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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] [What about the content of this article? (0)] [Affiliation(s)] [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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2
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Gerrard AD, Maeda Y, Miller J, Gunn F, Theodoratou E, Noble C, Porteous L, Glancy S, MacLean P, Pattenden R, Dunlop MG, Din FVN. Double faecal immunochemical testing in patients with symptoms suspicious of colorectal cancer. Br J Surg 2023; 110:471-480. [PMID: 36785496 PMCID: PMC10364540 DOI: 10.1093/bjs/znad016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Faecal immunochemical test (FIT)-directed pathways based on a single test have been implemented for symptomatic patients. However, with a single test, the sensitivity is 87 per cent at 10 µg haemoglobin (Hb) per g faeces. This aims of this study were to define the diagnostic performance of a single FIT, compared with double FIT in symptomatic populations. METHODS Two sequential prospective patient cohorts referred with symptoms from primary care were studied. Patients in cohort 1 were sent a single FIT, and those in cohort 2 received two tests in succession before investigation. All patients were investigated, regardless of having a positive or negative test (threshold 10 µg Hb per g). RESULTS In cohort 1, 2260 patients completed one FIT and investigation. The sensitivity of single FIT was 84.1 (95 per cent c.i. 73.3 to 91.8) per cent for colorectal cancer and 67.4 (61.0 to 73.4) per cent for significant bowel pathology. In cohort 2, 3426 patients completed at least one FIT, and 2637 completed both FITs and investigation. The sensitivity of double FIT was 96.6 (90.4 to 99.3) per cent for colorectal cancer and 83.0 (77.4 to 87.8) per cent for significant bowel pathology. The second FIT resulted in a 50.0 per cent reduction in cancers missed by the first FIT, and 30.0 per cent for significant bowel pathology. Correlation between faecal Hb level was only modest (rs = 0.58), and 16.8 per cent of double tests were discordant, 11.4 per cent in patients with colorectal cancer and 18.3 per cent in those with significant bowel pathology. CONCLUSION FIT in patients with high-risk symptoms twice in succession reduces missed significant colorectal pathology and has an acceptable workload impact.
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Affiliation(s)
- A D Gerrard
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
| | - Y Maeda
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Department of Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - J Miller
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
| | - F Gunn
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
| | - E Theodoratou
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - C Noble
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - L Porteous
- Lead GP for Cancer and Palliative Care, NHS Lothian, Edinburgh, UK
| | - S Glancy
- Department of Radiology, Western General Hospital, Edinburgh, UK
| | - P MacLean
- Department of Radiology, Western General Hospital, Edinburgh, UK
| | - R Pattenden
- Department of Biochemistry, Western General Hospital, Edinburgh, UK
| | - M G Dunlop
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- UK Colon Cancer Genetics Group, Medical Research Council Human Genetics Unit, Medical Research Council Institute of Genetics & Cancer, Western General Hospital, The University of Edinburgh, Edinburgh, UK
| | - F V N Din
- Cancer Research UK Scotland Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Department of Colorectal surgery, Western General Hospital, Edinburgh, UK
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3
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Farkas NG, Fraser CG, Maclean W, Jourdan I, Rockall T, Benton SC. Replicate and repeat faecal immunochemical tests in symptomatic patients: A systematic review. Ann Clin Biochem 2023; 60:27-36. [PMID: 35394384 DOI: 10.1177/00045632221096036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Faecal Immunochemical tests (FITs) in the assessment of patients presenting with symptoms have generally used a single sample. Little evidence pertains to the use of replicate, where a number of tests are done prior to decision-making or repeat FIT, where additional FIT are performed following clinical decision-making. Overwhelmingly, research has focussed on FIT to help identify colorectal cancer (CRC). The aim of this review is to assess the available literature concerning replicate and repeat FIT in symptomatic patients to help generate consensus and guide future research. METHODS The terms 'faecal immunochemical test' or 'FIT' were combined with 'multiple' or 'repeat'. EMBASE, Medline and PubMed database and other searches were conducted. All papers published in English were included with no exclusion date limits until November 2021. RESULTS Of the 161 initial papers screened, seven were included for review. Qualitative and quantitative FIT outcomes were assessed in the studies. The primary aims of most related to whether replicate FIT increased diagnostic yield of CRC, with colonoscopy used as the reference standard. One publication assessed the impact of a new COVID-adapted pathway on CRC detection. No consensus on replicate FIT was apparent. Some concluded that FITs may help minimise missed CRC diagnoses: others showed no increase in diagnostic yield of CRC. CONCLUSIONS Current evidence on replicate and repeat FIT is both minimal and conflicting. FIT is a superb clinical tool, but significant gaps surrounding application remain. Further studies relating to replicate and repeat FIT are required.
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Affiliation(s)
- Nicholas G Farkas
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Callum G Fraser
- Centre for Research Into Cancer Prevention and Screening, Population Health and Genomics, School of Medicine, 85326University of Dundee, Scotland, UK
| | - William Maclean
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Iain Jourdan
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Tim Rockall
- Minimal Access Therapy and Training Unit (MATTU), 3661Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sally C Benton
- Department of Clinical Biochemistry, Royal Surrey County Hospital, Berkshire and Surrey Pathology Services, Guildford, UK.,NHS Bowel Cancer Screening South of England Hub, Berkshire and Surrey Pathology Services, Royal Surrey County Hospital, Guildford, UK
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Booth R, Carten R, D'Souza N, Westwood M, Kleijnen J, Abulafi M. Role of the faecal immunochemical test in patients with risk-stratified suspected colorectal cancer symptoms: A systematic review and meta-analysis to inform the ACPGBI/BSG guidelines. Lancet Reg Health Eur 2022; 23:100518. [PMID: 36212984 PMCID: PMC9535300 DOI: 10.1016/j.lanepe.2022.100518] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background The UK National Institute for Health and Care Excellence (NICE), recommended in 2017 the use of the faecal immunochemical test (FIT) to guide investigations in patients presenting with NICE-defined low-risk symptoms suspicious for colorectal cancer (CRC). At that time, NICE did not recommend FIT use for high-risk symptoms. This is the first systematic review to evaluate the diagnostic accuracy of FIT in NICE-defined high and low-risk symptoms and was designed to inform the joint ACPGBI/BSG guidelines. Methods We performed a systematic literature review and meta-analysis. PROSPERO registration number CRD42021224674. Medline and EMBASE databases were searched from inception to 31st March 2022. We included studies recruiting adult patients presenting with suspected CRC symptoms in whom FIT was performed and diagnostic accuracy data for CRC detection could be derived at a limit of detection (LoD) and/or 10 µg haemoglobin/gram faeces threshold in four commonly used analysers. FIT performance was assessed for high-risk, low-risk and individual symptoms where possible. Bivariate meta-analysis was performed where study numbers allowed. Findings Thirty-one studies (79566 patients) met inclusion criteria. At 10 µg/g, for "all symptoms" (n = 35,945) sensitivity and specificity were 91.0% (95% CI: 88.9, 92.7) and 75.2% (95% CI: 69.6, 80.1); for "high-risk" symptoms (n = 18,264), 88.7% (95% CI: 84.4, 92.0) and 78.5% (95% CI: 73.0, 83.2); and for "low-risk" symptoms (n = 2161), 88.7% (95% CI: 78.1, 95.3) and 88.5% (95% CI: 87.1, 89.9), respectively. At LoD, for "all symptoms" (n = 26,056) sensitivity and specificity were 94.7% (95% CI: 90.5, 97.1) and 66.5% (95% CI: 58.7, 73.6); for "high-risk" symptoms (n = 16,768), 92.8% (95% CI: 86.4, 96.3) and 70.3% (95% CI: 66.5, 73.8); and for "low-risk" symptoms (n = 2082), 94.7% (95% CI: 85.4, 98.9) and 71.9% (95% CI: 69.9, 73.9), respectively. Summary estimates were similar across different analysers. Interpretation FIT sensitivity for CRC detection is maximised at the LoD; its performance is similar in high and low-risk symptoms, and across different analysers where a common threshold is used. FIT performance for CRC detection is adequate and transferrable to clinical diagnostic pathways. Funding This review was part-funded by NHS England awarded to RM Partners. RB and RC were funded by research fellowships awarded by Croydon University Hospital.
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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: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Benton SC, Piggott C, Zahoor Z, O'Driscoll S, Fraser CG, D'Souza N, Chen M, Georgiou Delisle T, Abulafi M. A comparison of the faecal haemoglobin concentrations and diagnostic accuracy in patients suspected with colorectal cancer and serious bowel disease as reported on four different faecal immunochemical test systems. Clin Chem Lab Med 2022; 60:1278-1286. [PMID: 35637625 DOI: 10.1515/cclm-2021-1248] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/17/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Faecal immunochemical tests for haemoglobin (FIT) are used in colorectal cancer (CRC) screening programmes and to triage patients presenting with symptoms suggestive of CRC for further bowel investigations. There are a number of quantitative FIT analytical systems available. Currently, there is no harmonisation or standardisation of FIT methods. The aim of the study was to assess the comparability of numerical faecal haemoglobin concentrations (f-Hb) obtained with four quantitative FIT systems and the diagnostic accuracy at different f-Hb thresholds. METHODS A subgroup of the National Institute for Health and Care Excellence (NICE) FIT study, a multicentre, prospective diagnostic accuracy study were sent four FIT specimen collection devices from four different FIT systems or two FIT devices for one FIT system. Faecal samples were examined and analysis of results carried out to assess difference between methods at thresholds of limit of detection (LoD), 10 µg haemoglobin/g faeces (µg/g) and 100 μg/g. RESULTS 233 patients returned specimen collection devices for examination on four different systems; 189 patients returned two FIT kits for one system. At a threshold of 100 μg/g the sensitivity is the same for all methods. At lower thresholds of LoD and 10 μg/g differences were observed between systems in terms of patients who would be referred and diagnostic accuracies. CONCLUSIONS The lack of standardisation or harmonisation of FIT means that differences are observed in f-Hb generated on different systems. Further work is required to understand the clinical impact of these differences and to minimise them.
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Affiliation(s)
- Sally C Benton
- Clinical Biochemistry, Royal Surrey County Hospital, Berkshire and Surrey Pathology Services, Guildford, Surrey, UK.,NHS Bowel Cancer Screening South of England Hub, Berkshire and Surrey Pathology Services, Guildford, Surrey, UK
| | - Carolyn Piggott
- NHS Bowel Cancer Screening South of England Hub, Berkshire and Surrey Pathology Services, Guildford, Surrey, UK
| | - Zahida Zahoor
- NHS Bowel Cancer Screening South of England Hub, Berkshire and Surrey Pathology Services, Guildford, Surrey, UK
| | - Shane O'Driscoll
- NHS Bowel Cancer Screening South of England Hub, Berkshire and Surrey Pathology Services, Guildford, Surrey, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, Population Health and Genomics, School of Medicine, University of Dundee, Scotland, UK
| | - Nigel D'Souza
- Department of Colorectal Surgery, Croydon University Hospital, Croydon, UK
| | - Michelle Chen
- Research and Development, RM Partners, the West London Cancer Alliance, London, UK
| | | | - Muti Abulafi
- Department of Colorectal Surgery, Croydon University Hospital, Croydon, UK
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Schwettmann L, Lied A, Eriksen R. Evaluation of the Sentinel-FOB gold faecal immunochemical test for the presence of haemoglobin using the automated Roche Cobas 8000 system. Pract Lab Med 2022; 29:e00263. [PMID: 35198716 PMCID: PMC8792414 DOI: 10.1016/j.plabm.2022.e00263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/14/2021] [Accepted: 01/12/2022] [Indexed: 02/07/2023] Open
Abstract
Objectives Design Results Conclusion The SENTIFIT-FOB Gold assay for the quantitation of haemoglobin in faeces was evaluated on the widely used automated Roche Cobas 8000 system. Good analytical and clinical performance were confirmed. The diagnostic accuracy was assessed and the optimal cutoff for use in symptomatic patients was determined.
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Maclean W, Zahoor Z, O'Driscoll S, Piggott C, Whyte MB, Rockall T, Jourdan I, Benton SC. Comparison of the QuikRead go ® point-of-care faecal immunochemical test for haemoglobin with the FOB Gold Wide ® laboratory analyser to diagnose colorectal cancer in symptomatic patients. Clin Chem Lab Med 2022; 60:101-108. [PMID: 34679264 DOI: 10.1515/cclm-2021-0655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 10/08/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Faecal immunochemical testing for haemoglobin (FIT) is used to triage patients for colonic investigations. Point-of-care (POC) FIT devices on the market have limited data for their diagnostic accuracy for colorectal cancer (CRC). Here, a POC FIT device is compared with a laboratory-based FIT system using patient collected samples from the urgent referral pathway for suspected CRC. METHODS A prospective, observational cohort study. Patients collected two samples from the same stool. These were measured by POC QuikRead go® (Aidian Oy, Espoo, Finland) and laboratory-based FOB Gold Wide® (Sentinel Diagnostics, Italy). Faecal haemoglobin <10 μg haemoglobin/g of faeces was considered as negative. At this threshold, comparisons between the two systems were made by calculating percentage agreement and Cohen's kappa coefficient. Proportion of negative results were compared with Chi squared testing. Sensitivities for CRC were calculated. RESULTS A total of 629 included patients provided paired samples for FIT to compare the QuikRead go® and FOB Gold Wide®. The agreement around the negative threshold was 83.0% and Cohen's kappa coefficient was 0.54. The QuikRead go® reported 440/629 (70.0% of samples) as negative compared to 523/629 (83.1%) for the FOB Gold Wide®, this difference was significant (p-value<0.001). Sensitivities for CRC detection by the QuikRead go® and FOB Gold Wide® were 92.9% (95% confidence interval (CI): 68.5-98.7%) and 100% (CI: 78.5-100%) respectively. CONCLUSIONS Both systems were accurate in their ability to detect CRC. Whilst good agreement around the negative threshold was identified, more patients would be triaged to further colonic investigation if using the QuikRead go®.
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Affiliation(s)
- William Maclean
- Research Fellow in General Surgery at Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Zahida Zahoor
- Research Assistant at the Bowel Cancer Screening Hub at Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Shane O'Driscoll
- Research Assistant at the Bowel Cancer Screening Hub at Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Carolyn Piggott
- Research and Development Scientist at the Bowel Cancer Screening Hub at Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Martin B Whyte
- Clinical Reader in Metabolic Medicine at University of Surrey, Guildford, UK
| | - Timothy Rockall
- Consultant Colorectal Surgeon at Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Iain Jourdan
- Consultant Colorectal Surgeon at Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Sally C Benton
- Consultant Biochemist and Clinical Director at the Bowel Cancer Screening Hub at Royal Surrey NHS Foundation Trust, Guildford, UK
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Saw KS, Liu C, Xu W, Varghese C, Parry S, Bissett I. Faecal immunochemical test to triage patients with possible colorectal cancer symptoms: meta-analysis. Br J Surg 2021; 109:182-190. [PMID: 34907419 PMCID: PMC10364725 DOI: 10.1093/bjs/znab411] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/31/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND This review evaluated the utility of single quantitative faecal immunochemical test (FIT) as a triaging tool for patients with symptoms of possible colorectal cancer, the effect of symptoms on FIT accuracy, and the impact of triaging incorporating FIT on service provision. METHODS Five databases were searched. Meta-analyses of the extracted FIT sensitivities and specificities for detection of colorectal cancer at reported f-Hb thresholds were performed. Secondary outcomes included sensitivity and specificity of FIT for advanced colorectal neoplasia and serious bowel disease. Subgroup analysis by FIT brand and symptoms was undertaken. RESULTS Fifteen prospective cohort studies, including 28 832 symptomatic patients were included. At the most commonly reported f-Hb positivity threshold of ≥ 10 µg Hb/g faeces (n=13), the summary sensitivity was 88.7% (95% c.i. 85.2 to 91.4) and the specificity was 80.5% (95% c.i. 75.3 to 84.8) for colorectal cancer. At lower limits of detection of ≥ 2 µg Hb/g faeces, the summary sensitivity was 96.8% (95% c.i. 91.0 to 98.9) and the specificity was 65.6% (95% c.i. 59.0 to 71.6). At the upper f-Hb positivity thresholds of ≥ 100 µg Hb/g faeces and ≥ 150 µg Hb/g faeces, summary sensitivities were 68.1% (95% c.i. 59.2 to 75.9) and 66.3% (95% c.i. 52.2 to 78.0), with specificities of 93.4% (95% c.i. 91.3 to 95.1) and 95.1% (95% c.i. 93.6 to 96.3) respectively. FIT sensitivity was comparable between different assay brands. FIT sensitivity may be higher in patients reporting rectal bleeding. CONCLUSION Single quantitative FIT at lower f-Hb positivity thresholds can adequately exclude colorectal cancer in symptomatic patients and provides a data-based approach to prioritization of colonoscopy resources.
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Affiliation(s)
- Kai Sheng Saw
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Chen Liu
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - William Xu
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Susan Parry
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ian Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Laszlo HE, Seward E, Ayling RM, Lake J, Malhi A, Stephens C, Pritchard-Jones K, Chung D, Hackshaw A, Machesney M. Faecal immunochemical test for patients with 'high-risk' bowel symptoms: a large prospective cohort study and updated literature review. Br J Cancer 2021. [PMID: 34903843 DOI: 10.1038/s41416-021-01653-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/21/2021] [Accepted: 11/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background We evaluated whether faecal immunochemical testing (FIT) can rule out colorectal cancer (CRC) among patients presenting with ‘high-risk’ symptoms requiring definitive investigation. Methods Three thousand five hundred and ninety-six symptomatic patients referred to the standard urgent CRC pathway were recruited in a multi-centre observational study. They completed FIT in addition to standard investigations. CRC miss rate (percentage of CRC cases with low quantitative faecal haemoglobin [f-Hb] measurement) and specificity (percentage of patients without cancer with low f-Hb) were calculated. We also provided an updated literature review. Results Ninety patients had CRC. At f-Hb < 10 µg/g, the miss rate was 16.7% (specificity 80.1%). At f-Hb < 4 µg/g, the miss rate was 12.2% (specificity 73%), which became 3.3% if low FIT plus the absence of anaemia and abdominal pain were considered (specificity 51%). Within meta-analyses of 9 UK studies, the pooled miss rate was 7.2% (specificity 74%) for f-Hb < 4 µg/g. Discussion FIT alone as a triage tool would miss an estimated 1 in 8 cases in our study (1 in 14 from meta-analysis), while many people without CRC could avoid investigations. FIT can focus secondary care diagnostic capacity on patients most at risk of CRC, but more work on safety netting is required before incorporating FIT triage into the urgent diagnostic pathway.
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Toyoshima O, Yamaji Y, Nishizawa T, Yoshida S, Yamada T, Kurokawa K, Obata M, Kondo R, Toba M, Koike K. Priority stratification for colonoscopy based on two-sample faecal immunochemical test screening: results from a cross-sectional study at an endoscopy clinic in Japan. BMJ Open 2021; 11:e046055. [PMID: 34011594 PMCID: PMC8137156 DOI: 10.1136/bmjopen-2020-046055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 04/20/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Little has been reported on the yield and characteristics of colorectal neoplasia detected by the two-sample faecal immunochemical test (FIT), particularly the difference between subjects with two-positive results on the two-sample FIT and those with one-positive results. We aimed to assess risk stratification among patients with positive two-sample FIT to prioritise colonoscopy. DESIGN A retrospective cross-sectional study. SETTING A single-centre, representative endoscopy clinic in Japan. PARTICIPANTS Consecutive patients who underwent colonoscopy were enrolled. Indications for colonoscopy included two-positive results on the two-sample FIT (FIT (+/+)), one-positive results on the two-sample FIT (FIT (+/-)), and other reasons (non-FIT group, including presence of symptoms, screening or surveillance). PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were detection rates of colorectal cancers, including in situ (all cancers) and invasive cancers, based on the indications for colonoscopy. Secondary outcomes were cancer features, such as location, size, T stage and histological subtype. RESULTS Of the 8724 patients, 264 underwent colonoscopy following FIT (+/+), 1018 following FIT (+/-) and 7442 for reasons other than positive FIT. Detection rates of all (and invasive) cancers in the FIT (+/+), FIT (+/-) and non-FIT groups were 12.1% (8.3%), 1.9% (0.3%) and 0.4% (0.2%), respectively. The cancer detection rates were much higher in the FIT (+/+) group than in the FIT (+/-) group, which in turn had higher rates than the non-FIT group. Moreover, the FIT (+/+) group showed more advanced T stages on tumour, node, metastasis (TNM) classification (Tis/T1/T2/T3/T4: 10/7/4/10/1) than the FIT (+/-) group (16/1/2/0/0, p<0.001). CONCLUSIONS Two-positive results for two-sample FIT showed a much higher yield for more advanced colorectal cancers than the one-positive result. High priority for diagnostic colonoscopy should be assigned to patients with two-positive-FIT results.
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Affiliation(s)
- Osamu Toyoshima
- Department of Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yutaka Yamaji
- Health Development Center, Tokyo Pharmaceutical Industry Health Insurance Society, Tokyo, Japan
| | - Toshihiro Nishizawa
- Department of Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology and Hepatology, International University of Health and Welfare, Narita Hosapital, Narita, Japan
| | - Shuntaro Yoshida
- Department of Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
| | - Tomoharu Yamada
- Department of Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ken Kurokawa
- Department of Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Miho Obata
- Department of Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryo Kondo
- Department of Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
| | - Masahito Toba
- Department of Gastroenterology, Toba Clinic, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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