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Gill I, Shams C, Hanna A, George J, Jamil LH, Patel A. Role of demographics in noninvasive testing for colorectal cancer screening: do targeted cut-off values improve detection? Minerva Gastroenterol (Torino) 2023; 69:459-469. [PMID: 35343664 DOI: 10.23736/s2724-5985.22.03124-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fecal immunochemical test (FIT) is a yearly alternative colorectal screening modality for average risk individuals unwilling or unable to undergo invasive colorectal cancer (CRC) screening due to cost and accessibility. This study aimed to determine whether FIT should be interpreted within the context of patient demographics and medical history. METHODS Patients >50 years old who had a FIT followed by colonoscopy within 1 year were analyzed based on age, race, BMI, social and medical comorbidities. False positive (FP) and false negative (FN) FIT results within each patient demographic and medical history variable were determined by comparing with the gold standard of colonoscopy using χ2 analysis. RESULTS One thousand twenty-five patients were reviewed. 21.8% of FIT results were positive. Factors which differed in positive FIT rates were age (P=0.003), smoking (P<0.001), alcohol (P=0.001), and hypertension (P<0.001). The difference in rates of FP and FN FIT outcomes among each variable underwent further subanalysis. The FP was 66.8% and the FN rate was 12.8%. Higher FN outcomes were noted in those above 70, males and smokers, though the result was only statistically significant for males (P=0.009). Females were observed to have higher FP rates (P=0.019). CONCLUSIONS Females had higher FP FIT rates compared to males, indicating that sex may influence FIT outcomes and should be accounted for when interpreting FIT results. This information can be utilized to identify populations at higher risk of FP or FN FIT results to target CRC screening. Additionally, recalculating the FP and FN rates for each variable may help determine new FIT targets.
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Affiliation(s)
- Inayat Gill
- Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA -
| | - Christienne Shams
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Angy Hanna
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Detroit Medical Center, Detroit, MI, USA
| | - Julie George
- Section of Biostatistics, Department of Beaumont Research Institute, Royal Oak, MI, USA
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
| | - Atulkumar Patel
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Beaumont Health, Royal Oak, MI, USA
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Yeh JH, Tseng CH, Wang WL, Chen CI, Liu YP, Lee YC, Wang JY, Lin YC. Performance of the Fecal Immunochemical Test in Detecting Advanced Colorectal Neoplasms and Colorectal Cancers in People Aged 40-49 Years: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15113006. [PMID: 37296969 DOI: 10.3390/cancers15113006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/24/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The incidence of early-onset colorectal cancer (CRC) is increasing. Many guidelines recommend initiating screening at 45 years. This study investigated the detection rate of advanced colorectal neoplasm (ACRN) by using fecal immunochemical tests (FITs) in individuals aged 40-49 years. METHODS PubMed, Embase, and Cochrane Library databases were searched from inception to May 2022. The primary outcomes were the detection rates and positive predictive values of FITs for ACRN and CRC in people aged 40-49 (younger age group) and ≥50 years (average risk group). RESULTS Ten studies with 664,159 FITs were included. The FIT positivity rate was 4.9% and 7.3% for the younger age and average risk groups, respectively. Younger individuals with positive FIT results had significantly higher risks of ACRN (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.79-3.73) or CRC (OR 2.86, 95% CI 1.59-5.13) than did individuals in the average-risk group, regardless of FIT results. Individuals aged 45-49 years with positive FIT results had a similar risk of ACRN (OR 0.80, 95% CI 0.49-1.29) to that of people aged 50-59 years with positive FIT results, although significant heterogeneity was observed. The positive predictive values of the FIT were 10-28.1% for ACRN and 2.7-6.8% for CRC in the younger age group. CONCLUSION The detection rate of ACRN and CRC based on FITs in individuals aged 40-49 years is acceptable, and the yield of ACRN might be similar between individuals aged 45-49 and 50-59 years. Further prospective cohort and cost-effective analysis are warranted.
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Affiliation(s)
- Jen-Hao Yeh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA DaChang Hospital, I-Shou University, Kaohsiung 813, Taiwan
- Department of Medical Technology, College of Medicine, I-Shou University, Kaohsiung 824, Taiwan
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung 813, Taiwan
| | - Cheng-Hao Tseng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Cancer Hospital, Kaohsiung 824, Taiwan
| | - Wen-Lun Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-DA Cancer Hospital, Kaohsiung 824, Taiwan
| | - Chih-I Chen
- Division of Colorectal Surgery, Department of Surgery, E-DA Hospital, Kaohsiung 824, Taiwan
| | - Yu-Peng Liu
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung 813, Taiwan
- Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung 813, Taiwan
| | - Yi-Chia Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Jaw-Yuan Wang
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung 813, Taiwan
- Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 813, Taiwan
- Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 813, Taiwan
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung 813, Taiwan
- Pingtung Hospital, Ministry of Health and Welfare, Pingtung 900, Taiwan
| | - Yu-Ching Lin
- Department of Family Medicine, E-DA DaChang Hospital, I-Shou University, Kaohsiung 824, Taiwan
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Kaalby L, Deding U, Kobaek-Larsen M, Havshoi ALV, Zimmermann-Nielsen E, Thygesen MK, Kroeijer R, Bjørsum-Meyer T, Baatrup G. Colon capsule endoscopy in colorectal cancer screening: a randomised controlled trial. BMJ Open Gastroenterol 2021; 7:bmjgast-2020-000411. [PMID: 32601101 PMCID: PMC7326244 DOI: 10.1136/bmjgast-2020-000411] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/07/2020] [Accepted: 05/31/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction The use of capsule endoscopy has become an approved method in small bowel diagnostics, but the same level of integration is not seen in large bowel diagnostics. We will use colon capsule endoscopy (CCE) as a filter test in colorectal cancer (CRC) screening between the faecal immunochemical test (FIT) and colonoscopy. We aim to investigate the clinical performance, population acceptability, and economic implications of the procedure in a large-scale clinical trial. Methods and analysis We will randomly allocate 124 214 Danish citizens eligible for participation in the national CRC screening programme within the Region of Southern Denmark to either an intervention group or a control group. Prior to submitting a FIT, citizens randomised to the intervention group will be informed about their opportunity to undergo CCE, instead of colonoscopy, if the FIT is positive. Suspected cancers; >3 adenomas <10 mm in size, 1 adenoma >10 mm in size or >4 adenomas regardless of size, detected during CCE will generate an invitation to colonoscopy as per regular screening guidelines, whereas citizens with suspected low risk polyps will re-enter the biennial screening programme. Citizens with no CCE findings will be excluded from screening for 8 years. In the control group, citizens will follow standard screening procedures. Ethics and dissemination All participants must consent prior to capsule ingestion. All collected data will be handled and stored in accordance with current data protection legislation. Approvals from the regional ethics committee (ref. S-20190100) and the Danish data protection agency have been obtained (ref. 19/29858). Trial registration details The study has been registered with ClinicalTrials.gov under: NCT04049357.
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Affiliation(s)
- Lasse Kaalby
- Department of Surgery, Odense University Hospital, Svendborg, Denmark .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ulrik Deding
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Morten Kobaek-Larsen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Erik Zimmermann-Nielsen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marianne Kirstine Thygesen
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rasmus Kroeijer
- Department of Surgery, Southwest Jutland Hospital Esbjerg, Esbjerg, Denmark
| | | | - Gunnar Baatrup
- Department of Surgery, Odense University Hospital, Svendborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Ibáñez-Sanz G, Sanz-Pamplona R, Garcia M. Future Prospects of Colorectal Cancer Screening: Characterizing Interval Cancers. Cancers (Basel) 2021; 13:cancers13061328. [PMID: 33809520 PMCID: PMC8001713 DOI: 10.3390/cancers13061328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/06/2021] [Accepted: 03/13/2021] [Indexed: 12/11/2022] Open
Abstract
Tumors that are not detected by screening tests are known as interval cancers and are diagnosed clinically after a negative result in the screening episode but before the next screening invitation. Clinical characteristics associated with interval colorectal cancers have been studied, but few molecular data are available that describe interval colorectal cancers. A better understanding of the clinical and biological characteristics associated with interval colorectal cancer may provide new insights into how to prevent this disease more effectively. This review aimed to summarize the current literature concerning interval colorectal cancer and its epidemiological, clinical, and molecular features.
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Affiliation(s)
- Gemma Ibáñez-Sanz
- Oncology Data Analytics Programme, Catalan Institute of Oncology, Hospitalet de Llobregat, 08907 Barcelona, Spain;
- Gastroenterology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Colorectal Cancer Research Group, ONCOBELL Programme, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, 08907 Barcelona, Spain
- CIBER Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
| | - Rebeca Sanz-Pamplona
- Oncology Data Analytics Programme, Catalan Institute of Oncology, Hospitalet de Llobregat, 08907 Barcelona, Spain;
- Colorectal Cancer Research Group, ONCOBELL Programme, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, 08907 Barcelona, Spain
- CIBER Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
- Correspondence: (R.S.-P.); (M.G.); Tel.: +349-32-607-186 (R.S.-P. & M.G.)
| | - Montse Garcia
- CIBER Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
- Cancer Screening Unit, Prevention and Control Programme, Catalan Institute of Oncology, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Early Detection of Cancer Research Group, EPIBELL Programme, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, 08907 Barcelona, Spain
- Correspondence: (R.S.-P.); (M.G.); Tel.: +349-32-607-186 (R.S.-P. & M.G.)
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Steel MJ, Bukhari H, Gentile L, Telford J, Schaeffer DF. Colorectal adenocarcinomas diagnosed following a negative faecal immunochemical test show high-risk pathological features in a colon screening programme. Histopathology 2020; 78:710-716. [PMID: 33037645 DOI: 10.1111/his.14278] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/06/2020] [Indexed: 12/30/2022]
Abstract
AIMS The faecal immunochemical test (FIT) is used every 2 years to screen average-risk British Columbians aged 50-74 years, with follow-up colonoscopy for positive results. Non-screen-detected colorectal adenocarcinomas are defined as those detected within 25 months following a negative FIT. We aimed to more clearly characterise these malignancies. METHODS AND RESULTS A medical chart and focused pathology review of colorectal malignancies from 926 individuals who completed FIT in the British Columbia Colon Screening Program in 2014, and whose pathology reports were available for review, was conducted. This cohort was divided into two groups: individuals with colorectal adenocarcinomas diagnosed following a positive FIT (screen-detected) and individuals with colorectal adenocarcinoma diagnosed within 25 months of a negative FIT (FIT-interval cancers). Rates of clinically relevant pathological parameters, as outlined in the American Joint Committee on Cancer (AJCC), 8th edition, were compared between the screen-detected and FIT-interval cancer groups. A total of 876 screen-detected and 50 FIT-interval cancers were identified. FIT-interval cancers exhibited higher rates of high-grade differentiation (including poorly differentiated and undifferentiated cases; P < 0.01) and aggressive histotype (signet ring cell and mucinous carcinomas; P < 0.01) than did screen-detected cancers after Bonferroni correction. Colorectal adenocarcinoma diagnosed after a negative FIT may therefore be associated with worse prognostic determinants than screen-detected cancers. CONCLUSION FIT-interval cancers are associated with high-risk pathological features; the possibility that more aggressive, fast-growing lesions which arise in the interval after truly negative FITs cannot be ruled out. Further study of a larger cohort of FIT-interval cancers controlling for interaction among the different pathologic parameters will be undertaken.
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Affiliation(s)
- Michael J Steel
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hussam Bukhari
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Laura Gentile
- British Columbia Colon Screening Program, Vancouver, BC, Canada
| | - Jennifer Telford
- British Columbia Colon Screening Program, Vancouver, BC, Canada.,Division of Gastroenterology, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David F Schaeffer
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Colon Screening Program, Vancouver, BC, Canada
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6
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Multitarget Stool DNA Screening in Clinical Practice: High Positive Predictive Value for Colorectal Neoplasia Regardless of Exposure to Previous Colonoscopy. Am J Gastroenterol 2020; 115:608-615. [PMID: 32068535 PMCID: PMC7127971 DOI: 10.14309/ajg.0000000000000546] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Multitarget stool DNA (MT-sDNA) testing has grown as a noninvasive screening modality for colorectal cancer (CRC), but real-world clinical data are limited in the post-FDA approval setting. The effect of previous colonoscopy on MT-sDNA performance is not known. We aimed to evaluate findings of colorectal neoplasia (CRN) at diagnostic colonoscopy in patients with positive MT-sDNA testing, stratified by patient exposure to previous colonoscopy. METHODS We identified consecutive patients completing MT-sDNA testing over a 39-month period and reviewed the records of those with positive tests for neoplastic findings at diagnostic colonoscopy. MT-sDNA test positivity rate, adherence to diagnostic colonoscopy, and the positive predictive value (PPV) of MT-sDNA for any CRN and neoplastic subtypes were calculated. RESULTS Of 16,469 MT-sDNA tests completed, testing returned positive in 2,326 (14.1%) patients. After exclusion of patients at increased risk for CRC, 1,801 patients remained, 1,558 (87%) of whom underwent diagnostic colonoscopy; 918 of 1,558 (59%) of these patients had undergone previous colonoscopy, whereas 640 (41%) had not. Any CRN was found in 1,046 of 1,558 patients (PPV = 67%). More neoplastic lesions were found in patients without previous colonoscopy (73%); however, the rates remained high among those who had undergone previous colonoscopy (63%, P < 0.0001). The large majority (79%) of patients had right-sided neoplasia. DISCUSSION MT-sDNA has a high PPV for any CRN regardless of exposure to previous colonoscopy. Right-sided CRN was found at colonoscopy in most patients with positive MT-sDNA testing, representing a potential advantage over other currently available screening modalities for CRC.
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7
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Ribbing Wilén H, Blom J, Höijer J, Andersson G, Löwbeer C, Hultcrantz R. Fecal immunochemical test in cancer screening - colonoscopy outcome in FIT positives and negatives. Scand J Gastroenterol 2019; 54:303-310. [PMID: 30907196 DOI: 10.1080/00365521.2019.1585569] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: Fecal immunochemical test (FIT) is used in colorectal cancer (CRC) screening, but evaluations of multiple sample strategies in colonoscopy screening cohorts are rare. The aim of this study was to assess accuracy of FIT for advanced neoplasia (AN) with two fecal samples in a colonoscopy screening cohort. Materials and methods: The study comprised 1155 participants of the colonoscopy arm in SCREESCO (Screening of Swedish Colons, NCT02078804), a randomized controlled study on CRC screening of 60-year-olds from the Swedish average-risk population. Participants provided two FIT samples prior to colonoscopy. First sample, mean of two, and any of the two samples above cut off level were assessed. Colonoscopy findings (CRC, advanced adenoma (AA), AN (CRC + AA) and adenoma characteristics) were evaluated in uni- and multivariable analysis in relation to FIT positivity (at ≥10 µg hemoglobin (Hb)/g). Results: Of 1155 invited, 806 (416 women, 390 men) participated. CRC, AA and non-AA were found in one (0.1%), 80 (9.9%) and 145 (18%), respectively. Sensitivity and specificity for AN were 20%/93%, 25%/92% and 26%/89% for first, mean of two and any of the two samples respectively at cut off level 10 µg/g, corresponding to 60 (74%)-65 (80%) participants with missed AN. The difference in sensitivity between screening strategies was non-significant. The specificity for first sample was significantly higher than for any of the two samples at cut off 10 µg/g (p = .02) and 20 µg/g (p = .04). FIT positivity in participants with adenoma was associated with pedunculated shape (p = .007) and high-risk dysplasia (p = .009). Conclusions: In an average-risk colonoscopy screening cohort of 60-year-olds, sensitivity for AN was modest and did not increase when using two samples instead of one. FIT predominantly detected adenomas with pedunculated shape and high-risk dysplasia, and participants with flat or broad based adenomas may thus be missed in screening.
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Affiliation(s)
- Hanna Ribbing Wilén
- a Department of Clinical Science, Intervention and Technology , Karolinska Institutet , Stockholm , Sweden.,b Trauma and Reparative Medicine, Division of Emergency Surgery , Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Johannes Blom
- c Department of Molecular Medicine and Surgery , Karolinska Institutet and Stockholm County Council , Stockholm , Sweden
| | - Jonas Höijer
- d Unit of Biostatistics Institute of Environmental Medicine , Karolinska Institutet , Stockholm , Sweden
| | - Gaya Andersson
- e Department of Clinical Chemistry , Aleris Medilab , Täby , Sweden
| | - Christian Löwbeer
- e Department of Clinical Chemistry , Aleris Medilab , Täby , Sweden.,f Department of Laboratory Medicine, Division of Clinical Chemistry , Karolinska Institutet , Stockholm , Sweden
| | - Rolf Hultcrantz
- g Department of Medicine , Solna Karolinska Institutet , Stockholm , Sweden
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8
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Amitay EL, Cuk K, Niedermaier T, Weigl K, Brenner H. Factors associated with false‐positive fecal immunochemical tests in a large German colorectal cancer screening study. Int J Cancer 2019; 144:2419-2427. [DOI: 10.1002/ijc.31972] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/15/2018] [Accepted: 10/26/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Efrat L. Amitay
- Division of Clinical Epidemiology and Aging ResearchGerman Cancer Research Center (DKFZ) Heidelberg Germany
| | - Katarina Cuk
- Division of Clinical Epidemiology and Aging ResearchGerman Cancer Research Center (DKFZ) Heidelberg Germany
| | - Tobias Niedermaier
- Division of Clinical Epidemiology and Aging ResearchGerman Cancer Research Center (DKFZ) Heidelberg Germany
- Heidelberg Medical FacultyHeidelberg University Heidelberg Germany
| | - Korbinian Weigl
- Division of Clinical Epidemiology and Aging ResearchGerman Cancer Research Center (DKFZ) Heidelberg Germany
- Heidelberg Medical FacultyHeidelberg University Heidelberg Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) Heidelberg Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging ResearchGerman Cancer Research Center (DKFZ) Heidelberg Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ) Heidelberg Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT) Heidelberg Germany
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Sekiguchi M, Igarashi A, Sakamoto T, Saito Y, Esaki M, Matsuda T. Cost-effectiveness analysis of postpolypectomy colonoscopy surveillance using Japanese data. Dig Endosc 2019; 31:40-50. [PMID: 30062760 DOI: 10.1111/den.13250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/26/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Recommendations vary on postpolypectomy surveillance, and no consensus has been reached even regarding the necessity of risk stratification based on polyp characteristics for surveillance. We examined an optimal postpolypectomy surveillance program by performing a cost-effectiveness analysis. METHODS We performed a Markov model analysis using parameters based on Japanese data and evaluated four postpolypectomy surveillance programs with respect to their effectiveness in terms of quality-adjusted life-years (QALYs), cost-effectiveness and required number of colonoscopies. Two were non-risk-stratified programs with 1-year (program 1) and 3-year (program 2) postpolypectomy surveillance colonoscopy, and the other two were risk-stratified programs. In program 3, surveillance colonoscopy was performed 3, 10 and 10 years after resection of advanced adenomas, low-risk adenomatous polyps, and no polyps, respectively. In program 4, those intervals were shortened to 1, 3 and 5 years, respectively. RESULTS Risk-stratified programs (3 and 4) yielded higher QALYs with lower costs than non-risk-stratified programs (1 and 2). Program 4 yielded higher QALYs (23.046) and lower required cost (107,717 JPY) than program 3. The required number of colonoscopies for program 4 was 1.2, 1.5 and 1.6 times that for programs 1, 2 and 3, respectively. A probabilistic sensitivity analysis showed that the probability of program 4 being chosen as the most cost-effective was highest. CONCLUSIONS After polypectomy, risk-stratified colonoscopy surveillance based on the polyp characteristics should be considered. A risk-stratified program with relatively short examination intervals could be effective and cost-effective in Japan, although further investigation and consideration of colonoscopy capacity are required.
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Affiliation(s)
- Masau Sekiguchi
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan.,Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.,Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Ataru Igarashi
- Department of Health Economics and Outcomes Research, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Minoru Esaki
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahisa Matsuda
- Cancer Screening Center, National Cancer Center Hospital, Tokyo, Japan.,Division of Screening Technology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.,Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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10
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Participant-Related Risk Factors for False-Positive and False-Negative Fecal Immunochemical Tests in Colorectal Cancer Screening: Systematic Review and Meta-Analysis. Am J Gastroenterol 2018; 113:1778-1787. [PMID: 30158713 PMCID: PMC6768609 DOI: 10.1038/s41395-018-0212-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Colorectal cancer (CRC) screening using fecal immunochemical tests (FIT) may reduce CRC-related mortality but its effectiveness is influenced by the limited accuracy of FIT. Identifying individuals at increased risk of a false FIT result could improve screening, but the available evidence is conflicting. We performed a systematic review and meta-analysis on risk factors for false-positive and false-negative FIT results in CRC screening. METHODS A systematic search in MEDLINE, EMBASE, and Cochrane Library identified publications (before 29 January 2017) on risk factors (known at time of FIT invitation) associated with false FIT results (presence/absence of advanced neoplasia) in a CRC screening setting. Risk of bias was assessed using QUIPS. In meta-analysis, summary relative risk ratios and corresponding 95% confidence intervals were calculated for each risk factor. RESULTS Of 518 records identified, 14 studies with 54,499 participants in total were included for analysis. In meta-analysis, male sex was associated with a significantly lower risk of false-positivity (RR 0.84, CI 0.74-0.94), whereas participants using non-steroidal anti-inflammatory drugs (NSAIDs) had a higher risk (RR 1.16, CI 1.06-1.27). The use of anticoagulants was most frequently studied, without a significant effect on FIT positivity. Males (RR 1.83, CI 1.53-2.19), participants with a family history for CRC (RR 1.61, CI 1.19-2.15), hyperglycemia (RR 1.29, CI 1.02-1.65), hypertension (RR 1.50, CI 1.14-1.98), obesity (RR 1.38, CI 1.11-1.71), and (former) smokers (RR 1.93, CI 1.52-2.45) were all at significantly higher risk for false-negative results. Age was not found to have a systematic effect on either FIT false-positivity or false-negativity in meta-analysis. CONCLUSIONS Multiple risk factors, known at time of FIT invitation, are associated with false FIT results in CRC screening. This information can be used to identify populations risking false reassurance after a negative result or unnecessary colonoscopy after a positive result, and to further optimize CRC screening effectiveness.
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11
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Kobaek-Larsen M, Kroijer R, Dyrvig AK, Buijs MM, Steele RJC, Qvist N, Baatrup G. Back-to-back colon capsule endoscopy and optical colonoscopy in colorectal cancer screening individuals. Colorectal Dis 2018; 20:479-485. [PMID: 29166546 DOI: 10.1111/codi.13965] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/02/2017] [Indexed: 02/08/2023]
Abstract
AIM The aim was to determine the polyp detection rate and per-patient sensitivity for polyps > 9 mm of colon capsule endoscopy (CCE) compared with colonoscopy as well as the diagnostic accuracy of CCE. METHOD Individuals who had a positive immunochemical faecal occult blood test during screening had investigator blinded CCE and colonoscopy. Participants underwent repeat endoscopy if significant lesions detected by CCE were considered to have been missed by colonoscopy. RESULTS There were 253 participants. The polyp detection rate was significantly higher in CCE compared with colonoscopy (P = 0.02). The per-patient sensitivity for > 9 mm polyps for CCE and colonoscopy was 87% (95% CI: 83-91%) and 88% (95% CI: 84-92%) respectively. In participants with complete CCE and colonoscopy examinations (N = 126), per-patient sensitivity of > 9 mm polyps in CCE (97%; 95% CI: 94-100%) was superior to colonoscopy (89%; 95% CI: 84-94%). A complete capsule endoscopy examination (N = 134) could detect patients with intermediate or greater risk (according to the European guidelines) with an accuracy, sensitivity, specificity and positivity rate of 79%, 93%, 69% and 58% respectively, using a cut-off of at least one polyp > 10 mm or more than two polyps. CONCLUSION CCE is superior to colonoscopy in polyp detection rate and per-patient sensitivity to > 9 mm polyps, but only in complete CCE examinations. The rate of incomplete CCE examinations must be improved.
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Affiliation(s)
- M Kobaek-Larsen
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - R Kroijer
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - A-K Dyrvig
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - M M Buijs
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - R J C Steele
- Dundee University Hospital and National Screening Centre, Dundee, UK
| | - N Qvist
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - G Baatrup
- Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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12
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Abstract
PURPOSE OF REVIEW The goal of this review is to summarize stool-based testing for colorectal cancer (CRC). The key questions answered in this review were the advantages and limitations of each available stool-based test for CRC and to examine their comparative efficacy. RECENT FINDINGS Guaiac-based fecal occult blood testing (gFOBT) is no longer a relevant test for CRC screening. fecal immunochemical testing (FIT) tests, especially quantitative assays, are clearly a reliable stool-based test. Multitarget DNA (mtsDNA) stool testing may represent a viable option as well, although cost and test characteristics are yet fully defined. FIT and mtsDNA represent the options for stool-based CRC screening. In larger screening centers, quantitative FIT assays represent an attractive option for stool-based testing. Qualitative FIT has applicability in smaller centers. Although a large validation trial showed promising results for mtsDNA, further head-to-head trials with FIT will help define the ultimate role of mtsDNA. Ultimately, however, the best test for CRC screening is the one performed stool-based CRC screening as an initial or alternative option can increase participation in CRC screening.
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13
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Alexander M, Burch JB, Steck SE, Chen CF, Hurley TG, Cavicchia P, Shivappa N, Guess J, Zhang H, Youngstedt SD, Creek KE, Lloyd S, Jones K, Hébert JR. Case-control study of candidate gene methylation and adenomatous polyp formation. Int J Colorectal Dis 2017; 32:183-192. [PMID: 27771773 PMCID: PMC5288296 DOI: 10.1007/s00384-016-2688-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Colorectal cancer (CRC) is one of the most common and preventable forms of cancer but remains the second leading cause of cancer-related death. Colorectal adenomas are precursor lesions that develop in 70-90 % of CRC cases. Identification of peripheral biomarkers for adenomas would help to enhance screening efforts. This exploratory study examined the methylation status of 20 candidate markers in peripheral blood leukocytes and their association with adenoma formation. METHODS Patients recruited from a local endoscopy clinic provided informed consent and completed an interview to ascertain demographic, lifestyle, and adenoma risk factors. Cases were individuals with a histopathologically confirmed adenoma, and controls included patients with a normal colonoscopy or those with histopathological findings not requiring heightened surveillance (normal biopsy, hyperplastic polyp). Methylation-specific polymerase chain reaction was used to characterize candidate gene promoter methylation. Odds ratios (ORs) and 95 % confidence intervals (95% CIs) were calculated using unconditional multivariable logistic regression to test the hypothesis that candidate gene methylation differed between cases and controls, after adjustment for confounders. RESULTS Complete data were available for 107 participants; 36 % had adenomas (men 40 %, women 31 %). Hypomethylation of the MINT1 locus (OR 5.3, 95% CI 1.0-28.2) and the PER1 (OR 2.9, 95% CI 1.1-7.7) and PER3 (OR 11.6, 95% CI 1.6-78.5) clock gene promoters was more common among adenoma cases. While specificity was moderate to high for the three markers (71-97 %), sensitivity was relatively low (18-45 %). CONCLUSION Follow-up of these epigenetic markers is suggested to further evaluate their utility for adenoma screening or surveillance.
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Affiliation(s)
- M Alexander
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Room 228, Columbia, SC, 29209, USA
| | - J B Burch
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA.
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Room 228, Columbia, SC, 29209, USA.
- William Jennings Bryant Dorn Department of Veterans Affairs Medical Center, Columbia, SC, USA.
| | - S E Steck
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Room 228, Columbia, SC, 29209, USA
| | - C-F Chen
- Center for Molecular Studies, Greenwood Genetic Center, Greenwood, SC, USA
| | - T G Hurley
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA
| | - P Cavicchia
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Room 228, Columbia, SC, 29209, USA
- Division of Community Health Promotion, Florida Department of Health, Tallahassee, FL, USA
| | - N Shivappa
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Room 228, Columbia, SC, 29209, USA
| | - J Guess
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Room 228, Columbia, SC, 29209, USA
| | - H Zhang
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - S D Youngstedt
- College of Nursing and Health Innovation, College of Health Solutions, Arizona State University and Phoenix VA Health Care System, Phoenix, AZ, USA
| | - K E Creek
- Department of Drug Discovery and Biomedical Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - S Lloyd
- South Carolina Medical Endoscopy Center, and Department of Family Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
| | - K Jones
- Center for Molecular Studies, Greenwood Genetic Center, Greenwood, SC, USA
| | - J R Hébert
- South Carolina Statewide Cancer Prevention and Control Program, University of South Carolina, Columbia, SC, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St, Room 228, Columbia, SC, 29209, USA
- Department of Family and Preventive Medicine, School of Medicine, University of South Carolin, Columbia, SC, USA
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14
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Abstract
GOALS We investigated the factors associated with false fecal immunochemical test (FIT) results for advanced colorectal neoplasm (ACRN). BACKGROUND Data on whether certain subgroups of patients have an increased risk of inaccurate FIT results are extremely limited. STUDY This was a retrospective study conducted in a university hospital in Korea from June 2013 to May 2015. Out of 34,547 participants who had an FIT completed, we analyzed a total of 3990 subjects aged 50 years and above who underwent colonoscopy. RESULTS The rates of false-negative and false-positive results were 58.0% and 15.7%, respectively. Elevated fasting blood glucose [adjusted odds ratio (AOR), 0.59; 95% confidence interval (CI), 0.36-0.97], the presence of high-grade dysplasia (AOR, 0.49; 95% CI, 0.25-0.95), 3 or more adenomas (AOR, 0.56; 95% CI, 0.35-0.89), cancer (AOR, 0.20; 95% CI, 0.11-0.38), and distal ACRN (AOR, 0.61; 95% CI, 0.39-0.96) were associated with a lower risk of false-negative FIT results. The presence of proximal ACRN (AOR, 1.59; 95% CI, 1.01-2.51) and adenoma ≥10 mm (AOR, 4.38; 95% CI, 2.17-8.87) were associated with a higher risk of false-negative results. Older age (70 y and above; AOR, 1.67; 95% CI, 1.29-2.17), diverticulum (AOR, 1.94; 95% CI, 1.45-2.58), and hemorrhoid (AOR, 1.63; 95% CI, 1.32-2.01) were associated with false-positive results. CONCLUSIONS Subjects with a higher risk of false-negative results should be prioritized for earlier colonoscopy and subjects with inaccurate results should be more cautiously considered for screening by using modalities other than FIT. Our findings will contribute to individualization of screening programs.
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15
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Sali L, Mascalchi M, Falchini M, Ventura L, Carozzi F, Castiglione G, Delsanto S, Mallardi B, Mantellini P, Milani S, Zappa M, Grazzini G. Reduced and Full-Preparation CT Colonography, Fecal Immunochemical Test, and Colonoscopy for Population Screening of Colorectal Cancer: A Randomized Trial. J Natl Cancer Inst 2016; 108:djv319. [PMID: 26719225 DOI: 10.1093/jnci/djv319] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 10/05/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Population screening for colorectal cancer (CRC) is widely adopted, but the preferred strategy is still under debate. We aimed to compare reduced (r-CTC) and full cathartic preparation CT colonography (f-CTC), fecal immunochemical test (FIT), and optical colonoscopy (OC) as primary screening tests for CRC. METHODS Citizens of a district of Florence, Italy, age 54 to 65 years, were allocated (8:2.5:2.5:1) with simple randomization to be invited by mail to one of four screening interventions: 1) biennial FIT for three rounds, 2) r-CTC, 3) f-CTC, 4) OC. Patients tested positive to FIT or CTC (at least one polyp ≥6mm) were referred to OC work-up. The primary outcomes were participation rate and detection rate (DR) for cancer or advanced adenoma (advanced neoplasia). All statistical tests were two-sided. RESULTS Sixteen thousand eighty-seven randomly assigned subjects were invited to the assigned screening test. Participation rates were 50.4% (4677/9288) for first-round FIT, 28.1% (674/2395) for r-CTC, 25.2% (612/2430) for f-CTC, and 14.8% (153/1036) for OC. All differences between groups were statistically significant (P = .047 for r-CTC vs f-CTC; P < .001 for all others). DRs for advanced neoplasia were 1.7% (79/4677) for first-round FIT, 5.5% (37/674) for r-CTC, 4.9% (30/612) for f-CTC, and 7.2% (11/153) for OC. Differences in DR between CTC groups and FIT were statistically significant (P < .001), but not between r-CTC and f-CTC (P = .65). CONCLUSIONS Reduced preparation increases participation in CTC. Lower attendance and higher DR of CTC as compared with FIT are key factors for the optimization of its role in population screening of CRC.
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Affiliation(s)
- Lapo Sali
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD).
| | - Mario Mascalchi
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Massimo Falchini
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Leonardo Ventura
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Francesca Carozzi
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Guido Castiglione
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Silvia Delsanto
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Beatrice Mallardi
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Paola Mantellini
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Stefano Milani
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Marco Zappa
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
| | - Grazia Grazzini
- Department of Biomedical, Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy (LS, MM, MF, SM); Cancer Prevention and Research Institute (ISPO), Florence, Italy (LV, FC, GC, BM, PM, MZ, GG); im3D S.p.A., Turin, Italy (SD)
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16
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Sekiguchi M, Igarashi A, Matsuda T, Matsumoto M, Sakamoto T, Nakajima T, Kakugawa Y, Yamamoto S, Saito H, Saito Y. Optimal use of colonoscopy and fecal immunochemical test for population-based colorectal cancer screening: a cost-effectiveness analysis using Japanese data. Jpn J Clin Oncol 2015; 46:116-25. [PMID: 26685321 DOI: 10.1093/jjco/hyv186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/09/2015] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE There have been few cost-effectiveness analyses of population-based colorectal cancer screening in Japan, and there is no consensus on the optimal use of total colonoscopy and the fecal immunochemical test for colorectal cancer screening with regard to cost-effectiveness and total colonoscopy workload. The present study aimed to examine the cost-effectiveness of colorectal cancer screening using Japanese data to identify the optimal use of total colonoscopy and fecal immunochemical test. METHODS We developed a Markov model to assess the cost-effectiveness of colorectal cancer screening offered to an average-risk population aged 40 years or over. The cost, quality-adjusted life-years and number of total colonoscopy procedures required were evaluated for three screening strategies: (i) a fecal immunochemical test-based strategy; (ii) a total colonoscopy-based strategy; (iii) a strategy of adding population-wide total colonoscopy at 50 years to a fecal immunochemical test-based strategy. RESULTS All three strategies dominated no screening. Among the three, Strategy 1 was dominated by Strategy 3, and the incremental cost per quality-adjusted life-years gained for Strategy 2 against Strategies 1 and 3 were JPY 293 616 and JPY 781 342, respectively. Within the Japanese threshold (JPY 5-6 million per QALY gained), Strategy 2 was the most cost-effective, followed by Strategy 3; however, Strategy 2 required more than double the number of total colonoscopy procedures than the other strategies. CONCLUSIONS The total colonoscopy-based strategy could be the most cost-effective for population-based colorectal cancer screening in Japan. However, it requires more total colonoscopy procedures than the other strategies. Depending on total colonoscopy capacity, the strategy of adding total colonoscopy for individuals at a specified age to a fecal immunochemical test-based screening may be an optimal solution.
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Affiliation(s)
| | - Ataru Igarashi
- Graduate School of Pharmaceutical Science, The University of Tokyo, Tokyo
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo Cancer Screening Division, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo
| | | | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo
| | | | - Yasuo Kakugawa
- Endoscopy Division, National Cancer Center Hospital, Tokyo
| | - Seiichiro Yamamoto
- Public Health Policy Research Division, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo
| | - Hiroshi Saito
- Screening Assessment and Management Division, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo
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17
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Fedeli U, Zorzi M, Urso ED, Gennaro N, Dei Tos AP, Saugo M. Impact of fecal immunochemical test-based screening programs on proximal and distal colorectal cancer surgery rates: A natural multiple-baseline experiment. Cancer 2015; 121:3982-9. [DOI: 10.1002/cncr.29623] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/15/2015] [Accepted: 07/20/2015] [Indexed: 01/27/2023]
Affiliation(s)
- Ugo Fedeli
- Regional Epidemiological Department; Veneto Region Padua Italy
| | - Manuel Zorzi
- Veneto Tumour Registry; Veneto Region Padua Italy
| | - Emanuele D.L. Urso
- First Surgical Department; University of Padua Medical Center; Padua Italy
| | - Nicola Gennaro
- Regional Epidemiological Department; Veneto Region Padua Italy
| | - Angelo P. Dei Tos
- Veneto Tumour Registry; Veneto Region Padua Italy
- Department of Pathology; Treviso General Hospital; Treviso Italy
| | - Mario Saugo
- Regional Epidemiological Department; Veneto Region Padua Italy
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18
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Wakamura K, Kudo SE, Miyachi H, Kodama K, Hayashi S, Maeda Y, Ogawa Y, Kouyama Y, Kataoka SI, Kato K, Ichimasa K, Misawa M, Mori Y, Kudo T, Hayashi T, Ishida F, Ohkoshi S. Characteristics of colorectal tumours in asymptomatic patients with negative immunochemical faecal occult blood test results. Mol Clin Oncol 2015; 3:1019-1024. [PMID: 26623043 DOI: 10.3892/mco.2015.591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 12/22/2014] [Indexed: 02/06/2023] Open
Abstract
The immunochemical faecal occult blood test (iFOBT) is a simple, non-invasive colorectal cancer (CRC) screening method for reducing CRC-related mortality. However, the sensitivity of iFOBT is imperfect and certain colonic neoplasms that require removal may be missed. The aim of this study was to investigate the incidence and characteristics of CRC in asymptomatic, iFOBT-negative patients who underwent opportunistic screening. A total of 919 subclinical patients (276 iFOBT-positive and 643 iFOBT-negative) in the health screening program of our hospital underwent total colonoscopy (TCS) within 2 years after iFOBT. The patients were divided into an iFOBT-positive and an iFOBT-negative group and the TCS findings were compared between the two groups. Although the incidence of advanced neoplasia (CRC, high-grade dysplasia, adenoma sized ≥10 mm and tubulovillous adenoma) was significantly higher in the iFOBT-positive group, these lesions were also found in 6.3% of iFOBT-negative patients. The lesions tended to be proximally located and non-protruding. In conclusion, screening with iFOBT remains clinically significant. However, colonoscopy is indispensable for reducing the incidence and mortality of CRC.
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Affiliation(s)
- Kunihiko Wakamura
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Hideyuki Miyachi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Kenta Kodama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Seiko Hayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yasuharu Maeda
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yushi Ogawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yuta Kouyama
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Shin-Ichi Kataoka
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Kazuki Kato
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Katsuro Ichimasa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Toyoki Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Takemasa Hayashi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Fumio Ishida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan
| | - Shogo Ohkoshi
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa 224-8503, Japan ; Department of Internal Medicine, School of Life Dentistry, Nippon Dental University, Niigata, Niigata 951-8580, Japan
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19
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Symonds EL, Osborne JM, Cole SR, Bampton PA, Fraser RJL, Young GP. Factors affecting faecal immunochemical test positive rates: demographic, pathological, behavioural and environmental variables. J Med Screen 2015; 22:187-93. [PMID: 25977374 DOI: 10.1177/0969141315584783] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 04/02/2015] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Positive rates in faecal immunochemical test (FIT)-based colorectal cancer screening programmes vary, suggesting that differences between programmes may affect test results. We examined whether demographic, pathological, behavioural, and environmental factors affected haemoglobin concentration and positive rates where samples are mailed. METHODS A retrospective cohort study; 34,298 collection devices were sent, over five years, to screening invitees (median age 60.6). Participant demographics, temperature on sample postage day, and previous screening were recorded. Outcomes from colonoscopy performed within a year following FIT were collected. Multivariate logistic regression identified significant predictors of test positivity. RESULTS Higher positive rate was independently associated with male gender, older age, lower socioeconomic status, and distally located neoplasia, and negatively associated with previous screening (p < 0.05). Older males had higher faecal haemoglobin concentrations and were less likely to have a false positive result at colonoscopy (p < 0.05). High temperature on the sample postage day was associated with reduced haemoglobin concentration and positivity rate (26-35℃: Odds ratio 0.78, 95% confidence interval 0.66-0.93), but was not associated with missed significant neoplasia at colonoscopy (p > 0.05). CONCLUSIONS Haemoglobin concentrations, and therefore FIT positivity, were affected by factors that vary between screening programmes. Participant demographics and high temperature at postage had significant effects. The impact of temperature could be reduced by seasonal scheduling of invitations. The importance of screening, and following up positive test results, particularly in older males, should be promoted.
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Affiliation(s)
- Erin L Symonds
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia Bowel Health Service, Repatriation General Hospital, Daw Park, South Australia
| | - Joanne M Osborne
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia Bowel Health Service, Repatriation General Hospital, Daw Park, South Australia
| | - Stephen R Cole
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia Bowel Health Service, Repatriation General Hospital, Daw Park, South Australia
| | - Peter A Bampton
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia
| | - Robert J L Fraser
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, South Australia Bowel Health Service, Repatriation General Hospital, Daw Park, South Australia
| | - Graeme P Young
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia
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20
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Wong MCS, Ching JYL, Chan VCW, Lam TYT, Luk AKC, Ng SSM, Sung JJY. Factors associated with false-positive and false-negative fecal immunochemical test results for colorectal cancer screening. Gastrointest Endosc 2015; 81:596-607. [PMID: 25293827 DOI: 10.1016/j.gie.2014.08.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/04/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Certain subgroups have higher rates of false fecal immunochemical test (FIT) results, yet few studies have addressed this topic. OBJECTIVE To identify demographic factors associated with false-positive and false-negative FIT results in colorectal cancer screening. DESIGN Retrospective database review of prospectively collected data. SETTING A bowel cancer screening center in Hong Kong invited participants for colorectal cancer screening (2008-2012). PATIENTS Study participants who underwent both FIT and colonoscopy in the first year (n = 4482) and underwent colonoscopy after negative FIT results for 3 consecutive years (n = 857). MAIN OUTCOME MEASUREMENTS The diagnostic accuracy and predictive values of FIT according to participant characteristics. RESULTS The sensitivity, specificity, positive predictive values, and negative predictive values for advanced neoplasia were 33.1%, 91.9%, 19.0%, and 96.0%, respectively. Participants 66 to 70 years of age had higher sensitivity, whereas older age, smoking, and use of aspirin/nonsteroidal anti-inflammatory drugs were associated with lower specificity. The rates of false-positive and false-negative results were 8.1% and 66.9%, respectively. Older age (66-70 years; adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI], 1.35-2.81; P < .001), smoking (AOR 1.68; 95% CI, 1.08-2.61; P = .020), and the presence of polypoid adenoma (AOR 1.71; 95% CI, 1.14-2.57; P = .009) were associated with false-positive results. Younger participants (AOR for elderly participants 0.31) and the use of aspirin/nonsteroidal anti-inflammatory drugs (AOR 4.44) in participants with 1 FIT with negative results and the absence of high-grade dysplasia (AOR for presence 0.41) were associated with false-negative results. LIMITATIONS Self-referred participants who received one type of qualitative FIT. CONCLUSION These findings could be used to target screening more toward those with a higher risk of false-negative results and those with a lower risk of false-positive results for earlier colonoscopy.
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Affiliation(s)
- Martin C S Wong
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China; School of Public Health and Primary Care, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Jessica Y L Ching
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Victor C W Chan
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Thomas Y T Lam
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Arthur K C Luk
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Simon S M Ng
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
| | - Joseph J Y Sung
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong, HKSAR, China
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Sohn DK, Kim MJ, Park Y, Suh M, Shin A, Lee HY, Im JP, Cho HM, Hong SP, Kim BH, Kim Y, Kim JW, Kim HS, Nam CM, Park DI, Um JW, Oh SN, Lim HS, Chang HJ, Hahm SK, Chung JH, Kim SY, Kim Y, Lee WC, Jeong SY. The Korean guideline for colorectal cancer screening. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2015. [DOI: 10.5124/jkma.2015.58.5.420] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Dae Kyung Sohn
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Min Ju Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Younhee Park
- Department of Laboratory Medicine, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Mina Suh
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Aesun Shin
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoen-Min Cho
- Department of Surgery, The Catholic University of Korea Saint Vincent's Hospital, Suwon, Korea
| | - Sung Pil Hong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Baek-hui Kim
- Department of Pathology, Korea University College of Medicine, Seoul, Korea
| | - Yongsoo Kim
- Department of Radiology, Hanyang University College of Medicine, Seoul, Korea
| | - Jeong Wook Kim
- Department of Internal Medicine, Chungang University College of Medicine, Seoul, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Won Um
- Department of Surgery, Korea University Ansan Hospital, Ansan, Korea
| | - Soon Nam Oh
- Department of Radiology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hwan Sub Lim
- Department of Laboratory Medicine, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Sang Keun Hahm
- Department of Family Medicine/Health Promotion Center, KEPCO Medical Center, Seoul, Korea
| | - Ji Hye Chung
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Soo Young Kim
- Department of Family Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yeol Kim
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Won-Chul Lee
- Department of Preventive Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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22
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Stracci F, Zorzi M, Grazzini G. Colorectal cancer screening: tests, strategies, and perspectives. Front Public Health 2014; 2:210. [PMID: 25386553 PMCID: PMC4209818 DOI: 10.3389/fpubh.2014.00210] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/10/2014] [Indexed: 12/18/2022] Open
Abstract
Screening has a central role in colorectal cancer (CRC) control. Different screening tests are effective in reducing CRC-specific mortality. Influence on cancer incidence depends on test sensitivity for pre-malignant lesions, ranging from almost no influence for guaiac-based fecal occult blood testing (gFOBT) to an estimated reduction of 66–90% for colonoscopy. Screening tests detect lesions indirectly in the stool [gFOBT, fecal immunochemical testing (FIT), and fecal DNA] or directly by colonic inspection [flexible sigmoidoscopy, colonoscopy, CT colonography (CTC), and capsule endoscopy]. CRC screening is cost-effective compared to no screening but no screening strategy is clearly better than the others. Stool tests are the most widely used in worldwide screening interventions. FIT will soon replace gFOBT. The use of colonoscopy as a screening test is increasing and this strategy has superseded all alternatives in the US and Germany. Despite its undisputed importance, CRC screening is under-used and participation rarely reaches 70% of target population. Strategies to increase participation include ensuring recommendation by physicians, introducing organized screening and developing new, more acceptable tests. Available evidence for DNA fecal testing, CTC, and capsule endoscopy is reviewed.
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Affiliation(s)
- Fabrizio Stracci
- Public Health Section, Department of Experimental Medicine, University of Perugia , Perugia , Italy ; Regional Cancer Registry of Umbria , Perugia , Italy
| | | | - Grazia Grazzini
- Department of Screening, ISPO Cancer Prevention and Research Institute , Florence , Italy
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23
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Cubiella J, Castro I, Hernandez V, González-Mao C, Rivera C, Iglesias F, Cid L, Soto S, de-Castro L, Vega P, Hermo JA, Macenlle R, Martínez A, Martínez-Ares D, Estevez P, Cid E, Herreros-Villanueva M, Portillo I, Bujanda L, Fernández-Seara J. Characteristics of adenomas detected by fecal immunochemical test in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2014; 23:1884-92. [PMID: 24962836 DOI: 10.1158/1055-9965.epi-13-1346] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fecal immunochemical test (FIT) diagnostic accuracy for colorectal adenoma detection in colorectal cancer screening is limited. METHODS We analyzed 474 asymptomatic subjects with adenomas detected on colonoscopy in two blinded diagnostic tests studies designed to assess FIT diagnostic accuracy. We determined the characteristics of adenomas (number, size, histology, morphology, and location) and the risk of metachronous lesions (according to European guidelines). Finally, we performed a logistic regression to identify those variables independently associated with a positive result. RESULTS Advanced adenomas were found in 145 patients (75.6% distal and 24.3% only proximal to splenic flexure). Patients were classified as low (59.5%), intermediate (30.2%), and high risk (10.3%) according to European guidelines. At a 100-ng/mL threshold, FIT was positive in 61 patients (12.8%). Patients with advanced adenomas [odds ratio (OR), 8.8; 95% confidence interval (CI), 4.76-16.25], distal advanced adenomas (OR, 6.7; 95% CI, 1.9-8.8), high risk (OR, 20.1; 95% CI, 8.8-45.8), or intermediate risk lesions (OR, 6; 95% CI, 2.9-12.4) had more probabilities to have a positive test. The characteristics of adenomas independently associated were number of adenomas (OR, 1.22; 95% CI, 1.04-1.42), distal flat adenomas (OR, 0.44; 95% CI, 0.21-0.96), pedunculated adenomas (OR, 2.28; 95% CI, 1.48-3.5), and maximum size of distal adenomas (mm; OR, 1.24; 95% CI, 1.16-1.32). CONCLUSIONS European guidelines classification and adenoma location correlates with the likelihood of a positive FIT result. IMPACT This information allows us to understand the FIT impact in colorectal cancer prevention. Likewise, it should be taken into account in the development of new colorectal adenomas biomarkers.
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Affiliation(s)
- Joaquín Cubiella
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain.
| | - Inés Castro
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Vicent Hernandez
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain. "IBIV" Institute of Biomedical Research of Vigo, Vigo, Spain
| | - Carmen González-Mao
- "IBIV" Institute of Biomedical Research of Vigo, Vigo, Spain. Department of Clinical Analysis, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Concepción Rivera
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Felipe Iglesias
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Lucía Cid
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain. "IBIV" Institute of Biomedical Research of Vigo, Vigo, Spain
| | - Santiago Soto
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Luisa de-Castro
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain. "IBIV" Institute of Biomedical Research of Vigo, Vigo, Spain
| | - Pablo Vega
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Jose Antonio Hermo
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Ramiro Macenlle
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Alfonso Martínez
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain. "IBIV" Institute of Biomedical Research of Vigo, Vigo, Spain
| | - David Martínez-Ares
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain. "IBIV" Institute of Biomedical Research of Vigo, Vigo, Spain
| | - Pamela Estevez
- Department of Gastroenterology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain. "IBIV" Institute of Biomedical Research of Vigo, Vigo, Spain
| | - Estela Cid
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Marta Herreros-Villanueva
- Donostia Hospital, Biodonostia Institute, University of the Basque Country UPV/EHU, CIBERehd, San Sebastian, Spain
| | - Isabel Portillo
- Programa de Cribado de Cáncer Colorrectal, Servicio Vasco de Salud, País Vasco, Spain
| | - Luis Bujanda
- Donostia Hospital, Biodonostia Institute, University of the Basque Country UPV/EHU, CIBERehd, San Sebastian, Spain
| | - Javier Fernández-Seara
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
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24
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Chiu HM, Lee YC, Tu CH, Chen CC, Tseng PH, Liang JT, Shun CT, Lin JT, Wu MS. Association between early stage colon neoplasms and false-negative results from the fecal immunochemical test. Clin Gastroenterol Hepatol 2013; 11:832-8.e1-2. [PMID: 23376002 DOI: 10.1016/j.cgh.2013.01.013] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/03/2013] [Accepted: 01/11/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The fecal immunochemical test (FIT) can identify patients with advanced colorectal neoplasms, but it also has a high rate of false-negative results. It would be helpful to characterize colorectal neoplasms that are not detected by FIT to aid in development of new tests. We characterized colorectal neoplasms from patients who had negative results from the FIT. METHODS We analyzed data from 18,296 subjects who were screened for colorectal cancer by colonoscopy and the FIT at the Health Management Center of National Taiwan University Hospital from September 2005 through September 2010. We identified 4045 subjects with colorectal neoplasms (3385 with nonadvanced adenomas, 632 with advanced adenomas, and 28 with cancer). We analyzed the sensitivity of the FIT in identifying these patients, along with information on lesion size, location, and morphology. RESULTS The FIT identified patients with nonadvanced adenomas, advanced adenomas, and cancer with sensitivity values of 10.6% (95% confidence interval [CI], 10.2%-12.3%), 28.0% (95% CI, 24.6%-31.7%), and 78.6% (95% CI, 58.5%-91.0%), respectively. The FIT detected proximal advanced adenomas and nonpolypoid lesions with lower levels of sensitivity than distal advanced adenomas; it had a high false-negative rate in detection of adenomas <15 mm (adjusted odds ratio, 2.85; 95% CI, 1.79-4.54) and nonpolypoid adenomas (adjusted odds ratio, 2.15; 95% CI, 1.22-3.80), after adjusting for demographic characteristics, colonoscopy findings, and potential confounders. The FIT produced a higher percentage of false-negative results in detection of carcinoma in situ and T1 cancer than in T2-T4 cancers (66.7% sensitivity vs 100%; P = .049). CONCLUSIONS The FIT produces a high rate of false-negative results for patients with small or nonpolypoid adenomas. Early-stage cancers are associated with a high rate of false-negative results from the FIT.
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Affiliation(s)
- Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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25
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Levy BT, Daly JM, Luxon B, Merchant ML, Xu Y, Levitz CE, Wilbur JK. The "Iowa get screened" colon cancer screening program. J Prim Care Community Health 2013; 1:43-9. [PMID: 23804068 DOI: 10.1177/2150131909352191] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To implement a colon cancer screening program for uninsured or underinsured Iowans. METHODS All 1995 uninsured patients or patients with Iowa Care insurance aged 50 to 64 years attending the University of Iowa Clinic or the Iowa City Free Medical Clinic were mailed information about the project. Recruitment also took place in person, by having the clinic receptionist hand subjects a research packet, and through community posters. Individuals with colonic symptoms or who were up to date with screening were ineligible. Eligible subjects received a free fecal immunochemical test (FIT), and those with positive FITs were provided with a colonoscopy at no cost to them. RESULTS Of 449 individuals who completed eligibility forms (23% of the study population), 297 (66%) were eligible and were provided with an FIT. Two-hundred thirty-five (79%) returned a stool sample, with 49 (21%) testing positive. Thirty of the 49 (61%) individuals had a colonoscopy, and 20 individuals had at least 1 polyp biopsied. Thirteen individuals had at least 1 tubular adenoma; 2 had adenomas more than 1 cm in diameter, with no colon cancers identified. Face-to-face recruitment had the highest rate of returned FITs (72%) compared with handing the subject a research packet (3%) or a mailing only (9%) (Chi-square, P < .001). CONCLUSION There was high interest in and compliance with colon cancer screening using a FIT among underinsured individuals. Although the FIT positivity rate was higher than expected, many individuals did not complete recommended follow-up colonoscopies. Population-based strategies for offering FIT could significantly increase colon cancer screening among disadvantaged individuals, but programs will have to develop sustainable mechanisms to include the necessary organization and address substantial costs of providing mass screening, as well as facilitating and providing colonoscopies for those who test positive.
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Affiliation(s)
- Barcey T Levy
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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26
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Stegeman I, de Wijkerslooth TR, Stoop EM, van Leerdam M, van Ballegooijen M, Kraaijenhagen RA, Fockens P, Kuipers EJ, Dekker E, Bossuyt PM. Risk factors for false positive and for false negative test results in screening with fecal occult blood testing. Int J Cancer 2013; 133:2408-14. [PMID: 23649826 DOI: 10.1002/ijc.28242] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/09/2013] [Indexed: 12/27/2022]
Abstract
Differences in the risk of a false negative or a false positive fecal immunochemical test (FIT) across subgroups may affect optimal screening strategies. We evaluate whether subgroups are at increased risk of a false positive or a false negative FIT result, whether such variability in risk is related to differences in FIT sensitivity and specificity or to differences in prior CRC risk. Randomly selected, asymptomatic individuals were invited to undergo colonoscopy. Participants were asked to undergo one sample FIT and to complete a risk questionnaire. We identified patient characteristics associated with a false negative and false positive FIT results using logistic regression. We focused on statistically significant differences as well as on variables influencing the false positive or negative risk for which the odds ratio exceeded 1.25. Of the 1,426 screening participants, 1,112 (78%) completed FIT and the questionnaire; 101 (9.1%) had advanced neoplasia. 102 Individuals were FIT positive, 65 (64%) had a false negative FIT result and 66 (65%) a false positive FIT result. Participants at higher age and smokers had a significantly higher risk of a false negative FIT result. Males were at increased risk of a false positive result, so were smokers and regular NSAID users. FIT sensitivity was lower in females. Specificity was lower for males, smokers and regular NSAID users. FIT sensitivity was lower in women. FIT specificity was lower in males, smokers and regular NSAID users. Our results can be used for further evidence based individualization of screening strategies.
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Affiliation(s)
- Inge Stegeman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academical Medical Center, Amsterdam, The Netherlands; Department of research and development, NDDO Institute for Prevention and Early Diagnostic, Amsterdam, The Netherlands
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27
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Garborg K, Holme Ø, Løberg M, Kalager M, Adami HO, Bretthauer M. Current status of screening for colorectal cancer. Ann Oncol 2013; 24:1963-72. [PMID: 23619033 DOI: 10.1093/annonc/mdt157] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality. A well-defined precursor lesion (adenoma) and a long preclinical course make CRC a candidate for screening. This paper reviews the current evidence for the most important tests that are widely used or under development for population-based screening. MATERIAL AND METHODS In this narrative review, we scrutinized all papers we have been aware of, and carried out searches in PubMed and Cochrane library for relevant literature. RESULTS Two screening methods have been shown to reduce CRC mortality in randomised trials: repetitive faecal occult blood testing (FOBT) reduces CRC mortality by 16%; once-only flexible sigmoidoscopy (FS) by 28%. FS screening also reduces CRC incidence (by 18%), FOBT does not. Colonoscopy screening has a potentially larger effect on CRC incidence and mortality, but randomised trials are lacking. New screening methods are on the horizon but need to be tested in large clinical trials before implementation in population screening. CONCLUSIONS FS screening reduces CRC incidence and CRC mortality by removal of adenomas; FOBT reduces CRC mortality by early detection of cancer. Several other tests are available, but none has been evaluated in randomised trials. Screening strategies differ considerably across countries.
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Affiliation(s)
- K Garborg
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway.
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28
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Sharp L, Tilson L, Whyte S, Ceilleachair AO, Walsh C, Usher C, Tappenden P, Chilcott J, Staines A, Barry M, Comber H. Using resource modelling to inform decision making and service planning: the case of colorectal cancer screening in Ireland. BMC Health Serv Res 2013; 13:105. [PMID: 23510135 PMCID: PMC3637462 DOI: 10.1186/1472-6963-13-105] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 01/10/2013] [Indexed: 12/14/2022] Open
Abstract
Background Organised colorectal cancer screening is likely to be cost-effective, but cost-effectiveness results alone may not help policy makers to make decisions about programme feasibility or service providers to plan programme delivery. For these purposes, estimates of the impact on the health services of actually introducing screening in the target population would be helpful. However, these types of analyses are rarely reported. As an illustration of such an approach, we estimated annual health service resource requirements and health outcomes over the first decade of a population-based colorectal cancer screening programme in Ireland. Methods A Markov state-transition model of colorectal neoplasia natural history was used. Three core screening scenarios were considered: (a) flexible sigmoidoscopy (FSIG) once at age 60, (b) biennial guaiac-based faecal occult blood tests (gFOBT) at 55–74 years, and (c) biennial faecal immunochemical tests (FIT) at 55–74 years. Three alternative FIT roll-out scenarios were also investigated relating to age-restricted screening (55–64 years) and staggered age-based roll-out across the 55–74 age group. Parameter estimates were derived from literature review, existing screening programmes, and expert opinion. Results were expressed in relation to the 2008 population (4.4 million people, of whom 700,800 were aged 55–74). Results FIT-based screening would deliver the greatest health benefits, averting 164 colorectal cancer cases and 272 deaths in year 10 of the programme. Capacity would be required for 11,095-14,820 diagnostic and surveillance colonoscopies annually, compared to 381–1,053 with FSIG-based, and 967–1,300 with gFOBT-based, screening. With FIT, in year 10, these colonoscopies would result in 62 hospital admissions for abdominal bleeding, 27 bowel perforations and one death. Resource requirements for pathology, diagnostic radiology, radiotherapy and colorectal resection were highest for FIT. Estimates depended on screening uptake. Alternative FIT roll-out scenarios had lower resource requirements. Conclusions While FIT-based screening would quite quickly generate attractive health outcomes, it has heavy resource requirements. These could impact on the feasibility of a programme based on this screening modality. Staggered age-based roll-out would allow time to increase endoscopy capacity to meet programme requirements. Resource modelling of this type complements conventional cost-effectiveness analyses and can help inform policy making and service planning.
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Affiliation(s)
- Linda Sharp
- National Cancer Registry Ireland, Cork Airport Business Park, Kinsale Road, Cork, Ireland.
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29
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Urine Metabolite Profiling of Human Colorectal Cancer by Capillary Electrophoresis Mass Spectrometry Based on MRB. Gastroenterol Res Pract 2012; 2012:125890. [PMID: 23243419 PMCID: PMC3518074 DOI: 10.1155/2012/125890] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 06/12/2012] [Indexed: 12/31/2022] Open
Abstract
Aim. The study was to investigate the metabolic profile of urine metabolites and to elucidate their clinical significance in patients with colorectal cancer. Methods. Colorectal cancers from early stage and advanced stage were used in this study. Urine samples of colorectal cancer patients and healthy adults were collected and subjected to capillary electrophoresis mass spectrometry based on moving reaction boundary analysis. The metabolic data were analyzed by SPSS 17.0 to find urinary biomarkers for colorectal cancer. Results. The results indicated that the urine metabolic profiling of colorectal cancer patients had significant changes compared with the normal controls, and there were also differences between early stage and advanced colorectal cancer patients. Compared with the control group, the levels of isoleucine, valine, arginine, lactate acid and leucine increased (P < 0.05), but those of histidine, methionine, serine, aspartic acid, citric acid, succinate, and malic acid decreased in urine samples from colorectal cancer (P < 0.05). Furthermore, the levels of isoleucine and valine were lower in urine of patients with advanced colorectal cancer than those in early stage colorectal cancer (P < 0.05). Conclusion. The technique of capillary electrophoresis mass spectrometry based on MRB could reveal the significant metabolic alterations during progression of colorectal cancer, and the method is feasible and may be useful for the early diagnosis of colorectal cancer.
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30
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Sherer EA, Imler TD, Imperiale TF. The effect of colonoscopy preparation quality on adenoma detection rates. Gastrointest Endosc 2012; 75:545-53. [PMID: 22138085 DOI: 10.1016/j.gie.2011.09.022] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/12/2011] [Accepted: 09/12/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonoscopy reduces the risk of colorectal cancer mortality by removing precancerous adenomas. The detection rate of subcentimeter (<10 mm) polyps is lower for procedures with inadequate preparation quality. OBJECTIVE To compare the adenoma detection rates of small (6-9 mm) and diminutive (≤ 5 mm) adenomas in patients with poor and fair quality preparations with those with adequate quality preparations. DESIGN Cross-sectional study and multivariable, hierarchical model. SETTING Roudebush Veterans Affairs Medical Center. PATIENTS This study involved 8800 colonoscopies performed from 2001 to 2010. MAIN OUTCOME MEASUREMENTS Preparation quality rating, polyp size, and polyp histology. RESULTS Preparation quality was rated as fair in 2809 (31.9%) and poor in 829 (9.4%) colonoscopies. In patients with poor compared with adequate quality, the detection rate was lower for diminutive adenomas (odds ratio [OR] 0.57; 95% CI, 0.47-0.70) but not for small adenomas (OR 0.84; 95% CI, 0.65-1.07). There were no differences in the detection rate of diminutive (OR 1.08; 95% CI, 0.94-1.24]) or small (OR 1.09; 95% CI, 0.94-1.27) adenomas in patients with fair compared with adequate quality preparation. Detection of advanced histology in patients with poor preparation quality was lower than in those with adequate quality (P = .027; 3.3% vs 5.0%), but there was no difference in those with fair compared with adequate quality (P = .893; 4.9% vs 5.0%). LIMITATIONS Single-center study; no standardization of preparation quality or size measurements. CONCLUSIONS A fair preparation quality rating does not decrease the detection rate for adenomas of any size or for advanced histology, suggesting that fair quality may be considered adequate and that follow-up intervals may not need to be shortened. Poor preparation quality decreases the detection rate of diminutive adenomas and advanced histology, suggesting substandard colonoscopy performance.
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Affiliation(s)
- Eric A Sherer
- Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana 46202, USA
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Sharp L, Tilson L, Whyte S, O'Ceilleachair A, Walsh C, Usher C, Tappenden P, Chilcott J, Staines A, Barry M, Comber H. Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy. Br J Cancer 2012; 106:805-16. [PMID: 22343624 PMCID: PMC3305953 DOI: 10.1038/bjc.2011.580] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 11/10/2011] [Accepted: 11/22/2011] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Several colorectal cancer-screening tests are available, but it is uncertain which provides the best balance of risks and benefits within a screening programme. We evaluated cost-effectiveness of a population-based screening programme in Ireland based on (i) biennial guaiac-based faecal occult blood testing (gFOBT) at ages 55-74, with reflex faecal immunochemical testing (FIT); (ii) biennial FIT at ages 55-74; and (iii) once-only flexible sigmoidoscopy (FSIG) at age 60. METHODS A state-transition model was used to estimate costs and outcomes for each screening scenario vs no screening. A third party payer perspective was adopted. Probabilistic sensitivity analyses were undertaken. RESULTS All scenarios would be considered highly cost-effective compared with no screening. The lowest incremental cost-effectiveness ratio (ICER vs no screening euro 589 per quality-adjusted life-year (QALY) gained) was found for FSIG, followed by FIT euro 1696) and gFOBT (euro 4428); gFOBT was dominated. Compared with FSIG, FIT was associated with greater gains in QALYs and reductions in lifetime cancer incidence and mortality, but was more costly, required considerably more colonoscopies and resulted in more complications. Results were robust to variations in parameter estimates. CONCLUSION Population-based screening based on FIT is expected to result in greater health gains than a policy of gFOBT (with reflex FIT) or once-only FSIG, but would require significantly more colonoscopy resources and result in more individuals experiencing adverse effects. Weighing these advantages and disadvantages presents a considerable challenge to policy makers.
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Affiliation(s)
- L Sharp
- National Cancer Registry Ireland, Cork Airport Business Park, Building 6800, Kinsale Road, Cork, Ireland.
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Haug U, Knudsen AB, Brenner H, Kuntz KM. Is fecal occult blood testing more sensitive for left- versus right-sided colorectal neoplasia? A systematic literature review. Expert Rev Mol Diagn 2011; 11:605-16. [PMID: 21745014 DOI: 10.1586/erm.11.41] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Owing to its slow development from removable precursor lesions and early cancer stages with good prognosis, screening for colorectal cancer holds potential to reduce both the incidence and mortality of the disease. While sigmoidoscopy only detects left-sided neoplasia, there is accumulating evidence that colonoscopy is also more effective in protecting from neoplasia in the left versus the right colon and rectum. In this context, it is an important question whether the sensitivity of the most common noninvasive screening tool for colorectal cancer, fecal occult blood testing (FOBT), also differs for left- versus right-sided neoplasia. Therefore, we systematically searched the literature for prospective screening studies conducted in average-risk adults that performed FOBT (immunochemical and/or guaiac-based) and colonoscopy among all participants, and reported site-specific sensitivities of FOBT for advanced colorectal neoplasia. Most of the seven included studies showed a higher sensitivity of FOBT for advanced neoplasia in the left versus right colon, but this finding needs to be confirmed since the available literature is scarce and not entirely consistent.
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Affiliation(s)
- Ulrike Haug
- Division of Preventive Oncology, National Center for Tumor Diseases/German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany.
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Park JJ, Cheon JH. Small bowel evaluation in asymptomatic fecal immunochemical test-positive patients with a negative colonoscopy: is it necessary? Dig Dis Sci 2011; 56:2773-5. [PMID: 21800155 DOI: 10.1007/s10620-011-1837-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Ikeda A, Nishiumi S, Shinohara M, Yoshie T, Hatano N, Okuno T, Bamba T, Fukusaki E, Takenawa T, Azuma T, Yoshida M. Serum metabolomics as a novel diagnostic approach for gastrointestinal cancer. Biomed Chromatogr 2011; 26:548-58. [PMID: 21773981 DOI: 10.1002/bmc.1671] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 05/29/2011] [Accepted: 06/06/2011] [Indexed: 12/22/2022]
Abstract
Conventional tumor markers are unsuitable for detecting carcinoma at an early stage and lack clinical efficacy and utility. In this study, we attempted to investigate the differences in serum metabolite profiles of gastrointestinal cancers and healthy volunteers using a metabolomic approach and searched for sensitive and specific metabolomic biomarker candidates. Human serum samples were obtained esophageal (n = 15), gastric (n = 11), and colorectal (n = 12) cancer patients and healthy volunteers (n = 12). A model for evaluating metabolomic biomarker candidates was constructed using multiple classification analysis, and the results were assessed with receiver operating characteristic curves. Among the 58 metabolites, the levels of nine, five and 12 metabolites were significantly changed in the esophageal, gastric and colorectal cancer patients, respectively, compared with the healthy volunteers. Multiple classification analysis revealed that the variations in the levels of malonic acid and L-serine largely contributed to the separation of esophageal cancer; gastric cancer was characterized by changes in the levels of 3-hydroxypropionic acid and pyruvic acid; and L-alanine, glucuronoic lactone and L-glutamine contributed to the separation of colorectal cancer. Our approach revealed that some metabolites are more sensitive for detecting gastrointestinal cancer than conventional biomarkers. Our study supports the potential of metabolomics as an early diagnostic tool for cancer.
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Affiliation(s)
- Atsuki Ikeda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chu-o-ku, Kobe, Hyogo 650-0017, Japan
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Sensitivity of immunochemical faecal occult blood testing for detecting left- vs right-sided colorectal neoplasia. Br J Cancer 2011; 104:1779-85. [PMID: 21559011 PMCID: PMC3111170 DOI: 10.1038/bjc.2011.160] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Faecal occult blood tests (FOBTs) are used for colorectal cancer (CRC) screening. We aimed to assess the sensitivity of an immunochemical FOBT for detecting advanced colorectal neoplasia in the left vs the right colon and to explore reasons for potential differences in site-specific test performance. Methods: We prospectively measured faecal occult blood levels by a quantitative immunochemical FOBT (RIDASCREEN) in 2310 average-risk subjects undergoing screening colonoscopy. We compared diagnostic performance for subjects with left- vs right-sided advanced neoplasia, as well as patient characteristics and adenoma characteristics that have been suggested to impact faecal haemoglobin levels. Results: Sensitivities for subjects with left- vs right-sided advanced neoplasia were 33% (95% confidence interval (CI), 26–41%) and 20% (CI, 11–31%) (P=0.04) at a specificity of 95% (overall sensitivity: 29%) and the areas under the receiver-operating characteristics curve were 0.71 (CI, 0.69–0.72) and 0.60 (CI, 0.58–0.63), respectively. Pedunculated shape was strikingly more common in participants with left- vs right-sided advanced neoplasia (47% vs 14%). In logistic regression analyses adjusted for site, pedunculated shape was statistically significantly associated with test sensitivity (P=0.04). Conclusions: The immunochemical FOBT in our study was more sensitive for detecting subjects with left- vs right-sided advanced colorectal neoplasia. Our findings may stimulate further diagnostic research in the field as well as modelling analyses to estimate the potential effect of site-specific test performance on the effectiveness of annual or biennial FOBT-based screening programmes, in particular with respect to protection from right-sided CRC.
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Heitman SJ, Hilsden RJ, Au F, Dowden S, Manns BJ. Colorectal cancer screening for average-risk North Americans: an economic evaluation. PLoS Med 2010; 7:e1000370. [PMID: 21124887 PMCID: PMC2990704 DOI: 10.1371/journal.pmed.1000370] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 10/14/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) fulfills the World Health Organization criteria for mass screening, but screening uptake is low in most countries. CRC screening is resource intensive, and it is unclear if an optimal strategy exists. The objective of this study was to perform an economic evaluation of CRC screening in average risk North American individuals considering all relevant screening modalities and current CRC treatment costs. METHODS AND FINDINGS An incremental cost-utility analysis using a Markov model was performed comparing guaiac-based fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, fecal DNA every 3 years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. All strategies were also compared to a no screening natural history arm. Given that different FIT assays and collection methods have been previously tested, three distinct FIT testing strategies were considered, on the basis of studies that have reported "low," "mid," and "high" test performance characteristics for detecting adenomas and CRC. Adenoma and CRC prevalence rates were based on a recent systematic review whereas screening adherence, test performance, and CRC treatment costs were based on publicly available data. The outcome measures included lifetime costs, number of cancers, cancer-related deaths, quality-adjusted life-years gained, and incremental cost-utility ratios. Sensitivity and scenario analyses were performed. Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high. Among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,393 [corrected] and the number of CRC deaths from 1,782 [corrected] to 457, while saving CAN$68 per person. Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive. CONCLUSIONS CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies. Health policy decision makers should consider prioritizing funding for CRC screening using FIT.
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Affiliation(s)
- Steven J. Heitman
- The Department of Medicine, University of Calgary, Alberta, Canada
- The Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Robert J. Hilsden
- The Department of Medicine, University of Calgary, Alberta, Canada
- The Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Flora Au
- The Department of Medicine, University of Calgary, Alberta, Canada
| | - Scot Dowden
- The Department of Medicine, University of Calgary, Alberta, Canada
- Alberta Health Services - Cancer Care, Alberta, Canada
| | - Braden J. Manns
- The Department of Medicine, University of Calgary, Alberta, Canada
- The Department of Community Health Sciences, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Alberta, Canada
- * E-mail:
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Abstract
OBJECTIVES Immunological and guaiac-based fecal occult blood tests (iFOBTs and gFOBTs) are widely used for early detection of colorectal cancer (CRC). We aimed to assess potential sex differences in performance of iFOBTs and gFOBT in the screening setting. METHODS The sensitivity, specificity, and positive and negative predictive values for detection of advanced colorectal neoplasms (CRC or advanced adenoma) were assessed by sex for a range of cutpoints of a quantitative iFOBT (RIDASCREEN Hemoglobin), six qualitative iFOBTs, and a gFOBT (HemOccult) among 1,157 male and 1,167 female participants of the German screening colonoscopy program (mean age: 63.0 and 62.0 years, respectively). RESULTS The prevalence of advanced colorectal neoplasms was much higher among men (13.5%) than among women (7.5%). At any cutpoint of the quantitative iFOBT, and for all qualitative iFOBTs and the gFOBT, the sensitivity and positive predictive value were substantially higher, and specificity and negative predictive value were substantially lower among men than among women. At the cutpoint of 2 μg/g stool given by the manufacturer of the quantitative iFOBT, sensitivity, specificity, and the positive and negative predictive values were 47.6, 85.0, 33.0, and 91.3% among men, and 30.7, 89.5, 19.3, and 94.1% among women (P value for sex differences 0.001, 0.002, 0.004, and 0.019, respectively). Sex differences in predictive values were mostly explained by sex differences in the prevalence of advanced colorectal neoplasms. CONCLUSIONS There are major sex differences in the performance of fecal occult blood testing, which might require careful attention in the interpretation of test results, and in the design, modeling, and evaluation of CRC screening strategies.
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Affiliation(s)
- Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.
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Lansdorp-Vogelaar I, Kuntz KM, Knudsen AB, Wilschut JA, Zauber AG, van Ballegooijen M. Stool DNA testing to screen for colorectal cancer in the Medicare population: a cost-effectiveness analysis. Ann Intern Med 2010. [PMID: 20855801 DOI: 10.1059/0003-4819-153-6-201009210-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services considered whether to reimburse stool DNA testing for colorectal cancer screening among Medicare enrollees. OBJECTIVE To evaluate the conditions under which stool DNA testing could be cost-effective compared with the colorectal cancer screening tests currently reimbursed by the Centers for Medicare & Medicaid Services. DESIGN Comparative microsimulation modeling study using 2 independently developed models. DATA SOURCES Derived from literature. TARGET POPULATION A cohort of persons aged 65 years. A sensitivity analysis was also conducted, in which a cohort of persons aged 50 years was studied. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Stool DNA test every 3 or 5 years in comparison with currently recommended colorectal cancer screening strategies. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios, and threshold costs. RESULTS OF BASE-CASE ANALYSIS Assuming a cost of $350 per test, strategies of stool DNA testing every 3 or 5 years yielded fewer life-years and higher costs than the currently recommended colorectal cancer screening strategies. Screening with the stool DNA test would be cost-effective at a per-test cost of $40 to $60 for stool DNA testing every 3 years, depending on the simulation model used. There were no levels of sensitivity and specificity for which stool DNA testing would be cost-effective at its current cost of $350 per test. Stool DNA testing every 3 years would be cost-effective at a cost of $350 per test if the relative adherence to stool DNA testing were at least 50% better than that with other screening tests. RESULTS OF SENSITIVITY ANALYSIS None of the results changed substantially when a cohort of persons aged 50 years was considered. LIMITATION No pathways other than the traditional adenoma-carcinoma sequence were modeled. CONCLUSION Stool DNA testing could be a cost-effective alternative for colorectal cancer screening if the cost of the test substantially decreased or if its availability would entice a large fraction of otherwise unscreened persons to receive screening.
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Lansdorp-Vogelaar I, Kuntz KM, Knudsen AB, Wilschut JA, Zauber AG, van Ballegooijen M. Stool DNA testing to screen for colorectal cancer in the Medicare population: a cost-effectiveness analysis. Ann Intern Med 2010; 153:368-77. [PMID: 20855801 PMCID: PMC3578600 DOI: 10.7326/0003-4819-153-6-201009210-00004] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services considered whether to reimburse stool DNA testing for colorectal cancer screening among Medicare enrollees. OBJECTIVE To evaluate the conditions under which stool DNA testing could be cost-effective compared with the colorectal cancer screening tests currently reimbursed by the Centers for Medicare & Medicaid Services. DESIGN Comparative microsimulation modeling study using 2 independently developed models. DATA SOURCES Derived from literature. TARGET POPULATION A cohort of persons aged 65 years. A sensitivity analysis was also conducted, in which a cohort of persons aged 50 years was studied. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Stool DNA test every 3 or 5 years in comparison with currently recommended colorectal cancer screening strategies. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios, and threshold costs. RESULTS OF BASE-CASE ANALYSIS Assuming a cost of $350 per test, strategies of stool DNA testing every 3 or 5 years yielded fewer life-years and higher costs than the currently recommended colorectal cancer screening strategies. Screening with the stool DNA test would be cost-effective at a per-test cost of $40 to $60 for stool DNA testing every 3 years, depending on the simulation model used. There were no levels of sensitivity and specificity for which stool DNA testing would be cost-effective at its current cost of $350 per test. Stool DNA testing every 3 years would be cost-effective at a cost of $350 per test if the relative adherence to stool DNA testing were at least 50% better than that with other screening tests. RESULTS OF SENSITIVITY ANALYSIS None of the results changed substantially when a cohort of persons aged 50 years was considered. LIMITATION No pathways other than the traditional adenoma-carcinoma sequence were modeled. CONCLUSION Stool DNA testing could be a cost-effective alternative for colorectal cancer screening if the cost of the test substantially decreased or if its availability would entice a large fraction of otherwise unscreened persons to receive screening.
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Abstract
PURPOSE OF REVIEW The review will summarize the state of the art in colon cancer screening. Recently published screening guidelines will be reviewed so physicians can understand them and how to deal with the differences. Each screening modality presently in use will then be reviewed with emphasis on efficacy and problems. RECENT FINDINGS During the past two decades research has clearly demonstrated colon cancer screening to be effective. New modalities such as virtual colonoscopy and stool DNA screening have been introduced and are recommended by some organizations but not others. Ages to discontinue screening have also been suggested. Fecal immunochemical testing exhibits some advantages over guaiac-based testing. Problematic issues with the effectiveness of colonoscopy have arisen, particularly in the proximal colon. Both technical and biological reasons have been suggested for this decrease in effectiveness. SUMMARY Colon cancer screening is effective and continues to improve. Refinements of guidelines as well as refinements in each screening modality have occurred. Several screening tools are newly available and quality studies and efforts for present and new tests are imperative.
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Park DI, Ryu S, Kim YH, Lee SH, Lee CK, Eun CS, Han DS. Comparison of guaiac-based and quantitative immunochemical fecal occult blood testing in a population at average risk undergoing colorectal cancer screening. Am J Gastroenterol 2010; 105:2017-25. [PMID: 20502450 DOI: 10.1038/ajg.2010.179] [Citation(s) in RCA: 230] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Although some studies have shown that the quantitative, immunochemical fecal occult blood test (FOBT) (qFIT) has better performance characteristics than the standard guaiac-based FOBT (GT) for identifying advanced colorectal neoplasia (ACRN), there is limited information on test performance of these tests in average-risk populations. METHODS Seven hundred seventy consecutive average-risk patients from four centers who were undergoing screening colonoscopy also provided stool samples. Stool specimens from three consecutive bowel movements were applied to a hemoccult II test card (Beckman Coulter, Fullerton, CA) and OC-SENSA MICRO (Eiken Chemical, Tokyo, Japan) sampling probes at the same time. We measured the diagnostic value of the qFIT for detecting an ACRN by using three criteria: sensitivity, specificity, and likelihood ratios. A receiver operating characteristic curve for determining the qFIT cutoff values and the number of tests that best discriminated between ACRNs and other findings were determined. RESULTS Seventy-eight ACRNs were identified during colonoscopy. At all hemoglobin thresholds, the sensitivity of the qFIT was higher than that of the GT for cancer or ACRN. The sensitivity and specificity of the GT for detecting advanced adenomas, cancer, and ACRNs were 13.6%/92.4%, 30.8%/92.4%, and 16.7%/92.9%, respectively. Using the 100 ng/ml cut point and three-sample qFIT results, the sensitivity and specificity of the qFIT for detecting advanced adenomas, cancer, and ACRNs were 33.9%/90.6%, 84.6%/89.8%, and 43.7%/91.9%, respectively. The area under the curve for cancer indicated that using either 2 or 3 tests provided the best discrimination for cancer. CONCLUSIONS The qFIT provides a higher sensitivity for detecting ACRN and cancer than the GT, and has an acceptable specificity that significantly reduces the need for colonoscopic evaluation in the screened population.
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Affiliation(s)
- Dong Il Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Haug U, Hundt S, Brenner H. Quantitative immunochemical fecal occult blood testing for colorectal adenoma detection: evaluation in the target population of screening and comparison with qualitative tests. Am J Gastroenterol 2010; 105:682-90. [PMID: 19953091 DOI: 10.1038/ajg.2009.668] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Quantitative and qualitative immunochemical fecal occult blood tests (FOBTs) have been proposed for noninvasive colorectal cancer screening, but comparative evaluation is lacking. The aim of this study was to determine the diagnostic accuracy of two (quantitative) enzyme-linked immunosorbent assay (ELISA)-based immunochemical FOBTs for identifying colorectal adenomas in the target population of screening and to compare the results with six (qualitative) immunochromatographic FOBTs, previously evaluated in the same study participants using the same stool samples. METHODS A total of 1,319 participants of screening colonoscopy at average risk for colorectal neoplasia (mean age 63 years; age range 31-86 years; 50% men) were recruited prospectively from January 2006 to December 2007 in collaboration with 20 gastroenterological practices in Germany. Fecal hemoglobin and hemoglobin-haptoglobin levels were measured using an automated ELISA (RIDASCREEN). Test performance characteristics at different cutoff values were derived by comparing the results of stool testing with the results of colonoscopy in a blinded manner. RESULTS A total of 130 participants (10%) had an advanced adenoma. The area under the receiver-operating characteristic curve with regard to advanced adenomas was 0.68 (0.65-0.71) for hemoglobin and 0.64 (0.61-0.67) for hemoglobin-haptoglobin (P=0.034). At a specificity of approximately 95%, the sensitivity (95% confidence interval) for advanced adenomas was 33% (25-42%) for hemoglobin and 24% (17-32%) for hemoglobin-haptoglobin, respectively. The sensitivity for hemoglobin was very close to sensitivities of the six qualitative FOBTs at (strongly divergent) levels of specificity observed for the latter. CONCLUSIONS ELISA-based measurement of hemoglobin was superior to hemoglobin-haptoglobin, but showed a similar sensitivity for advanced adenomas compared with (qualitative) immunochromatographic FOBTs at defined levels of specificity. Compared with the latter, its quantitative nature offers advantages in terms of transparency and flexibility regarding the positivity threshold (e.g., specificity can be oriented toward available colonoscopy resources or personal risk profiles) and in terms of a higher level of standardization regarding test analysis and interpretation.
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Affiliation(s)
- Ulrike Haug
- German Cancer Research Center, Heidelberg, Germany.
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Sieg A, Friedrich K. Perspectives of colorectal cancer screening in Germany 2009. World J Gastrointest Endosc 2009; 1:12-6. [PMID: 21160645 PMCID: PMC2999070 DOI: 10.4253/wjge.v1.i1.12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 03/26/2009] [Accepted: 04/02/2009] [Indexed: 02/06/2023] Open
Abstract
Adequate screening methods can decrease colorectal cancer (CRC) mortality. The guaiac test for fecal occult-blood (FOBT) is part of the German CRC Screening Program since 1970 and has evidence level Ia. In randomized multicenter-studies FOBT has an average sensitivity of 24% and decreases CRC mortality up to 30%. Immunological tests for human haemoglobin (iFOBT) show better performance characteristics than guaiac FOBT, with augmented sensitivity and specificity. However, the single tests show wide differences in diagnostic performance and iFOBT is not yet covered by insurance companies although it should replace the guaiac test for CRC screening. Visual colonoscopy, which was introduced to the German National Cancer Screening Program in 2002, is the gold standard for the diagnosis of colorectal neoplasia. From 2003 to 2007 more than 2.8 million examinations have been documented in Germany. The prevalence of adenomas is around 20% and of CRC about 0.7% to 1.0% of the screenings. Seventy percent of the carcinomas detected during screening are in an early stage (UICC I and II). Furthermore, screening colonoscopy is a cost saving procedure with a low complication rate (0.25% overall). Insurance companies save 216€ for each screening colonoscopy mainly by prevention of neoplasia due to polypectomy. In Germany, virtual colonography by computed tomography (CT) or magnetic resonance imaging still lacks standardization of the hard and software. In experienced centres the sensitivity for CRC and large polyps of CT colonography is comparable to colonoscopy but in meta-analyses the ranking is lower. New technologies like computer-aided colonoscopies with sheath or double balloon techniques are coming up as well as capsule colonoscopy, which sensitivity for large polyps is about 70%. Advised by his physician, the patient can choose his most acceptable examination method from this whole set of screening tools.
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Affiliation(s)
- Andreas Sieg
- Andreas Sieg, Kilian Friedrich, Practice of Gastroenterology and University of Heidelberg, Faculty of Medicine, D-69117 Heidelberg, Germany
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Rozen P, Levi Z, Hazazi R, Waked A, Vilkin A, Maoz E, Birkenfeld S, Leshno M, Niv Y. Identification of colorectal adenomas by a quantitative immunochemical faecal occult blood screening test depends on adenoma characteristics, development threshold used and number of tests performed. Aliment Pharmacol Ther 2009; 29:906-17. [PMID: 19183147 DOI: 10.1111/j.1365-2036.2009.03946.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Faecal occult blood tests (FOBT) are faulted by low sensitivity for advanced adenomatous polyps (AAP). Quantified, immunochemical, haemoglobin (Hb)-specific immunochemical FOBT (I-FOBT) measurements are now used for colorectal screening. AIMS To correlate adenoma characteristics to amount of faecal Hb lost and to evaluate sensitivity and specificity for AAP by faecal Hb development threshold used and number of I-FOBTs collected. METHODS Three daily I-FOBTs were collected and analysed in 1221 patients scheduled for colonoscopy. Faecal Hb was analysed as ngHb/mL of buffer and the highest result related to colonoscopy findings. RESULTS In 1204 patients without cancer, colonoscopy identified adenomas in 294, 99 with AAPs. Adenoma patients had elevated faecal Hb increasing with advanced histology, size, pedunculated shape and multiplicity (P < 0.001 for all). At 50 ngHb/mL threshold, sensitivity and specificity for AAPs were 54.5% (95%CI 44.7, 64.7) and 88.1% (95%CI 86.2, 90.1) for three tests. At higher thresholds, sensitivity decreased, but was significantly higher with more samples collected. Conversely, specificity increased at higher thresholds, but decreased with more samples. CONCLUSIONS Faecal Hb loss from adenomas is significantly associated with size, number and advanced features. Sensitivity and specificity for AAPs are determined by test threshold chosen and number of samples collected; these determine the number of colonoscopies needed for positive tests.
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Affiliation(s)
- P Rozen
- Gastroenterology Department, Rabin Medical Center, Beilinson Hospital, Petach Tikva.
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Levin TR. Editorial: It's time to make organized colorectal cancer screening convenient and easy for patients. Am J Gastroenterol 2009; 104:939-41. [PMID: 19293790 DOI: 10.1038/ajg.2009.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Colorectal cancer (CRC) screening is widely recommended, but underused. To increase screening rates, we need to implement organized and population-based systems to promote CRC screening among people in a single region, health plan, or health system. This is ideally accomplished using fecal immunochemical tests (FITs), which can be sent through a mass mailing. The study by Levi and colleagues shows that patients using aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), anti-platelet agents, or anti-coagulants do not need to stop these medications while doing the fecal collection. This makes the testing more convenient for patients, and avoids the risk of adverse cardiovascular events caused by stopping these medications.
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Vogt TM. Improving CRC screening requires innovative approaches: can electronic medical records help? Am J Prev Med 2008; 35:317-8. [PMID: 18692747 PMCID: PMC2562532 DOI: 10.1016/j.amepre.2008.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 06/02/2008] [Accepted: 06/02/2008] [Indexed: 10/21/2022]
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Sopeña F, Ferrandez A, Lanas A. Noninvasive diagnostic modalities for early detection of colorectal cancer. CURRENT COLORECTAL CANCER REPORTS 2008. [DOI: 10.1007/s11888-008-0006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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