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Berwald G, Young GP, Cock C, Bampton P, Fraser R, Symonds EL. The Diagnostic Performance of Fecal Immunochemical Tests for Detecting Advanced Neoplasia at Surveillance Colonoscopy. Clin Gastroenterol Hepatol 2024; 22:878-885.e2. [PMID: 37743036 DOI: 10.1016/j.cgh.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/16/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND & AIMS An increasing burden on health care resources has resulted in a backlog of individuals requiring colonoscopy, with delays in surveillance possibly detrimental for individuals at increased risk of colorectal cancer (CRC). This study investigated the use of a 2-sample fecal immunochemical test (FIT) to establish those most likely to have advanced neoplasia (AN) and in need of prioritized surveillance colonoscopy. METHODS This was a prospective study conducted in the tertiary care setting. Participants completed a 2-sample FIT (OC-Sensor, Eiken Chemical Company) within 90 days of surveillance colonoscopy. The sensitivity of FIT for detection of AN (CRC or advanced adenoma) in moderate- and high-risk individuals was determined at fecal hemoglobin thresholds between 2 and 80 μg/g feces. RESULTS A total of 766 patients were included (median age, 66.1 years [interquartile range, 58.1-72.9]; 49.9% male), with AN detected in 8.6% (66/766, including 5 CRC). For moderate-risk individuals (with prior history of adenoma or a significant family history of CRC), sensitivity of FIT for AN ranged from 73.5% at 2 μg/g feces, to 10.2% at 80 μg/g feces. For high-risk conditions (confirmed/suspected genetic syndromes or prior CRC), sensitivity of FIT was similar, ranging from 70.6% at the lowest positivity threshold of 2 μg/g feces, to 11.8% at 80 μg/g feces. Independent variables in the whole cohort for association with detection of AN at surveillance colonoscopy were age (odds ratio, 1.03; 95% confidence interval, 1.00-1.06) and FIT hemoglobin result ≥10 μg/g feces (odds ratio, 1.81; 95% confidence interval, 1.04-3.16). CONCLUSIONS The use of FIT before surveillance colonoscopy provides clinicians with insights into the risk of AN. This raises the possibility of a method to triage individuals, facilitating the more efficient management of endoscopic resources.
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Affiliation(s)
- Grace Berwald
- Department of Medicine, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Graeme P Young
- Cancer Research, Flinders Health and Medical Research Institute, Bedford Park, South Australia, Australia
| | - Charles Cock
- Cancer Research, Flinders Health and Medical Research Institute, Bedford Park, South Australia, Australia; Department of Gastroenterology and Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, South Australia, Australia
| | - Peter Bampton
- Cancer Research, Flinders Health and Medical Research Institute, Bedford Park, South Australia, Australia
| | - Robert Fraser
- Cancer Research, Flinders Health and Medical Research Institute, Bedford Park, South Australia, Australia; Department of Gastroenterology and Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, South Australia, Australia
| | - Erin L Symonds
- Cancer Research, Flinders Health and Medical Research Institute, Bedford Park, South Australia, Australia; Department of Gastroenterology and Hepatology, Flinders Medical Centre, Southern Adelaide Local Health Network, South Australia, Australia.
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Bresalier RS, Senore C, Young GP, Allison J, Benamouzig R, Benton S, Bossuyt PMM, Caro L, Carvalho B, Chiu HM, Coupé VMH, de Klaver W, de Klerk CM, Dekker E, Dolwani S, Fraser CG, Grady W, Guittet L, Gupta S, Halloran SP, Haug U, Hoff G, Itzkowitz S, Kortlever T, Koulaouzidis A, Ladabaum U, Lauby-Secretan B, Leja M, Levin B, Levin TR, Macrae F, Meijer GA, Melson J, O'Morain C, Parry S, Rabeneck L, Ransohoff DF, Sáenz R, Saito H, Sanduleanu-Dascalescu S, Schoen RE, Selby K, Singh H, Steele RJC, Sung JJY, Symonds EL, Winawer SJ. An efficient strategy for evaluating new non-invasive screening tests for colorectal cancer: the guiding principles. Gut 2023; 72:1904-1918. [PMID: 37463757 PMCID: PMC10511996 DOI: 10.1136/gutjnl-2023-329701] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE New screening tests for colorectal cancer (CRC) are rapidly emerging. Conducting trials with mortality reduction as the end point supporting their adoption is challenging. We re-examined the principles underlying evaluation of new non-invasive tests in view of technological developments and identification of new biomarkers. DESIGN A formal consensus approach involving a multidisciplinary expert panel revised eight previously established principles. RESULTS Twelve newly stated principles emerged. Effectiveness of a new test can be evaluated by comparison with a proven comparator non-invasive test. The faecal immunochemical test is now considered the appropriate comparator, while colonoscopy remains the diagnostic standard. For a new test to be able to meet differing screening goals and regulatory requirements, flexibility to adjust its positivity threshold is desirable. A rigorous and efficient four-phased approach is proposed, commencing with small studies assessing the test's ability to discriminate between CRC and non-cancer states (phase I), followed by prospective estimation of accuracy across the continuum of neoplastic lesions in neoplasia-enriched populations (phase II). If these show promise, a provisional test positivity threshold is set before evaluation in typical screening populations. Phase III prospective studies determine single round intention-to-screen programme outcomes and confirm the test positivity threshold. Phase IV studies involve evaluation over repeated screening rounds with monitoring for missed lesions. Phases III and IV findings will provide the real-world data required to model test impact on CRC mortality and incidence. CONCLUSION New non-invasive tests can be efficiently evaluated by a rigorous phased comparative approach, generating data from unbiased populations that inform predictions of their health impact.
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Affiliation(s)
- Robert S Bresalier
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlo Senore
- Epidemiology and screening unit, Centro di Riferimento per l'Epidemiologia e la Prevenzione Oncologica in Piemonte, Turin, Italy
| | - Graeme P Young
- Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, South Australia, Australia
| | - James Allison
- Internal Medicine/Division of Gastroenterology, University of California San Francisco (UCSF), San Francisco, California, USA
| | - Robert Benamouzig
- Gastroenterology & Digestive Oncology Department, Hôpital Avicenne University Paris Nord La Sorbonne, Bobigny, France
| | - Sally Benton
- Department of Clinical Biochemistry and NHS Bowel Cancer Screening South of England Hub, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Patrick M M Bossuyt
- Department of Epidemiology & Data Science, Amsterdam Public Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Luis Caro
- Carrera de especialista de Endoscopia Digestiva, Institución GEDYT (Gastroenterologia diagnostico y terapéutica), Buenos Aires, Argentina
| | - Beatriz Carvalho
- Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Han-Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Veerle M H Coupé
- Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Willemijn de Klaver
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Clasine Maria de Klerk
- Department of Gastroenterology and Hepatology C2-310, Amsterdam UMC University of Amsterdam, Amsterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology C2-115, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Sunil Dolwani
- Dept of Gastroenterology, Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee School of Medicine, Dundee, UK
| | - William Grady
- Division of Translational Science and Therapeutics, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Lydia Guittet
- ERI3 Cancers & Populations, Normandie University, UNICAEN, Caen, France
| | - Samir Gupta
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Ulrike Haug
- Division of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology, Bremen, Germany
| | - Geir Hoff
- Department of Research, Telemark Hospital, Skien, Norway
- Department of CRC screening, Cancer Registry of Norway, Oslo, Norway
| | - Steven Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tim Kortlever
- Gastroenterology and Hepatology, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | | | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Beatrice Lauby-Secretan
- Section of Evidence Synthesis and Classification, International Agency for Research on Cancer, Lyon, France
| | - Mārcis Leja
- Institute of Clinical and Preventive Medicine, Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Bernard Levin
- Division of Cancer Prevention and Population Sciences, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Finlay Macrae
- Colorectal Medicine and Genetics, The University of Melbourne Department of Medicine Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Gerrit A Meijer
- Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Joshua Melson
- High-Risk Clinic for Gastrointestinal Cancers, University of Arizona Cancer Center Division of Gastroenterology, Banner University, Tucson, Arizona, USA
| | - Colm O'Morain
- Gastroenterology, Trinity College Dublin Faculty of Health Sciences, Dublin, Ireland
| | - Susan Parry
- National Bowel Screening Programme, National Screening Unit, Te Whatu Ora Health New Zealand, Auckland, New Zealand
- Department of Medicine, The University of Auckland, Auckland, New Zealand
| | - Linda Rabeneck
- Department of Medicine, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - David F Ransohoff
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Roque Sáenz
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Hiroshi Saito
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | | | - Robert E Schoen
- Departments of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin Selby
- Department of ambulatory Care, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Harminder Singh
- Internal Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | | | - Joseph J Y Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Erin Leigh Symonds
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sidney J Winawer
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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van Wifferen F, de Jonge L, Worthington J, Greuter MJ, Lew JB, Nadeau C, van den Puttelaar R, Feletto E, Yong JH, Lansdorp-Vogelaar I, Canfell K, Coupé VM, Anderson L, Besó Delgado M, Binefa G, Cust A, Dekker E, Dell’Anna V, Essue B, Espinas J, Flander L, Garcia M, Hahn A, Idigoras I, Katanoda K, Laghi L, Lamrock F, McFerran E, Majek O, Molina-Barceló A, Ledger M, Musa O, Njor S, O’Connor K, Portillo I, Salas D, Senore C, Smith H, Symonds E, Tachecí I, Taksler G, Tolani M, Treby M, Zauber A, Zheng Y. Prioritisation of colonoscopy services in colorectal cancer screening programmes to minimise impact of COVID-19 pandemic on predicted cancer burden: A comparative modelling study. J Med Screen 2021; 29:72-83. [PMID: 35100894 PMCID: PMC9087314 DOI: 10.1177/09691413211056777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objectives Colorectal cancer (CRC) screening with a faecal immunochemical test (FIT) has
been disrupted in many countries during the COVID-19 pandemic. Performing
catch-up of missed screens while maintaining regular screening services
requires additional colonoscopy capacity that may not be available. This
study aimed to compare strategies that clear the screening backlog using
limited colonoscopy resources. Methods A range of strategies were simulated using four country-specific CRC
natural-history models: Adenoma and Serrated pathway to Colorectal CAncer
(ASCCA) and MIcrosimulation SCreening ANalysis for CRC (MISCAN-Colon) (both
in the Netherlands), Policy1-Bowel (Australia) and OncoSim (Canada).
Strategies assumed a 3-month screening disruption with varying recovery
period lengths (6, 12, and 24 months) and varying FIT thresholds for
diagnostic colonoscopy. Increasing the FIT threshold reduces the number of
referrals to diagnostic colonoscopy. Outcomes for each strategy were
colonoscopy demand and excess CRC-related deaths due to the disruption. Results Performing catch-up using the regular FIT threshold in 6, 12 and 24 months
could prevent most excess CRC-related deaths, but required 50%, 25% and
12.5% additional colonoscopy demand, respectively. Without exceeding usual
colonoscopy demand, up to 60% of excess CRC-related deaths can be prevented
by increasing the FIT threshold for 12 or 24 months. Large increases in FIT
threshold could lead to additional deaths rather than preventing them. Conclusions Clearing the screening backlog in 24 months could avert most excess
CRC-related deaths due to a 3-month disruption but would require a small
increase in colonoscopy demand. Increasing the FIT threshold slightly over
24 months could ease the pressure on colonoscopy resources.
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Affiliation(s)
- Francine van Wifferen
- Decision Modeling Center, Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lucie de Jonge
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joachim Worthington
- The Daffodil Centre, The University of Sydney, A Joint Venture With Cancer Council NSW, Sydney, Australia
| | - Marjolein J.E. Greuter
- Decision Modeling Center, Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jie-Bin Lew
- The Daffodil Centre, The University of Sydney, A Joint Venture With Cancer Council NSW, Sydney, Australia
| | - Claude Nadeau
- Health Analysis Division, Statistics Canada, Ottawa, Canada
| | | | - Eleonora Feletto
- The Daffodil Centre, The University of Sydney, A Joint Venture With Cancer Council NSW, Sydney, Australia
| | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, A Joint Venture With Cancer Council NSW, Sydney, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Veerle M.H. Coupé
- Decision Modeling Center, Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
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