Adding family history to faecal immunochemical testing increases the detection of advanced neoplasia in a colorectal cancer screening programme

A scoping review of risk-stratified bowel screening: current evidence, future directions

PURPOSE

In this scoping review, we examined the international literature on risk-stratified bowel screening to develop recommendations for future research, practice and policy.

METHODS

Six electronic databases were searched from inception to 18 October 2021: Medline, Embase, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. Forward and backwards citation searches were also undertaken. All relevant literature were included.

RESULTS

After de-deduplication, 3,629 records remained. 3,416 were excluded at the title/abstract screening stage. A further 111 were excluded at full-text screening stage. In total, 102 unique studies were included. Results showed that risk-stratified bowel screening programmes can potentially improve diagnostic performance, but there is a lack of information on longer-term outcomes. Risk models do appear to show promise in refining existing risk stratification guidelines but most were not externally validated and less than half achieved good discriminatory power. Risk assessment tools in primary care have the potential for high levels of acceptability and uptake, and therefore, could form an important component of future risk-stratified bowel screening programmes, but sometimes the screening recommendations were not adhered to by the patient or healthcare provider. The review identified important knowledge gaps, most notably in the area of organisation of screening services due to few pilots, and what risk stratification might mean for inequalities.

CONCLUSION

We recommend that future research focuses on what organisational challenges risk-stratified bowel screening may face and a consideration of inequalities in any changes to organised bowel screening programmes.

Selection of patients for large mailed fecal immunochemical test colorectal cancer screening outreach programs: A systematic review

OBJECTIVE

Digital health care offers an opportunity to scale and personalize cancer screening programs, such as mailed outreach for colorectal cancer (CRC) screening. However, studies that describe the patient selection strategy and process for CRC screening are limited. Our objective was to evaluate implementation strategies for selecting patients for CRC screening programs in large health care systems.

METHODS

We conducted a systematic review of 30 studies along with key informant surveys and interviews to describe programmatic implementation strategies for selecting patients for CRC screening. PubMed and Embase were searched since inception through December 2018, and hand searches were performed of the retrieved reference lists but none were incorporated (n = 0). No language exclusions were applied.

RESULTS

Common criteria for outreach exclusion included: being up-to-date with routine CRC screening (n = 22), comorbidities (n = 20), and personal history (n = 22) or family history of cancer (n = 9). Key informant surveys and interviews were performed (n = 28) to understand data sources and practices for patient outreach selection, and found that 13 studies leveraged electronic medical care records, 10 studies leveraged a population registry (national, municipal, community, health), 4 studies required patient opt-in, and 1 study required primary care provider referral. Broad ranges in fecal immunochemical test completion were observed in community clinic (n = 8, 31.0-59.6%), integrated health system (n = 5, 21.2-82.7%), and national regional CRC screening programs (n = 17, 23.0-64.7%). Six studies used technical codes, and four studies required patient self-reporting from a questionnaire to participate.

CONCLUSION

This systematic review provides health systems with the diverse outreach practices and technical tools to support efforts to automate patient selection for CRC screening outreach.

Evidenced-Based Screening Strategies for a Positive Family History

The most commonly recognized high-risk group for colorectal cancer (CRC) is individuals with a positive family history. It is generally recognized that those with a first-degree relative (FDR) with CRC are at a 2-fold or higher risk of CRC or advanced neoplasia. FDRs of patients with advanced adenomas have a similarly increased risk. Accordingly, all major US guidelines recommend starting CRC screening by age 40 in these groups. Barriers to screening this group include patient lack of knowledge on family and polyp history, provider limitations in collecting family history, and insufficient application of guidelines.

Addition of an online, validated family history questionnaire to the Dutch FIT-based screening programme did not improve its diagnostic yield

Background

Faecal immunochemical testing (FIT) is suboptimal in detecting advanced neoplasia (AN). To increase the sensitivity and yield of a FIT-based screening programme, FIT could be combined with risk factors for AN. We evaluated the incremental yield of adding a family history questionnaire (FHQ) on colorectal cancer (CRC) and Lynch syndrome-associated tumours to the Dutch FIT-based screening programme.

Methods

Six thousand screen-naive individuals, aged 59–75 years, were invited to complete a FIT (FOB-Gold, cut-off 47 µg Hb/g faeces) and a validated online FHQ. Participants with a positive FIT and/or positive FHQ, confirmed after genetic counselling, were referred for colonoscopy. Yield of detecting AN per 1000 invitees for the combined strategy was compared with the FIT-only strategy.

Results

Of the 5979 invitees, 1952 (32.6%) completed the FIT only, 2379 (39.8%) completed both the FIT and FHQ and 95 (1.6%) completed the FHQ only. Addition of the FHQ to FIT-based screening resulted in one extra case of AN detected after 16 additional colonoscopies, resulting in a yield of 19.6 (95% CI, 16.4–23.5) for the combined strategy versus 19.5 (95% CI, 16.3–23.3) for the FIT-only strategy (p = 1.0).

Conclusions

The addition of an FHQ to one round of FIT screening did not increase the detection of AN compared with FIT only (ClinicalTrials.gov NCT02698462).

The use of electronic healthcare records for colorectal cancer screening referral decisions and risk prediction model development

BACKGROUND

The database used for the NHS Bowel Cancer Screening Programme (BCSP) derives participant information from primary care records. Combining predictors with FOBTs has shown to improve referral decisions and accuracy. The richer data available from GP databases could be used to complement screening referral decisions by identifying those at greatest risk of colorectal cancer. We determined the availability of data for key predictors and whether this information could be used to inform more accurate screening referral decisions.

METHODS

An English BCSP cohort was derived using the electronic notifications received from the BCSP database to GP records. The cohort covered a period between 13th May 2009 to 17th January 2017. Completeness of variables and univariable associations were assessed. Risk prediction models were developed using Cox regression and multivariable fractional polynomials with backwards elimination. Optimism adjusted performance metrics were reported. The sensitivity and specificity of a combined approach using the negative FOBT model plus FOBT positive patients was determined using a probability equivalent to a 3% PPV NICE guidelines level.

RESULTS

292,059 participants aged 60-74 were derived for the BCSP screening cohort. A model including the screening test result had a C-statistic of 0.860, c-slope of 0.997, and R² of 0.597. A model developed for negative screening results only had a C-statistic of 0.597, c-slope of 0.940, and R² of 0.062. Risk predictors included in the models included; age, sex, alcohol consumption, IBS diagnosis, family history of gastrointestinal cancer, smoking status, previous negatives and whether a GP had ordered a blood test. For the combined screening approach, sensitivity increased slightly from 53.90% (FOBT only) to 58.82% but at the expense of an increased referral rate.

CONCLUSIONS

This research has identified several potential predictors for CRC in a BCSP population. A risk prediction model developed for BCSP FOBT negative patients was not clinically useful due to a low sensitivity and increased referral rate. The predictors identified in this study should be investigated in a refined algorithm combining the quantitative FIT result. Combining data from multiple sources enables fuller patient profiles using the primary care and screening database interface.

Participant-Related Risk Factors for False-Positive and False-Negative Fecal Immunochemical Tests in Colorectal Cancer Screening: Systematic Review and Meta-Analysis

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.