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Ribbing Wilén H, Blom J. Interval cancer after two rounds of a Swedish population-based screening program using gender-specific cut-off levels in fecal immunochemical test. J Med Screen 2024; 31:8-14. [PMID: 37455444 PMCID: PMC10878001 DOI: 10.1177/09691413231185722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/17/2023] [Accepted: 05/31/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To evaluate interval cancer (IC) after two screening rounds of the Swedish population-based screening program of Stockholm-Gotland applying gender-specific cut-off levels in the fecal immunochemical test (FIT). METHODS All 60- to 69-year-olds invited to screening 2015-2019 were included. The cut-off level for a positive test was 40 µg/g in women and 80 µg/g in men. Screening-detected colorectal cancers (SD CRCs) and ICs were verified in the Swedish Colorectal Cancer Register, and the follow-up time was two years from invitation. The test sensitivity, the IC rate (ICs per 10,000 screening negatives) and the IC incidence (ICs per 100,000 person-years) relative to the background CRC incidence were assessed by gender and age. The FIT levels were compared in men and women for CRCs diagnosed within one year of the sample. RESULTS In the second screening round, 229,187 were invited, and SD CRCs and ICs were diagnosed in 193 and 144, respectively. The IC rate was 8.9 (7.4-10.3) and test sensitivity 0.61 (0.55-0.66), and was similar in men and women. For two screening rounds, the IC rate was significantly higher in men than in women, but the IC incidence/ background CRC incidence was similar in both genders. The FIT levels in female participants with CRC were significantly lower overall, and in early-staged CRCs as compared to men, and proximal localization was more common in women. In multivariable analysis, FIT levels were significantly lower in proximal CRCs. CONCLUSION Over two rounds, the IC incidence relative to the background CRC incidence was similar in men and women supporting a gender-specific screening strategy. The results could be explained by lower FIT levels in women due to proximal CRC localization.
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Affiliation(s)
- Hanna Ribbing Wilén
- Department of Clinical Science and Education Södersjukhuset (KI SÖS), Karolinska Institutet, Stockholm, Sweden
| | - Johannes Blom
- Department of Clinical Science and Education Södersjukhuset (KI SÖS), Karolinska Institutet, Stockholm, Sweden
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Breekveldt ECH, Toes-Zoutendijk E, van de Schootbrugge-Vandermeer HJ, de Jonge L, Kooyker AI, Spaander MCW, van Vuuren AJ, van Kemenade FJ, Ramakers C, Dekker E, Nagtegaal ID, van Leerdam ME, Lansdorp-Vogelaar I. Factors associated with interval colorectal cancer after negative FIT: Results of two screening rounds in the Dutch FIT-based CRC screening program. Int J Cancer 2023; 152:1536-1546. [PMID: 36444504 PMCID: PMC10107864 DOI: 10.1002/ijc.34373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/30/2022]
Abstract
The interval colorectal cancer (CRC) rate after negative fecal immunochemical testing (FIT) is an important quality indicator of CRC screening programs. We analyzed the outcomes of two rounds of the FIT-based CRC screening program in the Netherlands, using data from individuals who participated in FIT-screening from 2014 to 2017. Data of individuals with one prior negative FIT (first round) or two prior negative FITs (first and second round) were included. Outcomes included the incidence of interval CRC in FIT-negative participants (<47 μg Hb/g feces [μg/g]), FIT-sensitivity, and the probability of detecting an interval CRC by fecal hemoglobin concentration (f-Hb). FIT-sensitivity was estimated using the detection method and the proportional incidence method (based on expected CRC incidence). Logistic regression analysis was performed to estimate whether f-Hb affects probability of detecting interval CRC, adjusted for sex- and age-differences. Incidence of interval CRC was 10.4 per 10 000 participants after the first and 9.6 after the second screening round. FIT-sensitivity based on the detection method was 84.4% (95%CI 83.8-85.0) in the first and 73.5% (95% CI 71.8-75.2) in the second screening round. The proportional incidence method resulted in a FIT-sensitivity of 76.4% (95%CI 73.3-79.6) in the first and 79.1% (95%CI 73.7-85.3) in the second screening round. After one negative FIT, participants with f-Hb just below the cut-off (>40-46.9 μg/g) had a higher probability of detecting an interval CRC (OR 16.9; 95%CI: 14.0-20.4) than had participants with unmeasurable f-Hb (0-2.6 μg/g). After two screening rounds, the odds ratio for interval CRC was 12.0 (95%CI: 7.8-17.6) for participants with f-Hb just below the cut-off compared with participants with unmeasurable f-Hb. After both screening rounds, the Dutch CRC screening program had a low incidence of interval CRC and an associated high FIT-sensitivity. Our findings suggest there is a potential for further optimizing CRC screening programs with the use of risk-stratified CRC screening based on prior f-Hb.
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Affiliation(s)
- Emilie C H Breekveldt
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Lucie de Jonge
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arthur I Kooyker
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Folkert J van Kemenade
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Christian Ramakers
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers-Academic Medical Center, Amsterdam, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Clark GRC, Steele RJC, Fraser CG. Strategies to minimise the current disadvantages experienced by women in faecal immunochemical test-based colorectal cancer screening. Clin Chem Lab Med 2022; 60:1496-1505. [PMID: 35848100 DOI: 10.1515/cclm-2022-0583] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/04/2022] [Indexed: 08/16/2024]
Abstract
Currently, women are disadvantaged compared to men in colorectal cancer (CRC) screening, particularly in programmes that use faecal immunochemical tests for haemoglobin (FIT) followed by colonoscopy. Although there is no single cause for all the known disadvantages, many can be attributed to the ubiquitous finding that women have lower faecal haemoglobin concentrations (f-Hb) than men; there are many plausible reasons for this. Generally, a single f-Hb threshold is used in CRC screening programmes, leading to lower positivity for women than men, which causes poorer outcomes for women, including lower CRC detection rate, higher interval cancer (IC) proportion, and higher CRC mortality. Many of the now widely advocated risk scoring strategies do include factors taking account of sex, but these have not been extensively piloted or introduced. Using different f-Hb thresholds for the sexes seems advantageous, but there are difficulties, including deciding which characteristic should be selected to achieve equivalency, for example, positivity, IC proportions, or specificity. Moreover, additional colonoscopy resources, often constrained, would be required. Governments and their agencies should be encouraged to prioritise the allocation of resources to put simple strategies into practice, such as different f-Hb thresholds to create equal positivity in both sexes.
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Affiliation(s)
- Gavin R C Clark
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
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