly higher than gFOBTs.
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Affiliation(s)
- Esmée J Grobbee
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Pieter HA Wisse
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Eline H Schreuders
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Aafke van Roon
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Leonie van Dam
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Wichor Bramer
- Medical Library , Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sarah Berhane
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Jonathan J Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Manon Cw Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Ito S, Hotta K, Imai K, Kishida Y, Takizawa K, Kakushima N, Kawata N, Yoshida M, Yabuuchi Y, Ishiwatari H, Matsubayashi H, Shiomi A, Ono H. Ultrathin colonoscopy can improve complete preoperative colonoscopy for stenotic colorectal cancer: Prospective observational study. Dig Endosc 2021; 33:621-628. [PMID: 32867005 DOI: 10.1111/den.13829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Preoperative colonoscopy is often incomplete for stenotic colorectal cancers (CRC). This prospective observational study aimed to evaluate the ability of an ultrathin colonoscope (UTC) to inspect the whole colon by passing through the stenotic CRC. METHODS All patients who underwent preoperative colonoscopy for stenotic CRCs at Shizuoka Cancer Center were examined for eligibility. If a standard colonoscope (PCF-H290ZI) could not pass because of a stenosis, the patients were recruited. All of the eligible patients were prospectively enrolled when informed consent could be obtained, and complete colonoscopy was attempted again using an UTC (PCF-PQ260L). Patients with stent placement and those requiring right hemicolectomy were not recruited. Primary endpoints were pass-through and cecal intubation rates. The detected synchronous neoplasias (adenomas and cancers) and their pathological findings after resection were evaluated. RESULTS A total of 100 patients were enrolled between September 2017 and February 2019. The mean age was 65.6 ± 10.8 years, and 59% were male. The pass-through and cecal intubation rates were 67% (67/100) and 58% (58/100), respectively. Synchronous lesions located proximal to the stenoses were detected in 65.5% (38/58) of the complete colonoscopies, with a total of 86 lesions, including 18 advanced neoplasias with three invasive cancers. CONCLUSION When standard colonoscopy cannot pass through stenotic CRC, ultrathin colonoscopy can be considered as an option to inspect the whole colon proximal to the stenosis because treatment strategy can potentially be changed by detecting synchronous neoplasias proximal to the stenosis before surgery. (UMIN000028505).
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Affiliation(s)
- Sayo Ito
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kinichi Hotta
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kenichiro Imai
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoshihiro Kishida
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kohei Takizawa
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naomi Kakushima
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Noboru Kawata
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masao Yoshida
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yohei Yabuuchi
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | | | - Akio Shiomi
- Division of, Colon and Rectal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Divisions of, Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Chen CH, Lin CL, Hsu CY, Kao CH. Insulin enhances and metformin reduces risk of colorectal carcinoma in type-2 diabetes. QJM 2020; 113:194-200. [PMID: 31593243 DOI: 10.1093/qjmed/hcz253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/25/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Identifying colorectal cancer associated risks is important for conducting a program for the survey and prevention of colorectal cancer. AIM To investigate the association between use of insulin or metformin with colorectal cancer (CRC) in type 2 diabetes (T2DM). DESIGN Population-based cohort study. METHODS Through analysis of National Health Insurance (NHI) database between 1998 and 2010 in Taiwan, we identified 66 324 T2DM patients aged ≥ 20 years and selected subjects without diabetes by 1: 1 randomly matching with the study cohort based on age, sex and index date. We followed up the participants until 31 December 2011 or when they withdrew from the NHI program. RESULTS Compared with non-diabetic subjects, the T2DM patients exhibited an increased risk of CRC [adjusted HR (aHR) = 1.56, 95% confidence interval (CI) = 1.39-1.75], after adjustment for age, sex, urbanization level, comorbidities and examinations of colonoscopy, sigmoidoscopy, or stool occult blood test. Among the T2DM patients, insulin usage increased the risk of CRC (aHR = 1.86, 95% CI = 1.58-0-2.19) after adjustment for age, sex, urbanization level, comorbidities, metformin usage and examinations; nevertheless, metformin decreased the risk of CRC (aHR = 0.65, 95% CI = 0.54-0.77) after adjustment for age, sex, urbanization level, comorbidities, insulin usage and examinations. Compared with the non-insulin cohort, the risk of CRC tended to increase with the incremental dosage of insulin exposure. CONCLUSION Our population-based cohort study demonstrated an association between T2DM and CRC. Among the T2DM patients, insulin use was associated with an increased risk of CRC and metformin use was associated with a decreased risk of CRC. Inability to obtain information on several potential confounding factors, such as lifestyle and dietary habits, is the major limitation of the study.
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Affiliation(s)
- C-H Chen
- From the Digestive Disease Center, Changbing Show-Chwan Memorial Hospital 505, Taiwan
- Department of Food Science and Technology, Hungkuang University, Taichung, Taiwan
| | - C-L Lin
- Management Office for Health Data, School of Medicine, College of Medicine, China Medical University, Taichung 404, Taiwan
- College of Medicine, School of Medicine, College of Medicine, China Medical University, Taichung 404, Taiwan
| | - C-Y Hsu
- Graduate Institute of Biomedical Sciences, School of Medicine, College of Medicine, China Medical University, Taichung 404, Taiwan
| | - C-H Kao
- Graduate Institute of Biomedical Sciences, School of Medicine, College of Medicine, China Medical University, Taichung 404, Taiwan
- Department of Nuclear Medicine and PET Center, and Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan, Republic of China
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Roos VH, Mangas-Sanjuan C, Rodriguez-Girondo M, Medina-Prado L, Steyerberg EW, Bossuyt PMM, Dekker E, Jover R, van Leerdam ME. Effects of Family History on Relative and Absolute Risks for Colorectal Cancer: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2019; 17:2657-2667.e9. [PMID: 31525516 DOI: 10.1016/j.cgh.2019.09.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/27/2019] [Accepted: 09/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend that individuals with familial colorectal cancer undergo colonoscopy surveillance instead of average-risk screening. However, these recommendations vary widely. To substantiate appropriate surveillance strategies, precise and valid evidence-based risk estimates are needed for individuals with a family history of colorectal cancer (CRC). METHODS We systematically searched MEDLINE, EMBASE, and Cochrane from inception to July 2018 for case-control and cohort studies investigating the effect of family history on CRC risk. We calculated summary estimates of pooled relative risks (RRs) using a random-effects model. Life tables were created to convert RR estimates into absolute risk estimates. RESULTS We screened 4417 articles and identified 42 eligible case-control and 20 cohort studies. In case-control studies, the RR for CRC in patients with 1 first-degree relative (FDR with CRC) was 1.92 (95% CI, 1.53-2.41) and 1.37 (95% CI, 0.76-2.46) for cohort studies. For individuals with 2 or more FDRs with CRC, the RR was 2.81 in case-control studies (95% CI, 1.73-4.55) and 2.40 in cohort studies (95% CI, 1.76-3.28). For individuals having a FDR diagnosed with CRC at an age younger than 50 years, the RR for CRC in their FDRs was 3.57 in case-control studies (95% CI, 1.07-11.85) and 3.26 in cohort studies (95% CI, 2.82-3.77). The cumulative absolute risks for CRC at 85 years in Western Europe were 4.8% for persons with 1 FDR with CRC (95% CI, 2.7%-8.3%), 8.2% for individuals with 2 or more FDRs (95% CI, 6.1%-10.9%), and 11% for persons with a FDR diagnosed with CRC at an age younger than 50 years (95% CI, 9.5%-12.4%). CONCLUSIONS In this systematic review and meta-analysis, we found that the RR of CRC among FDRs is lower than previously expected, especially based on cohort studies. Risk estimates are affected by the number of relatives with CRC and their age at diagnosis. Intensified colonoscopy surveillance strategies could be considered for high-risk groups. PROSPERO trial identification no: CRD42018103058.
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Affiliation(s)
- Victorine H Roos
- Department of Gastroenterology and Hepatology, University of Amsterdam, Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Carolina Mangas-Sanjuan
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
| | - Mar Rodriguez-Girondo
- Department of Biomedical Data Sciences, Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia Medina-Prado
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Patrick M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, University of Amsterdam, Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Rodrigo Jover
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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Selby K, Levine EH, Doan C, Gies A, Brenner H, Quesenberry C, Lee JK, Corley DA. Effect of Sex, Age, and Positivity Threshold on Fecal Immunochemical Test Accuracy: A Systematic Review and Meta-analysis. Gastroenterology 2019; 157:1494-1505. [PMID: 31472152 PMCID: PMC6878177 DOI: 10.1053/j.gastro.2019.08.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/18/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Quantitative fecal immunochemical tests (FITs) for hemoglobin are commonly used for colorectal cancer (CRC) screening. We aimed to quantify the change in CRC and advanced adenoma detection and number of positive test results at different positivity thresholds and by sex and age. METHODS We searched MEDLINE and EMBASE, selecting articles of FIT for CRC detection in asymptomatic adults undergoing screening. We calculated sensitivity and specificity, as well as detected number of cancers, advanced adenomas, and positive test results at positivity thresholds ≤10 μg hemoglobin/g feces, 10 to ≤20 μg/g, 20 to ≤30 μg/g, and >30 μg/g. We also analyzed results from stratified by patient sex, age, and reference standard. RESULTS Our meta-analysis comprised 46 studies with 2.4 million participants and 6478 detected cancers. Sensitivity for detection of CRC increased from 69% (95% confidence interval [CI], 63%-75%) at thresholds >10 μg/g and ≤20 μg/g to 80% (95% CI, 76%-83%) at thresholds ≤10 μg/g. At these threshold values, sensitivity for detection of advanced adenomas increased from 21% (95% CI, 18%-25%) to 31% (95% CI, 27%-35%), whereas specificity decreased from 94% (95% CI, 93%-96%) to 91% (95% CI, 89%-93%). In 3 studies stratified by sex, sensitivity of CRC detection was 77% in men (95% CI, 75%-79%) and 81% in women (95% CI, 60%-100%) (P = .68). In 3 studies stratified by age groups, sensitivity of CRC detection was 85% for ages 50-59 years (95% CI, 71%-99%) and 73% for ages 60-69 years (95% CI, 71%-75%) (P = .10). All studies with colonoscopy follow-up had similar sensitivity levels for detection of CRC to studies that analyzed 2-year registry follow-up data (74%; 95% CI, 68%-78% vs 75%; 95% CI, 73%-77%). CONCLUSIONS In a meta-analysis of studies that analyzed detection of CRC and advanced adenomas at different FIT positivity thresholds, we found the sensitivity and specificity of detection to vary with positive cutoff value. It might be possible to decrease positive threshold values for centers with sufficient follow-up colonoscopy resources. More research is needed to precisely establish FIT thresholds for each sex and age subgroup. PROTOCOL PROSPERO CRD42017068760.
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Affiliation(s)
- Kevin Selby
- Kaiser Permanente Division of Research, Oakland, California; Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland.
| | | | - Cecilia Doan
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, California
| | - Anton Gies
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany,Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Hermann Brenner
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | | | - Jeffrey K. Lee
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, California
| | - Douglas A. Corley
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, California
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Overestimated Sensitivity of Fecal Immunochemical Tests in Screening Cohorts With Registry-Based Follow-up. Am J Gastroenterol 2019; 114:1795-1801. [PMID: 31658130 DOI: 10.14309/ajg.0000000000000412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several recent studies have reported very high estimates of sensitivity and specificity of fecal immunochemical tests (FITs) at seemingly high levels of precision using registry-based follow-up of participants in very large FIT-based screening programs. We aimed to assess the validity of estimates of diagnostic performance parameters derived by this indirect approach. METHODS We modeled expected values of sensitivity and specificity of colorectal cancer detection in studies using the indirect approach and their deviation from true values under a broad range of plausible assumptions, and we compared these expected values with recently reported estimates of FIT sensitivity and specificity from such studies. RESULTS Using a sensitivity of 75% and specificity of 93.6% (from studies using a direct approach, i.e., colonoscopy follow-up of all participants), the indirect approach would be expected to yield sensitivities between 84.5% and 91.1% and specificities between 93.4% and 93.6% under a range of realistic assumptions regarding colonoscopic follow-up rates of positive FITs and clinical manifestation rates of preclinical colorectal cancer. DISCUSSION Very high sensitivities of FITs recently reported with seemingly very high levels of precision by several large-scale registry-based studies, which are in line with expected results based on our model calculations, are likely to be strongly overestimated and need to be interpreted with due caution.
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Ku MS, Fann JCY, Chiu SYH, Chen HH, Hsu CY. Elucidating bidirectional relationship between metabolic syndrome and elevated faecal haemoglobin concentration: a Taiwanese community-based cohort study. BMJ Open 2019; 9:e021153. [PMID: 30826754 PMCID: PMC6429718 DOI: 10.1136/bmjopen-2017-021153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To elucidate the bidirectional temporal relationship between elevated faecal haemoglobin (f-Hb) concentration and metabolic syndrome (MetS). DESIGN A longitudinal cohort study was conducted by utilising data on community-based periodical screening for colorectal cancer with faecal immunochemical test (FIT) and health check-up for MetS. SETTING Population-based organised integrated service screening in Keelung city, Taiwan. PARTICIPANTS We enrolled a total of 62,293 community residents aged 40-79 years. MAIN OUTCOMES AND MEASURES Bidirectional outcomes of FIT-positive and MetS were measured. RESULTS The presence of MetS at baseline led to a statistically significant 31% elevated risk of being incident FIT-positive (adjusted HR, (aHR)=1.31, 95% CI: 1.14 to 1.51) whereas the effect of those with FIT-positive at baseline on incident MetS was not statistically significant (aHR=1.06, 95% CI: 0.89 to 1.25) after adjusting for relevant confounders. Such an effect was particularly noted for three individual components (abnormal waist circumference, higher fasting plasma glucose and lower high-density lipoprotein). CONCLUSIONS Our finding on the presence of MetS before FIT-positive based on bidirectional relationship assessment suggests the control of MetS may contribute to reducing the risk of colorectal neoplasia through the early surveillance of f-Hb. However, such a temporal epidemiological finding still needs to be verified by using other external data.
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Affiliation(s)
- Mei-Sheng Ku
- Graduate Institute of Environmental Health, College of PublicHealth, National Taiwan University, Taipei, Taiwan
| | - Jean Ching-Yuan Fann
- Department of Health Industry Management, School of Healthcare Management, Kainan University, Taoyuan, Taiwan
| | - Sherry Yueh-Hsia Chiu
- Department of Health Care Management, Chang Gung University, Taoyuan, Taiwan
- Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital Kaohsiung Branch, Kaohsiung, Taiwan
| | - Hsiu-Hsi Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Innovation and Policy Center for Population Health and Sustainable Environment, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
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9
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Lower Relative Contribution of Positive Family History to Colorectal Cancer Risk with Increasing Age: A Systematic Review and Meta-Analysis of 9.28 Million Individuals. Am J Gastroenterol 2018; 113:1819-1827. [PMID: 29867176 PMCID: PMC6768593 DOI: 10.1038/s41395-018-0075-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/19/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Existing algorithms predicting the risk of colorectal cancer (CRC) assign a fixed score for family history of CRC. Whether the increased CRC risk attributed to family history of CRC was higher in younger patients remains inconclusive. We examined the risk of CRC associated with family history of CRC in first-degree relative (FDR) according to the age of index subjects (<40 vs. ≥40; <50 vs. ≥50; and <60 vs. ≥60 years). METHODS Ovid Medline, EMBASE, and gray literature from the reference lists of all identified studies were searched from their inception to March 2017. We included case-control/cohort studies that investigated the relationship between family history of CRC in FDR and prevalence of CRC. Two reviewers independently selected articles according to the PRISMA guideline. A random effects meta-analysis pooled relative risks (RR). RESULTS We analyzed 9.28 million subjects from 63 studies. A family history of CRC in FDR confers a higher risk of CRC (RR = 1.76, 95% CI = 1.57-1.97, p < 0.001). This increased risk was higher in younger individuals (RR = 3.29, 95% CI = 1.67-6.49 for <40 years versus RR = 1.42, 95% CI = 1.24-1.62 for ≥40 years, p = 0.017; RR = 2.81, 95% CI = 1.94-4.07 for <50 years versus RR = 1.47, 95% CI = 1.28-1.69 for ≥50 years, p = 0.001). No publication bias was identified, and the findings are robust in subgroup analyses. CONCLUSIONS The increase in relative risk of CRC attributed to family history was found to be higher in younger individuals. Family history of CRC could be assigned a higher score for younger subjects in CRC risk prediction algorithms. Future studies should examine if such approach may improve their predictive capability.
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Selby K, Jensen CD, Lee JK, Doubeni CA, Schottinger JE, Zhao WK, Chubak J, Halm E, Ghai NR, Contreras R, Skinner C, Kamineni A, Levin TR, Corley DA. Influence of Varying Quantitative Fecal Immunochemical Test Positivity Thresholds on Colorectal Cancer Detection: A Community-Based Cohort Study. Ann Intern Med 2018; 169:439-447. [PMID: 30242328 PMCID: PMC6433467 DOI: 10.7326/m18-0244] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background The fecal immunochemical test (FIT) is commonly used for colorectal cancer (CRC) screening. Despite demographic variations in stool hemoglobin concentrations, few data exist regarding optimal positivity thresholds by age and sex. Objective To identify programmatic (multitest) FIT performance characteristics and optimal FIT quantitative hemoglobin positivity thresholds in a large, population-based, screening program. Design Retrospective cohort study. Setting Kaiser Permanente Northern and Southern California. Participants Adults aged 50 to 75 years who were eligible for screening and had baseline quantitative FIT results (2013 to 2014) and 2 years of follow-up. Nearly two thirds (411 241) had FIT screening in the previous 2 years. Measurements FIT programmatic sensitivity for CRC and number of positive test results per cancer case detected, overall and by age and sex. Results Of 640 859 persons who completed a baseline FIT and were followed for 2 years, 481 817 (75%) had at least 1 additional FIT and 1245 (0.19%) received a CRC diagnosis. Cancer detection (programmatic sensitivity) increased at lower positivity thresholds, from 822 in 1245 (66.0%) at 30 µg/g to 925 (74.3%) at 20 µg/g and 987 (79.3%) at 10 µg/g; the number of positive test results per cancer case detected increased from 43 at 30 µg/g to 52 at 20 µg/g and 85 at 10 µg/g. Reducing the positivity threshold from 20 to 15 µg/g would detect 3% more cancer cases and require 23% more colonoscopies. At the conventional FIT threshold of 20 µg/g, programmatic sensitivity decreased with increasing age (79.0%, 73.4%, and 68.9% for ages 50 to 59, 60 to 69, and 70 to 75 years, respectively; P = 0.009) and was higher in men than women (77.0% vs. 70.6%; P = 0.011). Limitation Information on advanced adenoma was lacking. Conclusion Increased cancer detection at lower positivity thresholds is counterbalanced by substantial increases in positive tests. Tailored thresholds may provide screening benefits that are more equal among different demographic groups, depending on local resources. Primary Funding Source National Cancer Institute.
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Affiliation(s)
- Kevin Selby
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland
| | | | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA
| | - Joanne E. Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jessica Chubak
- Kaiser Permanente Center for Health Research, Seattle, Washington
| | - Ethan Halm
- University of Texas Southwestern Medical Center, Dallas TX
| | - Nirupa R. Ghai
- Department of Regional Clinical Effectiveness, Kaiser Permanente Southern California, Pasadena, CA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Aruna Kamineni
- Kaiser Permanente Center for Health Research, Seattle, Washington
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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11
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Kim DH, Cha JM, Kwak MS, Yoon JY, Cho YH, Jeon JW, Shin HP, Joo KR, Lee JI. Quality Metrics of a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program in Korea. Gut Liver 2018; 12:183-189. [PMID: 29212310 PMCID: PMC5832343 DOI: 10.5009/gnl17030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 05/01/2017] [Accepted: 06/19/2017] [Indexed: 12/12/2022] Open
Abstract
Background/Aims Knowledge regarding the quality metrics of fecal immunochemical test (FIT)-based colorectal cancer screening programs is limited. The aim of this study was to investigate the performance and quality metrics of a FIT-based screening program. Methods In our screening program, asymptomatic subjects aged ≥50 years underwent an annual FIT, and subjects with positive FIT results underwent a subsequent colonoscopy. The performance of the FIT and colonoscopy was analyzed in individuals with a positive FIT who completed the program between 2009 and 2015 at a university hospital. Results Among the 51,439 screened participants, 75.1% completed the FIT. The positive rate was 1.1%, and the colonoscopy completion rate in these patients was 68.6%. The positive predictive values of cancer and advanced neoplasia were 5.5% and 19.1%, respectively. The adenoma detection rate in the patients who underwent colonoscopy after a positive FIT was 48.2% (60.0% for men and 33.6% for women). The group with the highest tertile quantitative FIT level showed a significantly higher detection rate of advanced neoplasia than the group with the lowest tertile (odds ratio, 2.6; 95% confidence interval, 1.4 to 5.1; p<0.001). Conclusions The quality metrics used in the United States and Europe may be directly introduced to other countries, including Korea. However, the optimal quality metrics should be established in each country.
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Affiliation(s)
- Dae Ho Kim
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Young Yoon
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea.,Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Young-Hak Cho
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung Won Jeon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyun Phil Shin
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kwang Ro Joo
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Joung Il Lee
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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12
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Orságová Králová Z, Oriňak A, Oriňaková R, Petruš O, Macko J, Radoňak J, Sukovská Lakyová L, Jurašeková Z, Smith R, Strečková M, Koval K. Electrochemically deposited silver detection substrate for surface-enhanced Raman spectroscopy cancer diagnostics. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-11. [PMID: 29981226 DOI: 10.1117/1.jbo.23.7.075002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/18/2018] [Indexed: 05/20/2023]
Abstract
Surface-enhanced Raman spectroscopy (SERS) of blood plasma on an electrochemically prepared silver surface has been studied as a label-free, noninvasive diagnostic test for colorectal cancer. Indium tin oxide glass substrates were modified with 0.01 mol dm - 3 silver nitrate using the pulsed double-potentiostatic method. The prepared silver substrates were tested with Rhodamine 6G as a model analyte and the surface with the highest signal enhancement was selected. This silver dendritic surface was used as a diagnostic substrate for SERS measurements of human blood plasma. A group of oncological patients with declared colorectal carcinoma (n = 15) and the control group of healthy volunteers (n = 15) were compared. The biomolecular changes in chemical composition in the cancer samples were detected by statistical processing of the resulting SERS spectra. About 94% specificity and 100% sensitivity were achieved for the analysis by the ratio of the SERS peak intensity at 725 cm - 1 for adenine to the peak intensity at 638 cm - 1 for tyrosine and 100% specificity and sensitivity by using principal component analysis. This method of SERS diagnostics of colorectal cancer, which does not require the nanoparticle preparation, mixing, and incubation of plasma with a colloidal solution as in conventional tests, is a rapid, inexpensive method, which could be introduced as a primary diagnostic test.
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Affiliation(s)
| | | | | | | | - Ján Macko
- Pavol Jozef Šafárik Univ. in Košice, Slovakia
| | | | | | | | | | | | - Karol Koval
- Institute of Materials Research SAS, Slovakia
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13
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Ye D, Huang Q, Li Q, Jiang X, Mamat M, Tang M, Wang J, Chen K. Comparative Evaluation of Preliminary Screening Methods for Colorectal Cancer in a Mass Program. Dig Dis Sci 2017. [PMID: 28634645 DOI: 10.1007/s10620-017-4648-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The fecal immunochemical test (FIT) has been widely used in preliminary screening for colorectal cancer (CRC). The high-risk factor questionnaire (HRFQ) and quantitative risk-assessment method (QRAM) are recommended for estimating the risk of CRC qualitatively and quantitatively in China. AIM We aimed to prospectively compare the diagnostic values of CRC preliminary screening methods to identify which method is preferable as a screening strategy. METHODS Individuals aged 40-74 years old were enrolled in a mass CRC screening program from January 1, 2007 to December 31, 2014, in Jiashan County, Zhejiang Province, China. FIT of two stool specimens at 1-week intervals was performed by laboratory personnel and face-to-face interviews were conducted by trained investigators. Screening data in the program were linked to a CRC surveillance and registry system, and CRC cases reported in the system were regarded as true patients. RESULTS A total of 96,043 subjects were included. The sensitivity and specificity of FIT for detecting CRC cases were 75.49% (95% CI 69.84-80.39) and 90.36% (95% CI 90.17-90.54), respectively. QRAM was more sensitive (p < 0.001) and less specific (p < 0.001) than HRFQ. The sensitivity and specificity of FIT along with HRFQ were 86.56% (95% CI 81.81-90.22) and 81.37% (95% CI 81.12-81.62), and those of FIT along with QRAM were 88.93% (95% CI 84.47-92.23) and 73.95% (95% CI 73.67-74.23). CONCLUSIONS Our findings suggest that CRC preliminary screening with FIT and QRAM in parallel has high sensitivity and satisfactory specificity, and is a useful strategy in mass screening programs.
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Affiliation(s)
- Ding Ye
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, 310058, China
| | - Qiuchi Huang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, 310058, China
| | - Qilong Li
- Jiashan Institute of Cancer Prevention and Treatment, Jiaxing, 314100, China
| | - Xiyi Jiang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, 310058, China
| | - Mayila Mamat
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, 310058, China
| | - Mengling Tang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, 310058, China
| | - Jianbing Wang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, 310058, China
| | - Kun Chen
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, 310058, China.
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