1
|
Hampton JS, Kenny RP, Rees CJ, Hamilton W, Eastaugh C, Richmond C, Sharp L. The performance of FIT-based and other risk prediction models for colorectal neoplasia in symptomatic patients: a systematic review. EClinicalMedicine 2023; 64:102204. [PMID: 37781155 PMCID: PMC10541467 DOI: 10.1016/j.eclinm.2023.102204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
Background Colorectal cancer (CRC) incidence and mortality are increasing internationally. Endoscopy services are under significant pressure with many overwhelmed. Faecal immunochemical testing (FIT) has been advocated to identify a high-risk population of symptomatic patients requiring definitive investigation by colonoscopy. Combining FIT with other factors in a risk prediction model could further improve performance in identifying those requiring investigation most urgently. We systematically reviewed performance of models predicting risk of CRC and/or advanced colorectal polyps (ACP) in symptomatic patients, with a particular focus on those models including FIT. Methods The review protocol was published on PROSPERO (CRD42022314710). Searches were conducted from database inception to April 2023 in MEDLINE, EMBASE, Cochrane libraries, SCOPUS and CINAHL. Risk of bias of each study was assessed using The Prediction study Risk Of Bias Assessment Tool. A narrative synthesis based on the guidelines for Synthesis Without Meta-Analysis was performed due to study heterogeneity. Findings We included 62 studies; 23 included FIT (n = 22) or guaiac Faecal Occult Blood Testing (n = 1) combined with one or more other variables. Twenty-one studies were conducted solely in primary care. Generally, prediction models including FIT consistently had good discriminatory ability for CRC/ACP (i.e. AUC >0.8) and performed better than models without FIT although some models without FIT also performed well. However, many studies did not present calibration and internal and external validation were limited. Two studies were rated as low risk of bias; neither model included FIT. Interpretation Risk prediction models, including and not including FIT, show promise for identifying those most at risk of colorectal neoplasia. Substantial limitations in evidence remain, including heterogeneity, high risk of bias, and lack of external validation. Further evaluation in studies adhering to gold standard methodology, in appropriate populations, is required before widespread adoption in clinical practice. Funding National Institute for Health and Care Research (NIHR) [Health Technology Assessment Programme (HTA) Programme (Project number 133852).
Collapse
Affiliation(s)
- James S. Hampton
- Population Health Sciences Institute, Newcastle University, United Kingdom
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, United Kingdom
| | - Ryan P.W. Kenny
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
| | - Colin J. Rees
- Population Health Sciences Institute, Newcastle University, United Kingdom
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, United Kingdom
| | - William Hamilton
- College of Medicine and Health, University of Exeter, United Kingdom
| | - Claire Eastaugh
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
| | - Catherine Richmond
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, United Kingdom
| | - COLOFIT Research Team
- Population Health Sciences Institute, Newcastle University, United Kingdom
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, United Kingdom
- Evidence Synthesis Group, The Catalyst, Population Health Sciences Institute, Newcastle University, United Kingdom
- National Institute for Health and Care Research Innovation Observatory, The Catalyst, Newcastle University, United Kingdom
- College of Medicine and Health, University of Exeter, United Kingdom
| |
Collapse
|
2
|
Piper TB, Nielsen HJ, Christensen IJ. Serological cancer-associated protein biomarker levels at bowel endoscopy: Increased risk of subsequent primary malignancy. Tumour Biol 2022; 44:1-16. [PMID: 35180141 DOI: 10.3233/tub-211501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND It was previously shown in three subpopulations that subjects not identified with colorectal cancer (CRC) at bowel endoscopy, but with increased serological cancer-associated protein biomarker levels had an increased risk of being diagnosed with subsequent malignant diseases. OBJECTIVE The aim of the present study was to perform a pooled analysis of subjects from the three subpopulations and subsequently validate the results in an independent study. The study population denoted the training set includes N = 4,076 subjects with symptoms attributable to CRC and the independent validation set N = 3,774 similar subjects. METHODS Levels of CEA, CA19-9, TIMP-1 and YKL-40 were determined in blood samples collected prior to diagnostic bowel endoscopy. Follow-up of subjects not diagnosed with CRC at endoscopy, was ten years and identified subjects diagnosed with primary intra- or extra-colonic malignant diseases. The primary analysis was time to a newly diagnosed malignant disease and was analyzed with death as a competing risk in the training set. Subjects with HNPCC or FAP were excluded. The cumulated incidence was estimated for each biomarker and in a multivariate model. The resulting model was then validated on the second study population. RESULTS In the training set primary malignancies were identified in 515 (12.6%) of the 4,076 subjects, who had a colorectal endoscopy with non-malignant findings. In detail, 33 subjects were subsequently diagnosed with CRC and 482 subjects with various extra-colonic cancers. Multivariate additive analysis of the dichotomized biomarkers demonstrated that CEA (HR = 1.50, 95% CI:1.21-1.86, p < 0.001), CA19-9 (HR = 1.41, 95% CI:1.10-1.81, p = 0.007) and TIMP-1 (HR = 1.25 95% CI: 1.01-1.54, p = 0.041) were significant predictors of subsequent malignancy. The cumulated incidence at 5 years landmark time was 17% for those subjects with elevated CEA, CA19-9 and TIMP-1 versus 6.7% for those with low levels of all. When the model was applied to the validation set the cumulated 5-year incidence was 10.5% for subjects with elevated CEA, CA19-9 and TIMP-1 and 5.6% for subjects with low levels of all biomarkers. Further analysis demonstrated a significant interaction between TIMP-1 and age in the training set. The age dependency of TIMP-1 indicated a greater risk of malignancy in younger subjects if the biomarker was elevated. This observation was validated in the second set. CONCLUSION Elevated cancer-associated protein biomarker levels in subjects with non-malignant findings at large bowel endoscopy identifies subjects at increased risk of being diagnosed with subsequent primary malignancy. CEA, CA19-9 and TIMP-1 were significant predictors of malignant disease in this analysis. TIMP-1 was found dependent on age. The results were validated in an independent symptomatic population.
Collapse
Affiliation(s)
- Thomas B Piper
- Department of Surgical Gastroenterology, Hvidovre Hospital, Hvidovre, Denmark
| | - Hans J Nielsen
- Department of Surgical Gastroenterology, Hvidovre Hospital, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | |
Collapse
|
3
|
Gawel SH, Lucht M, Gomer H, Treado P, Christensen IJ, Nielsen HJ, Davis GJ. Evaluation of algorithm development approaches: Development of biomarker panels for early detection of colorectal lesions. Clin Chim Acta 2019; 498:108-115. [PMID: 31419412 DOI: 10.1016/j.cca.2019.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 08/01/2019] [Accepted: 08/13/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) is the third most common cancer in the U.S. Early detection of CRC can substantially increase survival rates. Test compliance may be improved by offering a blood-based test option. METHODS Endoscopy II trial specimens were tested for AFP, CA19-9, CEA, hs-CRP, CyFra 21-1, Ferritin, Galectin-3, and TIMP-1 levels. These biomarkers, as well as patient demographic information (e.g., age, gender), were included in algorithm development. Six statistical methods were utilized to develop algorithms that would discriminate cancer vs. noncancers. Statistical methods included logistic regression, adaptive index modeling, partial least-squares discriminant analysis, feature vector (weighted and unweighted), and random forest. The performance of these algorithms was compared against benchmark criteria established for stool-based tests. RESULTS Using several statistical methods, the presence of CRC and high-risk adenomas was detected with an AUCs of at least 0.65-0.76, with a few of models approaching the stool-based tests benchmark performance. Further, common markers were utilized across the different statistical techniques, with model complexities ranging from 3 to 9 markers. CONCLUSIONS Predictive models identified subjects with CRC and high-risk adenomas with the similar levels of statistical accuracy. Clinical performance differences were minimal across the statistical techniques, although the intuitive interpretations, model complexity, clinical adoption and implementation varied.
Collapse
Affiliation(s)
- Susan H Gawel
- Abbott Cancer Core R&D, Abbott Diagnostics Division, Abbott Park, IL, USA
| | - Michael Lucht
- Abbott Cancer Core R&D, Abbott Diagnostics Division, Abbott Park, IL, USA
| | - Heather Gomer
- ChemImage Life Sciences, ChemImage Corporation, Pittsburgh, PA, USA
| | - Patrick Treado
- ChemImage Life Sciences, ChemImage Corporation, Pittsburgh, PA, USA
| | - Ib J Christensen
- Department of Surgical Gastroenterology, Hvidovre Hospital, Denmark
| | - Hans J Nielsen
- Department of Surgical Gastroenterology, Hvidovre Hospital, Denmark
| | - Gerard J Davis
- Abbott Cancer Core R&D, Abbott Diagnostics Division, Abbott Park, IL, USA.
| | | |
Collapse
|
4
|
Piper TB, Jørgensen LN, Olsen J, Nielsen KT, Davis G, Johansen JS, Jarle Christensen I, Nielsen HJ. Increased serological, cancer-associated protein biomarker levels at diagnosis of large bowel adenoma: Risk of subsequent primary malignancy? Acta Oncol 2018; 58:S42-S48. [PMID: 30523734 DOI: 10.1080/0284186x.2018.1540885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Blood-based, cancer-associated biomarkers may detect subjects at risk of having neoplastic diseases. The aim of the present study was to evaluate whether elevated serological protein biomarker levels may identify adenoma patients, who are at increased risk of being diagnosed with subsequent primary malignancy. METHODS Levels of CEA, CA19-9, TIMP-1 and YKL-40 were determined in blood samples collected prior to diagnostic bowel endoscopy due to symptoms of colorectal neoplasia. Follow-up time was ten years, and identified adenoma patients, who were diagnosed with subsequent primary intra- or extra-colonic malignant diseases. The biomarker levels were also determined in 400 subjects, who underwent diagnostic colonoscopy, had clean colorectum and were without apparent co-morbidity; these levels were used as reference levels. In the present study, biomarkers were interpreted as elevated when levels were above the reference intervals adjusting for age and gender. The 1-year and 5-years cumulative incidences were calculated. RESULTS Primary malignancies were identified in 175 (19%) of the 923 subjects diagnosed with adenomas at the primary bowel endoscopy. In detail, 20 of the 175 subjects were diagnosed with colorectal cancer (CRC) and 155 subjects with extra-colonic cancers. Thirty patients were diagnosed with malignancy within the first year. Three groups were established: 0: no elevated biomarkers; 1: 1 of the 4 biomarkers elevated; and 2: ≥2 biomarkers elevated. The cumulative 5-years incidence of malignancy was: 0: 6.9%; 1: 11.8%; and 2: 17.5% (p = .0009). CONCLUSION Elevated blood-based, cancer-associated protein biomarker levels in subjects diagnosed with adenomas at large bowel endoscopy identifies subjects at increased risk of being diagnosed with subsequent primary malignancy.
Collapse
Affiliation(s)
- Thomas B. Piper
- Department of Surgical Gastroenterology, Center for Surgical Research, Hvidovre Hospital, Hvidovre, Denmark
| | - Lars N. Jørgensen
- Digestive Disease Center, Bispebjerg Hospital, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Olsen
- Department of Surgical Gastroenterology, Herlev Hospital, Herlev, Denmark
| | | | - Gerard Davis
- Abbott Diagnostics Division R&D, Chicago, IL, USA
| | - Julia S. Johansen
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Oncology, Herlev and Gentofte Hospital, Herlev, Denmark
- Department of Medicine, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Ib Jarle Christensen
- Department of Surgical Gastroenterology, Center for Surgical Research, Hvidovre Hospital, Hvidovre, Denmark
| | - Hans J. Nielsen
- Department of Surgical Gastroenterology, Center for Surgical Research, Hvidovre Hospital, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|