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Rees CJ, Hamilton W. BSG guidelines on faecal immunochemical testing: are they 'FIT' for purpose? Gut 2023; 72:1805-1806. [PMID: 36113978 DOI: 10.1136/gutjnl-2022-328201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/04/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Colin J Rees
- Gastroenterology, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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2
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Fraser CG. Faecal haemoglobin: Measurement, applications, and future potential. Best Pract Res Clin Gastroenterol 2023; 66:101833. [PMID: 37852705 DOI: 10.1016/j.bpg.2023.101833] [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: 03/14/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 10/20/2023]
Abstract
Faecal hemoglobin concentrations (f-Hb) can be quantitated using faecal immunochemical test for haemoglobin (FIT) analytical systems. FIT are of proven value and widely used in colorectal cancer (CRC) screening. Several factors affect f-Hb including sex, age, deprivation, geographical region, and FIT system. Thus, FIT data may not be transferable. Women are disadvantaged in programmes using a single f-Hb threshold for all participants, but risk scoring or sex stratified thresholds could be used to minimise this problem. In addition, low but detectable f-Hb, below the threshold, implies future risk of CRC. In several countries, where colonoscopy resources are constrained, FIT are now accepted as of added value in assessment of patients presenting in primary or secondary care with symptoms, although some serious colorectal disease is missed. Elevated f-Hb in the absence of any discernible colorectal lesions is common and has been found in several diseases with a systemic inflammatory component, including circulatory, respiratory, digestive, neuropsychological, blood and endocrine diseases, and others. There is growing evidence for the value of f-Hb in post-polypectomy surveillance, potentially saving costs and colonoscopy. There may be a role for FIT systems which have lower limits of detection than currently available methods. The faecal material remaining in FIT specimen collection devices could be used for further studies, including assessment of the microbiome. The estimation of f-Hb is now a mature investigative tool but further research will undoubtedly expand applications of value.
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Affiliation(s)
- Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK.
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3
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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).
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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
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4
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Monahan KJ, Davies MM, Abulafi M, Banerjea A, Nicholson BD, Arasaradnam R, Barker N, Benton S, Booth R, Burling D, Carten RV, D'Souza N, East JE, Kleijnen J, Machesney M, Pettman M, Pipe J, Saker L, Sharp L, Stephenson J, Steele RJ. Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG). Gut 2022; 71:gutjnl-2022-327985. [PMID: 35820780 PMCID: PMC9484376 DOI: 10.1136/gutjnl-2022-327985] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/01/2022] [Indexed: 12/12/2022]
Abstract
Faecal immunochemical testing (FIT) has a high sensitivity for the detection of colorectal cancer (CRC). In a symptomatic population FIT may identify those patients who require colorectal investigation with the highest priority. FIT offers considerable advantages over the use of symptoms alone, as an objective measure of risk with a vastly superior positive predictive value for CRC, while conversely identifying a truly low risk cohort of patients. The aim of this guideline was to provide a clear strategy for the use of FIT in the diagnostic pathway of people with signs or symptoms of a suspected diagnosis of CRC. The guideline was jointly developed by the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology, specifically by a 21-member multidisciplinary guideline development group (GDG). A systematic review of 13 535 publications was undertaken to develop 23 evidence and expert opinion-based recommendations for the triage of people with symptoms of a suspected CRC diagnosis in primary care. In order to achieve consensus among a broad group of key stakeholders, we completed an extended Delphi of the GDG, and also 61 other individuals across the UK and Ireland, including by members of the public, charities and primary and secondary care. Seventeen research recommendations were also prioritised to inform clinical management.
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Affiliation(s)
- Kevin J Monahan
- The Wolfson Endoscopy Unit, Gastroenterology Department, St Mark's Hospital and Academic Institute, Harrow, London, UK
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, UK
| | - Michael M Davies
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - Muti Abulafi
- Colorectal Surgery, Croydon Health Services NHS Trust, Croydon, Greater London, UK
| | - Ayan Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Brian D Nicholson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ramesh Arasaradnam
- University of Warwick, Clinical Sciences Research Institute, Coventry, UK
- Gastroenterology Department, University Hospital Coventry, Coventry, UK
| | | | - Sally Benton
- Hub Director, NHS Bowel Cancer Screening South of England Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Richard Booth
- Colorectal Surgery, Croydon University Hospital, Croydon, UK
| | - David Burling
- Radiology, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | | | | | - James Edward East
- Translational Gastroenterology Unit, Univerity of Oxford Nuffield Department of Medicine, Oxford, UK
- Gastroenterology, Mayo Clinic Healthcare, London, UK
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, North Yorkshire, UK
| | - Michael Machesney
- Colorectal Surgery, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Maria Pettman
- Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Lance Saker
- General Practice, Oak Lodge Medical Centre, London, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Robert Jc Steele
- Surgery and Oncology Department, University of Dundee, Dundee, UK
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5
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Withrow DR, Shine B, Oke J, Tamm A, James T, Morris E, Davies J, Harris S, East JE, Nicholson BD. Combining faecal immunochemical testing with blood test results for colorectal cancer risk stratification: a consecutive cohort of 16,604 patients presenting to primary care. BMC Med 2022; 20:116. [PMID: 35287679 PMCID: PMC8920746 DOI: 10.1186/s12916-022-02272-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/24/2022] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Faecal immunochemical tests (FITs) are used to triage primary care patients with symptoms that could be caused by colorectal cancer for referral to colonoscopy. The aim of this study was to determine whether combining FIT with routine blood test results could improve the performance of FIT in the primary care setting. METHODS Results of all consecutive FITs requested by primary care providers between March 2017 and December 2020 were retrieved from the Oxford University Hospitals NHS Foundation Trust. Demographic factors (age, sex), reason for referral, and results of blood tests within 90 days were also retrieved. Patients were followed up for incident colorectal cancer in linked hospital records. The sensitivity, specificity, positive and negative predictive values of FIT alone, FIT paired with blood test results, and several multivariable FIT models, were compared. RESULTS One hundred thirty-nine colorectal cancers were diagnosed (0.8%). Sensitivity and specificity of FIT alone at a threshold of 10 μg Hb/g were 92.1 and 91.5% respectively. Compared to FIT alone, blood test results did not improve the performance of FIT. Pairing blood test results with FIT increased specificity but decreased sensitivity. Multivariable models including blood tests performed similarly to FIT alone. CONCLUSIONS FIT is a highly sensitive tool for identifying higher risk individuals presenting to primary care with lower risk symptoms. Combining blood test results with FIT does not appear to lead to better discrimination for colorectal cancer than using FIT alone.
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Affiliation(s)
- Diana R Withrow
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - Brian Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation, Oxford, UK
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
| | - Andres Tamm
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Tim James
- Department of Computer Science, Big Data Institute, University of Oxford, Oxford, UK
| | - Eva Morris
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Jim Davies
- Department of Computer Science, Big Data Institute, University of Oxford, Oxford, UK
| | - Steve Harris
- Oxford BRC Informatics Theme, Big Data Institute, University of Oxford, Oxford, UK
| | - James E East
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
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Johnstone MS, Burton P, Kourounis G, Winter J, Crighton E, Mansouri D, Witherspoon P, Smith K, McSorley ST. Combining the quantitative faecal immunochemical test and full blood count reliably rules out colorectal cancer in a symptomatic patient referral pathway. Int J Colorectal Dis 2022; 37:457-466. [PMID: 34932152 PMCID: PMC8803704 DOI: 10.1007/s00384-021-04079-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Faecal Immunochemical Test (FIT) has proven utility for Colorectal Cancer (CRC) detection in symptomatic patients. Most studies have examined FIT in symptomatic patients subsequently referred from primary care. We investigated associations between CRC and FIT in both referred and non-referred symptomatic patients. METHODS A retrospective, observational study of all patients with a FIT submitted Aug 2018 to Jan 2019 in NHS GG&C was performed. Referral to colorectal/gastroenterology and decision to perform colonoscopy were recorded. FIT results were grouped as f-Hb < 10/10-149/150-399/ ≥ 400 μg/g. The MCN cancer registry identified new cases of CRC. Covariables were compared using the χ2 test. Multivariate binary logistic regression identified independent predictors of CRC. RESULTS A total of 4968 patients were included. Raised FIT correlated with decision to refer (p < 0.001) and scope (p < 0.001). With 23-month median follow-up, 61 patients were diagnosed with CRC. These patients were older (median 69 vs 59 years, cancer and no cancer respectively, p = 0.001), more likely to be male (55.7% vs 42.1%, p = 0.033), and to report rectal bleeding (51.7% vs 36.1%, p = 0.013). FIT (< 10 µg/g 8.2% vs 76.7% and ≥ 400 µg/g 55.7% vs 3.8%, p < 0.001) and anaemia (45.9% vs 19.7%, p < 0.001) were associated with CRC. On multivariate analysis, age (p = 0.023), male sex (p = 0.04), FIT (≥ 400 OR 54.256 (95% CI:20.683-142.325; p < 0.001)), and anaemia (OR 1.956 (1.071-3.574; p = 0.029)) independently predicted CRC. One patient (0.04%) with a negative FIT and normal haemoglobin had CRC. CONCLUSION GP referral and secondary care investigation patterns were influenced by FIT. The combination of normal Hb and f-Hb excluded CRC in 99.96% of cases, providing excellent reassurance to those prioritising access to endoscopy services.
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Affiliation(s)
- Mark S Johnstone
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, UK.
| | - Paul Burton
- eHealth, Corporate Services, Business Intelligence, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Georgios Kourounis
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, UK
| | - Jack Winter
- Department of Gastroenterology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Emilia Crighton
- Public Health, Health Service, Public Health Screening, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - David Mansouri
- Department of Coloproctology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Paul Witherspoon
- Department of Colorectal Surgery, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Karen Smith
- Department of Clinical Biochemistry, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow, UK
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McSorley ST, Digby J, Clyde D, Cruickshank N, Burton P, Barker L, Strachan JA, Fraser CG, Smith K, Mowat C, Winter J, Steele RJC. Yield of colorectal cancer at colonoscopy according to faecal haemoglobin concentration in symptomatic patients referred from primary care. Colorectal Dis 2021; 23:1615-1621. [PMID: 33064898 DOI: 10.1111/codi.15405] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/16/2020] [Accepted: 10/03/2020] [Indexed: 12/13/2022]
Abstract
AIM Lower gastrointestinal (GI) symptoms are poor predictors of colorectal cancer (CRC). The aim of this study was to examine the diagnostic yield of colonoscopy by faecal haemoglobin (f-Hb) concentration in symptomatic patients assessed in primary care by faecal immunochemical testing (FIT). METHOD In three Scottish NHS Boards, FIT kits (HM-JACKarc, Hitachi Chemical Diagnostics Systems Co., Ltd, Tokyo, Japan) were used by general practitioners to guide referrals for patients with lower GI symptoms (laboratory data studied for 12 months from December 2015 onwards in Tayside, 18 months from June 2018 onwards in Fife and 5 months from September 2018 onwards in Greater Glasgow and Clyde). Cases of CRC diagnosed at colonoscopy were ascertained from colonoscopy and pathology records. RESULTS Four thousand eight hundred and forty one symptomatic patients who underwent colonoscopy after FIT submission were included. Of the 2166 patients (44.7%) with f-Hb <10 µg Hb/g faeces (µg/g), 14 (0.6%) were diagnosed with CRC, with a number needed to scope (NNS) of 155. Of the 2675 patients (55.3%) with f-Hb ≥10 µg/g, 252 were diagnosed with CRC (9.4%) with a NNS of 11. Of the 705 patients with f-Hb ≥400 µg/g, 158 (22.4%) were diagnosed with CRC with a NNS of 5. Over half of those diagnosed with CRC with f-Hb <10 µg/g had coexisting anaemia. CONCLUSION Symptomatic patients with f-Hb ≥10 µg/g should undergo further investigation for CRC, while higher f-Hb concentrations could be used to triage for urgency during the COVID-19 recovery phase. Patients with f-Hb <10 µg/g and without anaemia are very unlikely to be diagnosed with CRC and the majority need no further investigation.
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Affiliation(s)
- Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Jayne Digby
- Centre for Research into Cancer Prevention and Screening, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Danielle Clyde
- Department of Surgery, NHS Fife, Victoria Hospital, Kirkcaldy, UK
| | - Neil Cruickshank
- Department of Surgery, NHS Fife, Victoria Hospital, Kirkcaldy, UK
| | - Paul Burton
- eHealth, Corporate Services, Business Intelligence, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Louise Barker
- Department of Surgery, NHS Fife, Victoria Hospital, Kirkcaldy, UK
| | - Judith A Strachan
- Department of Blood Sciences, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Karen Smith
- Department of Clinical Biochemistry, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, UK
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | - Jack Winter
- Department of Gastroenterology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Ayling RM, Wong A, Cotter F. Use of ColonFlag score for prioritisation of endoscopy in colorectal cancer. BMJ Open Gastroenterol 2021; 8:e000639. [PMID: 34083226 PMCID: PMC8183282 DOI: 10.1136/bmjgast-2021-000639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/18/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Colorectal cancer (CRC) is the fourth most common cancer in UK. Symptomatic patients are referred via an urgent pathway and although most are investigated with colonoscopy <4% are diagnosed with cancer. There is therefore a need for a suitable triage tool to prioritise investigations. This study retrospectively examined performance of various triage tools in patients awaiting investigation on the urgent lower gastrointestinal cancer pathway DESIGN: All patients over 40 years of age on the urgent pathway awaiting investigation for suspected CRC on 1 May were included. After 6 months, outcomes were evaluated and the performance of the faecal immunochemical test (FIT), faecal haemoglobin concentration, age and sex test (FAST) and the artificial intelligence algorithm ColonFlag were examined. RESULTS 532 completed investigations and received a diagnosis; 15 had CRC. 388 had a valid FIT result, of whom 11 had CRC; FAST Score ≥4.5 had sensitivity of 72.7%, specificity of 80.6% and would have failed to detect three tumours. Faecal haemoglobin (f-Hb) at cut-off of 10 µg/g and ColonFlag had equal sensitivity of 81.82%, ColonFlag had greater specificity 73.47%, compared with 64.99%. Both tests would have failed to detect two tumours but not in the same patients; when used in combination, sensitivity and specificity were 100% and 49.4%. When ColonFlag was applied to the cohort of 532, an additional four tumours would have been detected in patients without a valid FIT. CONCLUSION This study showed ColonFlag to have equal sensitivity and greater specificity than f-Hb at a cut-off of 10 µg/g as a triage tool for CRC.
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Affiliation(s)
- Ruth M Ayling
- Clinical Biochemistry, Barts Health NHS Trust, London, UK
| | - A Wong
- Gastroenterology, Barts Health NHS Trust, London, London, UK
| | - Finbarr Cotter
- Haemato-oncology, Barts Health NHS Trust, London, London, UK
- Joint NHS/academic appointment, Queen Mary University of London, London, London, UK
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Calanzani N, Chang A, Van Melle M, Pannebakker MM, Funston G, Walter FM. Recognising Colorectal Cancer in Primary Care. Adv Ther 2021; 38:2732-2746. [PMID: 33864597 PMCID: PMC8052540 DOI: 10.1007/s12325-021-01726-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/24/2021] [Indexed: 12/15/2022]
Abstract
Colorectal cancer (CRC) is the third most common cancer worldwide. Primary care professionals can play an important role in both prevention and early detection of CRC. Most CRCs are attributed to modifiable lifestyle factors, which can be addressed within primary care, and promotion of population-based screening programmes can aid early cancer detection in asymptomatic patients. Primary care professionals have a vital role in clinically assessing patients presenting with symptoms that may indicate cancer, as most patients with CRC first present with symptoms. These assessments are often challenging—many of the symptoms of CRC are non-specific and commonly occur in patients presenting with non-malignant disease. The range of options for investigating symptomatic patients in primary care is rapidly growing. Simple tests, such as faecal immunochemical testing (FIT), are now being used to guide decisions around referral for more invasive tests, such as colonoscopy, while direct access to specialist investigations is also becoming more common. Clinical decision support tools (CDSTs) which calculate cancer risk based on symptomatology, patient characteristics and test results can provide an additional resource to guide decisions on further investigation. This article explores the challenges of CRC prevention and detection from the primary care perspective, discusses current evidence-based approaches for CRC detection used in primary care (with examples from UK guidelines), and highlights emerging research which may likely alter practice in the future.
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Affiliation(s)
- Natalia Calanzani
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK
| | - Aina Chang
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marije Van Melle
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK
| | - Merel M Pannebakker
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK
| | - Garth Funston
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK.
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, Australia.
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Bailey JA, Weller J, Chapman CJ, Ford A, Hardy K, Oliver S, Morling JR, Simpson JA, Humes DJ, Banerjea A. Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation. BJS Open 2021; 5:6162967. [PMID: 33693553 PMCID: PMC7947575 DOI: 10.1093/bjsopen/zraa056] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A novel pathway incorporating faecal immunochemical testing (FIT) for rapid colorectal cancer diagnosis (RCCD) was introduced in 2017. This paper reports on the service evaluation after 2 years of pathway implementation. METHODS The RCCD protocol was based on FIT, blood results and symptoms to stratify adult patients in primary care. Two-week-wait (2WW) investigation was indicated for patients with rectal bleeding, rectal mass and faecal haemoglobin (fHb) level of 10 µg Hb/g faeces or above or 4 µg Hb/g faeces or more in the presence of anaemia, low ferritin or thrombocytosis, in all other symptom groups. Patients with 100 µg Hb/g faeces or above had expedited investigation . A retrospective audit of colorectal cancer detected between 2017 and 2019 was conducted, fHb thresholds were reviewed and critically assessed for cancer diagnoses. RESULTS In 2 years, 14788 FIT tests were dispatched with 13361 (90.4 per cent) completed returns. Overall, fHb was less than 4 µg Hb/g faeces in 9208 results (68.9 per cent), 4-9.9 µg Hb/g in 1583 (11.8 per cent), 10-99.9 µg Hb/g in 1850 (13.8 per cent) and 100 µg Hb/g faeces or above in 720 (5.4 per cent). During follow-up (median 10.4 months), 227 colorectal cancers were diagnosed. The cancer detection rate was 0.1 per cent in patients with fHb below 4 µg Hb/g faeces, 0.6 per cent in those with fHb 4-9.9 µg Hb/g faeces, 3.3 per cent for fHb 10-99.9 µg Hb/g faeces and 20.7 per cent for fHb 100 µg Hb/g faeces or above. The detection rate in the cohort with 10-19.9 µg Hb/g faeces was 1.4 per cent, below the National Institute for Health and Care Excellence threshold for urgent referral. The colorectal cancer rate in patients with fHb below 20 µg Hb/g faeces was less than 0.3 per cent. CONCLUSION Use of FIT to "rule out" urgent referral from primary care misses a small number of cases. The threshold for referral may be adjusted with blood results to improve stratification .
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Weller
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C J Chapman
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Ford
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Hardy
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Oliver
- Nottingham City Clinical Commissioning Group, Nottingham,UK
| | - J R Morling
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - J A Simpson
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK,National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK,Correspondence to: Nottingham Colorectal Service, E Floor West Block, Queen’s Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK (e-mail: )
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Bailey JA, Ibrahim H, Bunce J, Chapman CJ, Morling JR, Simpson JA, Humes DJ, Banerjea A. Quantitative FIT stratification is superior to NICE referral criteria NG12 in a high-risk colorectal cancer population. Tech Coloproctol 2021; 25:1151-1154. [PMID: 34263362 PMCID: PMC8279105 DOI: 10.1007/s10151-021-02466-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Guidelines for urgent investigation of colorectal cancer (CRC) are based on age and symptom-based criteria. This study aims to compare the diagnostic value of clinical features and faecal immunochemical test (FIT) results to identify those at a higher risk of CRC, thereby facilitating effective triage of patients. METHODS We undertook a review of all patients referred for investigation of CRC at our centre between September 2016 and June 2018. Patients were identified using a prospectively recorded local database. We performed a logistic regression analysis of factors associated with a diagnosis of CRC. RESULTS One-thousand-and-seven-hundred-eighty-four patients with FIT results were included in the study. Change in bowel habit (CIBH) was the most common referring clinical feature (38.3%). Patients diagnosed with CRC were significantly older than those without malignancy (74.0 years vs 68.9 years, p = 0.0007). Male patients were more likely to be diagnosed with CRC than females (6.5% vs 2.5%, Chi-squared 16.93, p < 0.0001). CRC was diagnosed in 3.5% (24/684) with CIBH compared to 8.1% (6/74) with both CIBH and iron deficiency anaemia. No individual or combination of referring clinical features was associated with an increased diagnosis of CRC (Chi-squared, 8.03, p = 0.155). Three patients with negative FIT results (< 4 µg Hb/g faeces) were diagnosed with CRC (3/1027, 0.3%). The highest proportion of cancers detected was in the ≥ 100 µg Hb/g faeces group (55/181, 30.4%). CONCLUSION In a multivariate model, FIT outperforms age, sex and all symptoms prompting referral. FIT has greater stratification value than any referral symptoms. FIT does have value in patients with iron deficiency anaemia.
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - H Ibrahim
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J Bunce
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C J Chapman
- Eastern Hub, Bowel Cancer Screening Programme, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J R Morling
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of NottinghamCity Hospital, Nottingham, UK
| | - J A Simpson
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Division of Epidemiology and Public Health, School of Medicine, University of NottinghamCity Hospital, Nottingham, UK
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Nicholson BD, James T, Paddon M, Justice S, Oke JL, East JE, Shine B. Faecal immunochemical testing for adults with symptoms of colorectal cancer attending English primary care: a retrospective cohort study of 14 487 consecutive test requests. Aliment Pharmacol Ther 2020; 52:1031-1041. [PMID: 32677733 DOI: 10.1111/apt.15969] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/02/2020] [Accepted: 06/25/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Faecal immunochemical testing (FIT) is recommended by the National Institute for Health and Care Excellence (NICE) to triage symptomatic primary care patients for further investigation of colorectal cancer. AIM To ascertain the diagnostic performance of FIT in symptomatic adult primary care patients. METHODS Faecal samples from routine primary care practice in Oxfordshire, UK were analysed using the HM-JACKarc FIT method between March 2017 and March 2020. Clinical details were recorded. Patients were followed for up to 36 months in linked hospital records for evidence of benign and serious (colorectal cancer, high-risk adenomas and bowel inflammation) colorectal disease. The diagnostic accuracy of FIT is reported by gender, age group and FIT threshold. RESULTS In 9896 adult patients with at least 6-month follow-up, a FIT result ≥10 µg Hb/g faeces had a sensitivity for colorectal cancer of 90.5% (95% CI 84.9%-96.1%), specificity 91.3% (90.8%-91.9%), positive predictive value (PPV) 10.1% (8.15%-12.0%) and negative predictive value (NPV) 99.9% (99.8%-100.0%). The PPV and specificity for serious colorectal disease were higher and the sensitivity and NPV lower than for colorectal cancer alone. The area under the curve for all adults did not change substantially by gender or by increasing the minimum age of testing. Using ≥10 µg Hb/g faeces, 10% of adults would be investigated to detect 91% of cancers, a number needed to scope of ten to detect one cancer. Using ≥7, ≥50 and ≥150 µg Hb/g faeces, 11%, 4% and 3% of adults would be investigated, and 91%, 74% and 54% cancers detected, respectively. CONCLUSION A FIT threshold of ≥10 µg Hb/g faeces would be appropriate to triage adult patients presenting to primary care with symptoms of serious colorectal disease. FIT may be used to reprioritise patients referred with colorectal cancer symptoms whose investigations have been delayed by the COVID-19 pandemic.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tim James
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
| | - Maria Paddon
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
| | - Steve Justice
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - James E East
- Translational Gastroenterology Unit, and Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Brian Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK
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Cubiella J. Not so FAST. Commentary on the article "Appraisal of the faecal haemoglobin, age and sex test (FAST) score in assessment of patients with lower bowel symptoms: an observational study". BMC Gastroenterol 2020; 20:231. [PMID: 32690047 PMCID: PMC7370509 DOI: 10.1186/s12876-020-01322-y] [Citation(s) in RCA: 1] [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: 01/15/2020] [Accepted: 05/28/2020] [Indexed: 11/25/2022] Open
Abstract
A recent study by Digby et al. in BMC Gastroenterology evaluated the faecal haemoglobin, age and sex test (FAST) score in the assessment of patients with lower bowel symptoms attended in primary healthcare. This article is a valuable source of information but the conclusions must be carefully assessed. Authors evaluated the FAST score threshold with a 99% sensitivity (≥ 2.12) for colorectal cancer (CRC). Although the number of patients meeting this criteria is high, 53.5% of the patients not referred initially to secondary healthcare, the results on the patients referred to colonoscopy validate the prediction model. The sensitivity and the specificity for CRC detection were 99.0 and 23.2% with a positive and negative predictive value of 8.0 and 99.7%. Additionally, the sensitivity and the specificity for significant bowel disease were 96.1 and 26.2% with a positive and negative predictive value of 24.3 and 96.1%, consistent with our initial results. To conclude, although we need the information regarding the risk of CRC in those patients not referred to colonoscopy, a FAST Score < 2.12 allows to determine a group of patients with a low risk of CRC detection that requires no further evaluation.
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Affiliation(s)
- Joaquín Cubiella
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Instituto de Investigación Sanitaria Galicia Sur, Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, C/ Rúa Ramón Puga 52-56, 32003, Ourense, Spain.
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Gutierrez-Stampa MA, Aguilar V, Sarasqueta C, Cubiella J, Portillo I, Bujanda L. Impact of the faecal immunochemical test on colorectal cancer survival. BMC Cancer 2020; 20:616. [PMID: 32611328 PMCID: PMC7328266 DOI: 10.1186/s12885-020-07074-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023] Open
Abstract
Background There is already evidence that the faecal immunochemical test (FIT) is a useful tool for the diagnosis of colorectal cancer (CRC) that helps to identify symptomatic patients requiring early colonoscopy. Although the recommendation to use FIT is widely accepted, there are no data concerning whether this strategy improves patient survival.The objective was to assess whether the survival is higher if CRC patients have been first diagnosed by FIT (as compared with the rest of patients with CRC). Methods We identified all cases of CRC diagnosed between 2009 and 2016 in Donostialdea (Spain), excluding all the CRC detected in population screening. We focused on symptomatic patients. One thousand five hundred twenty-seven cases of CRC were divided into two groups based on the route to diagnosis: group 1: individuals who tested positive in a FIT during the year before diagnosis, and group 2: others.Survival was assessed by Kaplan-Meier estimation, and with the log-rank test. A Cox regression model was used to adjust for differences between groups due to other variables associated with survival. Results One thousand nine hundred sixty-seven cases of invasive CRC were identified, of which 22.4% were detected in population screening. Of the 1527 cases diagnosed in symptomatic patients, 317 patients had undergone a FIT in the year before the diagnosis of CRC. In 279 cases(18.3%), the result had been positive and this was the first step towards their CRC diagnosis (group 1). Group 2 was composed of the 1248 cases of CRC (81.7%). Considering these cases, 1210 patients with CRC did not undergo any FIT while 38 patients presented a negative result in the year before the diagnosis. The rate of early-stage disease (stage I or II) was higher in group 1 (51.3% vs 45.5% in group 2) (p = 0.04). Furthermore, the 3-year survival was longer in group 1 (72% vs 59% in group 2) (HR 1.50; 95% CI 1.22–1.84).The variables independently associated with worse survival were: group 2, age > 70 years and stage at the moment of diagnosis. Conclusions The use of FIT as a diagnostic strategy in symptomatic patients may improve survival in CRC. Nonetheless,FIT is still not widely used in our region.
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Affiliation(s)
| | - Vanessa Aguilar
- Osakidetza, OSI Donostialdea, Altza Primary Care; Biodonostia Health Research Institute, San Sebastián, Spain
| | - Cristina Sarasqueta
- Biodonostia Health Research Institute, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), San Sebastián, Spain.,Osakidetza, Hospital Universitario Donostia, San Sebastian, Spain
| | - Joaquín Cubiella
- Gastroenterology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Isabel Portillo
- Colorectal Cancer Screening Programme, Osakidetza, Basque Health Service, Bilbao, Spain
| | - Luis Bujanda
- BIOEF: the Basque Foundation for Health Innovation and Research, Department of Gastroenterology, Biodonostia Institute, Avda Paseo Beguiristain s/n 20014, San Sebastián, Spain.
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