1
|
Digby J, Fraser CG, Clark G, Mowat C, Strachan JA, Steele RJC. Do risk scores improve use of faecal immunochemical testing for haemoglobin in symptomatic patients in primary care? Colorectal Dis 2024; 26:675-683. [PMID: 38424669 DOI: 10.1111/codi.16925] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/26/2023] [Accepted: 10/28/2023] [Indexed: 03/02/2024]
Abstract
AIM Faecal immunochemical testing (FIT) is used in the detection of colorectal cancer (CRC). FIT is invariably used at a single faecal haemoglobin (f-Hb) concentration threshold. The aim of this observational study was to explore risk scoring models (RSMs) with f-Hb and other risk factors for CRC in symptomatic patients attending primary care, potentially speeding diagnosis and saving endoscopy resources. METHOD Records of patients completing FIT were linked with The Scottish Cancer Registry and with other databases with symptoms, full blood count and demographic variables, and randomized into derivation and validation cohorts. Stepwise multivariable logistic regression created RSMs assessed in the validation cohort. RESULTS Of 18 805 unique patients, 9374 and 9431 were in the derivation and validation cohorts, respectively: f-Hb, male sex, increasing age, iron deficiency anaemia and raised systemic immune inflammation index created the final RSM. A risk score threshold of ≥2.363, generating the same number of colonoscopies as a f-Hb threshold of ≥10 μg Hb/g gave improved sensitivity for CRC in both cohorts. A RSM which excluded f-Hb was used to investigate the effect of raising the f-Hb threshold from ≥10 to ≥20 μg Hb/g in those with a low risk score. This approach would have generated 234 fewer colonoscopies but missed four CRCs. CONCLUSION The RSM conferred no significant benefit to patients with very low f-Hb and CRC. Alternative strategies combining FIT with other variables may be more appropriate for safety-netting of symptomatic patients. Further work to develop and investigate the value of RSM for significant bowel disease other than CRC may also be beneficial.
Collapse
Affiliation(s)
- Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | | | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital, Dundee, UK
| | - Judith A Strachan
- Blood Sciences and Scottish Bowel Screening Laboratory, Ninewells Hospital and Medical School, Dundee, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| |
Collapse
|
2
|
Digby J, Fraser CG, Clark G, Mowat C, Strachan JA, Steele RJC. Improved use of faecal immunochemical tests for haemoglobin in the Scottish bowel screening programme. J Med Screen 2023; 30:184-190. [PMID: 37229658 PMCID: PMC10629250 DOI: 10.1177/09691413231175611] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/26/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVES This study aimed to develop a risk-scoring model in the Scottish Bowel Screening Programme incorporating faecal haemoglobin concentration with other risk factors for colorectal cancer. METHODS Data were collected for all individuals invited to participate in the Scottish Bowel Screening Programme between November 2017 and March 2018 including faecal haemoglobin concentration, age, sex, National Health Service Board, socioeconomic status, and screening history. Linkage with The Scottish Cancer Registry identified all screening participants diagnosed with colorectal cancer. Logistic regression was performed to identify which factors demonstrated significant association with colorectal cancer and could be used in the development of a risk-scoring model. RESULTS Of 232,076 screening participants, 427 had colorectal cancer: 286 diagnosed following a screening colonoscopy and 141 arising after a negative screening test result giving an interval cancer proportion of 33.0%. Only faecal haemoglobin concentration and age showed a statistically significant association with colorectal cancer. Interval cancer proportion increased with age and was higher in women (38.1%) than men (27.5%). If positivity in women were mirrored in men at each age quintile interval cancer proportion would still have remained higher in women (33.2%). Moreover, an additional 1201 colonoscopies would be required to detect 11 colorectal cancers. CONCLUSIONS Development of a risk scoring model using early data from the Scottish Bowel Screening Programme was not feasible due to most variables showing insignificant association with colorectal cancer. Tailoring the faecal haemoglobin concentration threshold according to age could help to diminish some of the disparity in interval cancer proportion between women and men. Strategies to achieve sex equality using faecal haemoglobin concentration thresholds depend considerably on which variable is selected for equivalency and this requires further exploration.
Collapse
Affiliation(s)
- Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Dundee, Scotland, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Dundee, Scotland, UK
| | - Gavin Clark
- Public Health Scotland, Edinburgh, Scotland, UK
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital, Dundee, Scotland, UK
| | - Judith A Strachan
- Blood Sciences and Scottish Bowel Screening Laboratory, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Robert JC Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Dundee, Scotland, UK
| |
Collapse
|
3
|
Delson D, Ward M, Haddock R, Nobes J, Digby J, Strachan JA, Mowat C. Impact of faecal haemoglobin based triage of bowel symptoms presenting to primary care on colorectal cancer diagnosis. Colorectal Dis 2022; 25:787-793. [PMID: 36495081 DOI: 10.1111/codi.16451] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/20/2022] [Accepted: 11/02/2022] [Indexed: 12/30/2022]
Abstract
AIM Faecal immunochemical testing (FIT) for faecal haemoglobin was introduced into primary care in National Health Service Tayside in 2015 as an adjunct to clinical assessment of new bowel symptoms. We aimed to assess the impact of FIT-based triage in primary care on colorectal cancer (CRC) diagnosis. METHOD Cancer audit data between January 2016 and December 2019 were reviewed to identify all patients diagnosed locally with CRC. The mode of presentation and stage at diagnosis were noted and patient records were interrogated to identify whether FIT and full blood count (FBC) had been performed prior to referral. Results were compared between the FIT and non-FIT groups. RESULTS In all, 1245 patients were diagnosed with CRC of whom 581 (46.7%) presented through primary care. FIT was performed prior to referral in 440/581 (75.7%), with the proportion increasing from 62.3% in 2016 to 85.8% in 2019. At faecal haemoglobin ≥10 μg Hb/g faeces, sensitivity for CRC was 94.1%. Over the study period the annual proportion of non-emergency presentations increased significantly; presentations from primary care increased from 43.1% to 53.5% (P = 0.0096). After excluding non-FIT patients who had an overt CRC at referral, there was no difference in stage at diagnosis between FIT and non-FIT cancers. Safety-netting with FBC was widely used in our cohort with 97.3% of FIT patients having also had FBC. CONCLUSION FIT-based triage of new bowel symptoms in primary care is associated with increased non-emergency presentation of CRC but this did not influence stage at diagnosis.
Collapse
Affiliation(s)
- Dwi Delson
- School of Medicine, University of Dundee, Dundee, UK
| | - Mark Ward
- School of Medicine, University of Dundee, Dundee, UK
| | | | - Jennifer Nobes
- School of Medicine, University of Dundee, Dundee, UK.,Department of Blood Sciences, Ninewells Hospital, Dundee, UK
| | - Jayne Digby
- School of Medicine, University of Dundee, Dundee, UK
| | - Judith A Strachan
- School of Medicine, University of Dundee, Dundee, UK.,Department of Blood Sciences, Ninewells Hospital, Dundee, UK
| | - Craig Mowat
- School of Medicine, University of Dundee, Dundee, UK.,Department of Gastroenterology, Ninewells Hospital, Dundee, UK
| |
Collapse
|
4
|
Johnstone MS, MacLeod C, Digby J, Al-Azzawi Y, Pang G, Watson AJM, Strachan J, Mowat C, McSorley ST. Prevalence of repeat faecal immunochemical testing in symptomatic patients attending primary care. Colorectal Dis 2022; 24:1498-1504. [PMID: 35776684 PMCID: PMC10084108 DOI: 10.1111/codi.16240] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 01/07/2023]
Abstract
AIM The faecal immunochemical test (FIT) for faecal haemoglobin (f-Hb) helps determine the risk of colorectal cancer (CRC) and has been integrated into symptomatic referral pathways. 'Safety netting' advice includes considering referral for persistent symptoms, but no published data exists on repeated FITs. We aimed to examine the prevalence of serial FITs in primary care and CRC risk in these patients. METHOD A multicentre, retrospective, observational study was conducted of patients with two or more consecutive f-Hb results within a year from three Scottish Health Boards which utilize FIT in primary care. Cancer registry data ensured identification of CRC cases. RESULTS Overall, 135 396 FIT results were reviewed, of which 12 359 were serial results reported within 12 months (9.1%), derived from 5761 patients. Of these, 42 (0.7%) were diagnosed with CRC. A total of 3487 (60.5%) patients had two f-Hb < 10 μg/g, 944 (16.4%) had f-Hb ≥ 10 μg/g followed by <10 μg/g, 704 (12.2%) f-Hb < 10 μg/g followed by ≥10 μg/g and 626 (10.9%) had two f-Hb ≥ 10 μg/g. The CRC rate in each group was 0.1%, 0.4%, 1.4% and 4.0%, respectively. Seven hundred and thirty four patients submitted more than two FITs within a year. The likelihood of one or more f-Hb ≥ 10 μg/g rose from 40.4% with two samples to 100% with six, while the CRC rate fell from 0.8% to 0%. CONCLUSION Serial FITs within a year account for 9.1% of all results in our Boards. CRC prevalence amongst symptomatic patients with serial FIT is lower than in single-FIT cohorts. Performing two FITs within a year for patients with persistent symptoms effectively acts as a safety net, while performing more than two within this timeframe is unlikely to be beneficial.
Collapse
Affiliation(s)
- Mark S Johnstone
- 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
| | - Yassir Al-Azzawi
- Academic Unit of Surgery, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Grace Pang
- Academic Unit of Surgery, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Judith Strachan
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, UK
| | - Craig Mowat
- Population Health & Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Stephen T McSorley
- Academic Unit of Surgery, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| |
Collapse
|
5
|
Mowat C, Digby J, Cleary S, Gray L, Datt P, Goudie DR, Steele RJ, Strachan JA, Humphries A, Fraser CG. Faecal haemoglobin concentration in adenoma, before and after polypectomy, approaches the ideal tumour marker. Ann Clin Biochem 2022; 59:272-276. [PMID: 35235491 PMCID: PMC9280698 DOI: 10.1177/00045632221080897] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Polypectomy may be performed at colonoscopy and then subsequent surveillance undertaken. It is thought that faecal haemoglobin concentration (f-Hb), estimated by quantitative faecal immunochemical tests (FIT), might be a useful tumour marker. Methods Consecutive patients enrolled in colonoscopy surveillance were approached at two hospitals. A specimen for FIT was provided before colonoscopy and, ideally after 3 weeks, a second FIT sample from those who had polypectomy. A single FIT system (OC-Sensor io, Eiken Chemical Co., Ltd) was used to generate f-Hb. Results 1103 Patients were invited; 643 returned a FIT device (uptake: 58.3%). Four patients had known inflammatory bowel disease (IBD) and were excluded, leaving 639 (57.9%) with an age range of 25–90 years (median 64 years), 54.6% male. Of 593 patients who had a f-Hb result and completed colonoscopy, advanced neoplasia was found in 41 (6.9%); four colorectal cancer (CRC): 0.7% and 37 advanced adenoma (AA): 6.3%, and a further 127 (21.4%) had non-advanced adenoma (NAA). The median f-Hb was significantly greater in AA as compared to NAA; 6.0 versus 1.0 μg Hb/g faeces, p < 0.0001.134/164 (81.7%) of invited patients returned a second FIT device: 28 were patients with AA in whom median pre-polypectomy f-Hb was 19.2, falling to 3.5 μg Hb/g faeces post-polypectomy, p = 0.01, and 106 with NAA had median pre-polypectomy f-Hb 0.8 compared to 1.0 μg Hb/g faeces post-polypectomy, p = 0.96. Conclusions Quantitative FIT could provide a good tumour marker in post-polypectomy surveillance, reduce colonoscopy requirements and minimise potential risk to patients.
Collapse
Affiliation(s)
- Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, UK
| | - Jayne Digby
- Centre for Research Into Cancer Prevention and Screening, 85326University of Dundee School of Medicine, Dundee, UK
| | - Shirley Cleary
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, UK
| | - Lynne Gray
- Department of Surgery, Ninewells Hospital and Medical School, Dundee, UK
| | - Pooja Datt
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, London, UK
| | - David R Goudie
- Department of Genetics, Ninewells Hospital and Medical School, Dundee, UK
| | - Robert Jc Steele
- Centre for Research Into Cancer Prevention and Screening, 85326University of Dundee School of Medicine, Dundee, UK
| | - Judith A Strachan
- Department of Blood Sciences and Scottish Bowel Screening Laboratory, Ninewells Hospital and Medical School, Dundee, UK
| | - Adam Humphries
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, London, UK
| | - Callum G Fraser
- Centre for Research Into Cancer Prevention and Screening, 85326University of Dundee School of Medicine, Dundee, UK
| |
Collapse
|
6
|
Clark GR, Digby J, Fraser CG, Strachan JA, Steele RJ. Faecal haemoglobin concentrations in women and men diagnosed with colorectal cancer in a national screening programme. J Med Screen 2021; 29:26-31. [PMID: 34806935 PMCID: PMC8892068 DOI: 10.1177/09691413211056970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective There is evidence that colorectal cancer screening using faecal haemoglobin is less effective in women than men. The faecal haemoglobin concentrations were therefore examined in women and men with screen-detected colorectal cancer. Setting Scottish Bowel Screening Programme, following the introduction of a faecal immunochemical test from November 2017, to March 2020. Methods Data were collated on faecal haemoglobin concentrations, pathological stage and anatomical site of the main lesion in participants who had colorectal cancer detected. The data in women and men were compared. Results For the faecal haemoglobin concentrations studied (>80 µg Hb/g faeces), the distributions indicated lower concentrations in women. Marked differences were found between women and men diagnosed with colorectal cancer. The median faecal haemoglobin concentration for women (n = 720) was 408 µg Hb/g faeces compared to 473 µg Hb/g faeces for men (n = 959) (p = 0.004) and 50.6% of the results were >400 µg Hb/g faeces in women; in men, this was 57.8%. The difference in faecal haemoglobin concentrations in women and men became less statistically significant as stage advanced from stages I–IV. For right-sided, left-sided and rectal colorectal cancer, a similar gender difference persisted in all sites. Differences in faecal haemoglobin between the genders were significant for left-sided cancers and stage I and approached significance for rectal cancers and stage II, but all sites and stages showed lower median faecal haemoglobin concentrations for women. Conclusions To minimise gender inequalities, faecal immunochemical test-based colorectal cancer screening programmes should evaluate a strategy of using different faecal haemoglobin concentration thresholds in women and men.
Collapse
Affiliation(s)
| | - Jayne Digby
- Centre for Research into Cancer Prevention and Screening, 85326University of Dundee, Dundee, Scotland, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, 85326University of Dundee, Dundee, Scotland, UK
| | - Judith A Strachan
- Blood Sciences and Scottish Bowel Screening Laboratory, Dundee, Scotland, UK
| | - Robert Jc Steele
- Centre for Research into Cancer Prevention and Screening, 85326University of Dundee, Dundee, Scotland, UK
| |
Collapse
|
7
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
8
|
Clark GRC, Strachan JA, McPherson A, Digby J, Mowat C, Steele RJC, Fraser CG. Faecal haemoglobin distributions by sex, age, deprivation and geographical region: consequences for colorectal cancer screening strategies. Clin Chem Lab Med 2021; 58:2073-2080. [PMID: 32324157 DOI: 10.1515/cclm-2020-0268] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 03/06/2020] [Accepted: 04/02/2020] [Indexed: 02/07/2023]
Abstract
Objectives Faecal immunochemical tests for haemoglobin (FIT) are becoming widely used in colorectal cancer (CRC) screening and assessment of symptomatic patients. Faecal haemoglobin concentration (f-Hb) thresholds are used to guide subsequent investigation. We established the distributions of f-Hb in a large screening population by sex, age, deprivation and geography. Methods Single estimates of f-Hb were documented for all individuals participating in the first 18 months of the Scottish Bowel Screening Programme (SBoSP). The distributions of f-Hb were generated for all participants, all men and women, and men and women by age quintile and deprivation quintile. Distributions were also generated by geographical region for all participants, men and women, and by deprivation. Comparisons of f-Hb distributions with those found in a pilot evaluation of FIT and three other countries were performed. Results f-Hb was documented for 887,248 screening participants, 422,385 men and 464,863 women. f-Hb varied by sex, age, deprivation quintile and geographical region. The f-Hb distributions by sex and age differed between the SBoSP and the pilot evaluation and the three other countries. Conclusions f-Hb is higher in men than in women and increases with age and deprivation in both sexes. f-Hb also varies by geographical region, independently of deprivation, and by country. The f-Hb distribution estimated by pilot evaluation may not represent the population distribution. Decision limits have advantages over reference intervals. Use of partitioned f-Hb thresholds for further investigation, based on the data generated, has advantages and disadvantages, as do risk scores based on a spectrum of influencing variables.
Collapse
Affiliation(s)
- Gavin R C Clark
- Information Services Division, NHS National Services Scotland, Edinburgh, Scotland, UK.,Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Judith A Strachan
- Department of Blood Sciences and Scottish Bowel Screening Laboratory, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Alisson McPherson
- Scottish Bowel Screening Laboratory, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| |
Collapse
|
9
|
Digby J, Strachan JA, McCann R, Steele RJ, Fraser CG, Mowat C. Measurement of faecal haemoglobin with a faecal immunochemical test can assist in defining which patients attending primary care with rectal bleeding require urgent referral. Ann Clin Biochem 2021; 57:325-327. [PMID: 32482080 DOI: 10.1177/0004563220935622] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 01/07/2023]
Abstract
BACKGROUND Current guidelines document persistent rectal bleeding as an alarm symptom in patients presenting to primary care. We studied whether a faecal immunochemical test could assist in their assessment. METHODS From December 2015, faecal immunochemical tests were routinely available to primary care when assessing patients with new-onset bowel symptoms: general practitioners were encouraged to include faecal haemoglobin concentration (f-Hb) within any referral to secondary care. Results with f-Hb ≥10 μg Hb/g faeces were defined as positive. The incidence of significant bowel disease (SBD: colorectal cancer [CRC], higher-risk adenoma [HRA: any ≥1 cm, or three or more] and inflammatory bowel disease [IBD]) at subsequent colonoscopy, referred symptoms and f-Hb were recorded. RESULTS Of 1447 patients with a faecal immunochemical test result and colonoscopy outcome, SBD was diagnosed in 296 patients (20.5%; 95 with CRC, 133 with HRA, and 68 with IBD). Four hundred and sixty-two patients (31.9%) reported rectal bleeding: 294 had f-Hb ≥10 μg Hb/g faeces. At colonoscopy, 105/294 had SBD versus 14/168 with rectal bleeding and f-Hb <10 μg Hb/g faeces (P < 0.0001), comprising one case of CRC (0.6%), 12 HRA (7.1%) and one new case of IBD (0.6%); further, the single cancer and 8 of the 12 HRA were located in the descending colon. CONCLUSION Patients with rectal bleeding and f-Hb <10 μg Hb/g faeces are unlikely to have SBD and could be investigated by sigmoidoscopy alone. Using the faecal immunochemical test to guide investigation of patients with rectal bleeding is a rational and practical way forward.
Collapse
Affiliation(s)
- Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Judith A Strachan
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Rebecca McCann
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Robert Jc Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| |
Collapse
|
10
|
Mowat C, Digby J, Strachan JA, McCann RK, Carey FA, Fraser CG, Steele RJ. Faecal haemoglobin concentration thresholds for reassurance and urgent investigation for colorectal cancer based on a faecal immunochemical test in symptomatic patients in primary care. Ann Clin Biochem 2021; 58:211-219. [PMID: 33334134 PMCID: PMC8114428 DOI: 10.1177/0004563220985547] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Faecal haemoglobin concentration (f-Hb), estimated using a faecal immunochemical test, can be safely implemented in primary care to assess risk of colorectal cancer (CRC). Clinical outcomes of patients presenting with symptoms of lower gastrointestinal disease were examined using an extensive range of f-Hb thresholds to decide on reassurance or referral for further investigation. Methods All patients who attended primary care and submitted a single faecal specimen faecal immunochemical test in the first year of the routine service had f-Hb estimated using HM-JACKarc: f-Hb thresholds from <2 to ≥ 400 µg Hb/g faeces (µg/g) were examined. Results Low f-Hb thresholds of <2, <7, <10 and <20 µg/g gave respective CRC risks of 0.1, 0.3, 0.3 and 0.4%, numbers needed to scope for one CRC of 871, 335, 300 and 249, and ‘false negative’ rates of 2.9, 11.4, 13.3 and 17.1%. With thresholds of <2, <7, <10 and <20 µg/g, 48.6, 74.6, 78.1 and 83.2% respectively of symptomatic patients could be managed without further investigation. With reassurance thresholds of <2 µg/g, <7 µg/g and <10 µg/g, the thresholds for referral for urgent investigation would be >400 µg/g, ≥200 µg/g and ≥100 µg/g. However, patients with a f-Hb concentration of <10 or <20 µg/g with iron deficiency anaemia, or with severe or persistent symptoms, should not be denied further investigation. Conclusions In primary care, f-Hb, in conjunction with clinical assessment, can safely and objectively determine individual risk of CRC and decide on simple reassurance or urgent, or routine referral.
Collapse
Affiliation(s)
- Craig Mowat
- Department of Gastroenterology, University of Dundee, School of Medicine Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Judith A Strachan
- Department of Blood Sciences, Ninewells Hospital and Medical School, NHS Tayside, Dundee, Scotland, UK
| | - Rebecca K McCann
- Department of Blood Sciences, Ninewells Hospital and Medical School, NHS Tayside, Dundee, Scotland, UK
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital and Medical School, NHS Tayside, Dundee, Scotland, UK
| | - 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
| | - Robert Jc Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| |
Collapse
|
11
|
Digby J, Cleary S, Gray L, Datt P, Goudie DR, Steele RJC, Strachan JA, Humphries A, Fraser CG, Mowat C. Faecal haemoglobin can define risk of colorectal neoplasia at surveillance colonoscopy in patients at increased risk of colorectal cancer. United European Gastroenterol J 2020; 8:559-566. [PMID: 32213041 PMCID: PMC7268942 DOI: 10.1177/2050640620913674] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Indexed: 12/19/2022] Open
Abstract
Background Quantitative faecal immunochemical tests measure faecal haemoglobin concentration (f-Hb), which increases in the presence of colorectal neoplasia. Objective We examined the diagnostic accuracy of faecal immunochemical test (FIT)in patients at increased risk of colorectal cancer (CRC) attending for surveillance colonoscopy as per national guidelines. Methods A total of 1103 consecutive patients were prospectively invited to complete a FIT before their scheduled colonoscopy in two university hospitals in 2014– 2016. F-Hb was analysed on an OC-Sensor io automated analyser (Eiken Chemical Co., Ltd, Tokyo, Japan) with a limit of detection of 2 µg Hb/g faeces. The diagnostic accuracy of f-Hb for CRC and higher-risk adenoma was examined. Results A total of 643 patients returned a faecal test. After excluding 4 patients with known inflammatory bowel disease, 639 (57.9%) remained in the study: age range: 25–90 years (median: 64 years, interquartile range (IQR): 55–71): 54.6% male. Of 593 patients who also completed colonoscopy, 41 (6.9%) had advanced neoplasia (4 CRC, 37 higher-risk adenoma). Of the 238 patients (40.1%) who had detectable f-Hb, 31 (13.0%) had advanced neoplasia (2 CRC, 29 higher-risk adenoma) compared with 10 (2.8%) in those with undetectable f-Hb (2 CRC, 8 higher-risk adenoma). Detectable f-Hb gave negative predictive values of 99.4% for CRC and 97.2% for CRC plus higher-risk adenoma. Conclusion In patients at increased risk of CRC under colonoscopy surveillance, a test measuring faecal haemoglobin can provide an objective estimate of the risk of advanced neoplasia, and could enable tailored scheduling of colonoscopy.
Collapse
Affiliation(s)
- Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
| | - Shirley Cleary
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Lynne Gray
- Department of Surgery, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Pooja Datt
- Department of Gastroenterology, St. Mark's Hospital and Imperial College, London, UK
| | - David R Goudie
- Department of Clinical Genetics, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
| | - Judith A Strachan
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Adam Humphries
- Department of Gastroenterology, St. Mark's Hospital and Imperial College, London, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| |
Collapse
|
12
|
Digby J, Strachan JA, Mowat C, Steele RJC, Fraser CG. Appraisal of the faecal haemoglobin, age and sex test (FAST) score in assessment of patients with lower bowel symptoms: an observational study. BMC Gastroenterol 2019; 19:213. [PMID: 31829141 PMCID: PMC6907179 DOI: 10.1186/s12876-019-1135-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 02/26/2019] [Accepted: 12/04/2019] [Indexed: 12/21/2022] Open
Abstract
Background Many patients present in primary care with lower bowel symptoms, but significant bowel disease (SBD), comprising colorectal cancer (CRC), advanced adenoma (AA), or inflammatory bowel disease (IBD), is uncommon. Quantitative faecal immunochemical tests for haemoglobin (FIT), which examine faecal haemoglobin concentrations (f-Hb), assist in deciding who would benefit from colonoscopy. Incorporation of additional variables in an individual risk-score might improve this approach. We investigated if the published f-Hb, age and sex test score (FAST score) added value. Methods Data from the first year of routine use of FIT in primary care in one NHS Board in Scotland were examined: f-Hb was estimated using one HM-JACKarc FIT system (Kyowa Medex Co., Ltd., Tokyo, Japan) with a cut-off for positivity ≥10 μg Hb/g faeces. 5660 specimens were received for analysis in the first year. 4072 patients were referred to secondary care: 2881 (70.6%) of these had returned a FIT specimen. Of those referred, 1447 had colonoscopy data as well as the f-Hb result (group A): 2521 patients, also with f-Hb, were not immediately referred (group B). The FAST score was assessed in both groups. Results 1196 (41.7%) of patients who returned a specimen for FIT analysis had f-Hb ≥10 μg Hb/g faeces. In group A, 252 of 296 (85.1%) with SBD had f-Hb > 10 μg Hb/g faeces, as did 528 of 1151 (45.8%) without SBD. Using a FAST score > 2.12, which gives high clinical sensitivity for CRC, only 1143 would have been referred for colonoscopy (21.0% reduction in demand): 286 of 296 (96.6%) with SBD had a positive FAST score, as did 857 of 1151 (74.5%) without SBD. However, one CRC, five AA and four IBD would have been missed. In group B, although 95.2% had f-Hb < 10 μg Hb/g faeces, 1371 (53.7%) had FAST score ≥ 2.12: clinical rationale led to only 122 of group B completing subsequent bowel investigations: a FAST score > 2.12 was found in 13 of 15 (86.7%) with SBD. Conclusions The performance characteristics of the FAST score did not seem to enhance the utility of f-Hb alone. Locally-derived formulae might confer desired benefits.
Collapse
Affiliation(s)
- Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
| | - Judith A Strachan
- Blood Sciences and Scottish Bowel Screening Laboratory, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, Scotland, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, DD1 9SY, UK.
| |
Collapse
|
13
|
Mowat C, Digby J, Strachan JA, Steele RJC, Fraser CG. Low Sensitivity of Fecal Immunochemical Tests (FIT) for Detection of Sessile Serrated Adenomas/Polyps Confirmed Over Clinical Setting, Geography, and FIT System. Dig Dis Sci 2019; 64:3024-3026. [PMID: 31104198 DOI: 10.1007/s10620-019-05661-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/04/2019] [Indexed: 12/09/2022]
Affiliation(s)
- Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Jayne Digby
- Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, Scotland, UK
| | - Judith A Strachan
- Department of Blood Sciences and Scottish Bowel Screening Laboratory, NHS Tayside, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, Scotland, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, Scotland, UK.
| |
Collapse
|
14
|
Mowat C, Digby J, Strachan JA, McCann R, Hall C, Heather D, Carey F, Fraser CG, Steele RJC. Impact of introducing a faecal immunochemical test (FIT) for haemoglobin into primary care on the outcome of patients with new bowel symptoms: a prospective cohort study. BMJ Open Gastroenterol 2019; 6:e000293. [PMID: 31275586 PMCID: PMC6577357 DOI: 10.1136/bmjgast-2019-000293] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 12/14/2022] Open
Abstract
Objective To determine whether a faecal immunochemical test (FIT) for faecal haemoglobin concentration (f-Hb) can be safely implemented in primary care as a rule-out test for significant bowel disease (SBD) (colorectal cancer (CRC), higher risk adenoma (HRA) and inflammatory bowel disease (IBD)) when used as an adjunct to the clinical assessment of new bowel symptoms. Design Single-centre prospective cohort study of all patients who attended primary care and submitted a FIT in the first calendar year of the service beginning December 2015. f-Hb was estimated using HM-JACKarc (Kyowa Medex) with a clinical cut-off of ≥10 µg Hb/g faeces. Incident cases of CRC were verified via anonymised record linkage to the Scottish Cancer Registry. Results 5422 patients submitted 5660 FIT specimens, of which 5372 were analysed (positivity: 21.9%). 2848 patients were referred immediately to secondary care and three with f-Hb <10 µg/g presented acutely within days with obstructing CRC. 1447 completed colonoscopy in whom overall prevalence of SBD was 20.5% (95 CRC (6.6%), 133 HRA (9.2%) and 68 IBD (4.7%)); 6.6% in patients with f-Hb <10 µg/g vs 32.3% in patients with f-Hb ≥10 µg/g. One CRC was detected at CT colonoscopy. 2521 patients were not immediately referred (95.3% had f-Hb <10 µg/g) of which four (0.2%) later developed CRC. Record linkage identified no additional CRC cases within a follow-up period of 23–35 months. Conclusion In primary care, measurement of f-Hb, in conjunction with clinical assessment, can safely and objectively determine a patient’s risk of SBD.
Collapse
Affiliation(s)
- Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, UK
| | - Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Judith A Strachan
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, UK
| | - Rebecca McCann
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Duncan Heather
- Health Informatics Centre, University of Dundee, Dundee, UK
| | - Francis Carey
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, UK
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| |
Collapse
|
15
|
Digby J, Steele RJC, Strachan JA, Mowat C, Anderson AS, McCann R, Law L, Fraser CG. Do other variables add value to assessment of the risk of colorectal disease using faecal immunochemical tests for haemoglobin? Ann Clin Biochem 2019; 56:472-479. [DOI: 10.1177/0004563219839423] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Faecal immunochemical tests for haemoglobin have been recommended to assist in assessment of patients presenting in primary care with lower bowel symptoms. The aim was to assess if, and which, additional variables might enhance this use of faecal immunochemical tests. Methods Faecal immunochemical test analysis has been a NHS Tayside investigation since December 2015. During the first year, 993 patients attending colonoscopy were invited to complete a detailed questionnaire on demographic background, symptoms, smoking status, alcohol use, dietary fibre, red and processed meat intake, physical activity, sitting time, dietary supplement use, family history of colorectal cancer, adenoma, inflammatory bowel disease and diabetes. Significant bowel disease was classified as colorectal cancer, advanced adenoma or inflammatory bowel disease. Results A total of 470 (47.3%) invitees agreed to complete the questionnaire and 408 (41.1%) did. Unadjusted odds ratios for the presence of significant bowel disease compared with undetectable faecal haemoglobin increased with increasing faecal haemoglobin and for faecal haemoglobin 10–49, 50–199, 200–399 and ⩾400 μg Hb/g faeces were 0.95 (95% CI: 0.16–5.63), 2.47 (0.55–1.03), 6.30 (1.08–36.65) and 18.90 (4.22–84.62), respectively. Rectal bleeding and family history of polyps were the only other variables with statistically significant ( P < 0.05) odds ratios greater than 1.00, being 1.88 (1.13–3.17) and 2.93 (1.23–6.95), respectively. Odds ratios adjusted for all other variables showed similar associations, but only faecal haemoglobin and family history of polyps had significant associations. Conclusions Faecal haemoglobin is the most important factor to be considered when deciding which patients presenting in primary care with lower bowel symptoms would benefit most from referral for colonoscopy.
Collapse
Affiliation(s)
- Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Robert JC Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Judith A Strachan
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Annie S Anderson
- Centre for Public Health Nutrition, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Rebecca McCann
- Department of Blood Sciences, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Louise Law
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland
| |
Collapse
|
16
|
Steele RJC, Digby J, Chambers JA, O'Carroll RE. The impact of personalised risk information compared to a positive/negative result on informed choice and intention to undergo colonoscopy following colorectal Cancer screening in Scotland (PERICCS) - a randomised controlled trial: study protocol. BMC Public Health 2019; 19:411. [PMID: 30991987 PMCID: PMC6469206 DOI: 10.1186/s12889-019-6734-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/31/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In Scotland a new, easier to complete bowel screening test, the Faecal Immunochemical Test (FIT), has been introduced. This test gives more accurate information about an individual's risk of having colorectal cancer (CRC), based on their age and gender, and could lead to fewer missed cancers compared to the current screening test. However, there is no evidence of the effect on colonoscopy uptake of providing individuals with personalised risk information following a positive FIT test. The objectives of the study are: 1) To develop novel methods of presenting personalised risk information in an easy-to-understand format using infographics with involvement of members of the public 2) To assess the impact of different presentations of risk information on informed choice and intention to take up an offer of colonoscopy after FIT 3) To assess participants' responses to receiving personal risk information (knowledge, attitudes to screening/risk, emotional responses including anxiety). METHODS Adults (age range 50-74) registered on the Scottish Bowel Screening database will be invited by letter to take part. Consenting participants will be randomised to one of three groups to receive hypothetical information about their risk of cancer, based on age, gender and faecal haemoglobin concentration: 1) personalised risk information in numeric form (e.g. 1 in 100) with use of infographics, 2) personalised information described as 'highest', 'moderate' or 'lowest' risk with use of infographics, and 3) as a 'positive' test result, as is current practice. Groups will be compared on informed choice, intention to have a colonoscopy, and satisfaction with their decision. Follow-up semi-structured qualitative interviews will be conducted, by telephone, with a small number of consenting participants (n = 10 per group) to explore the acceptability/readability and any potential negative impact of the risk information, participants' understanding of risk factors, attitudes to the different scenarios, and reasons for reported intentions. DISCUSSION Proving personalised risk information and allowing patient choice could lead to improved detection of CRC and increase patient satisfaction by facilitating informed choice over when/whether to undergo further invasive screening. However, we need to determine whether/how informed choice can be achieved and assess the potential impact on the colonoscopy service. TRIAL REGISTRATION The trial is registered on www.isrctn.com on 08/12/2017. Registration no: ISRCTN14254582.
Collapse
Affiliation(s)
- Robert J C Steele
- Division of Cancer Research, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Jayne Digby
- Division of Cancer Research, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | | | | |
Collapse
|
17
|
Digby J, Fraser CG, Carey FA, Steele RJC. Can the performance of a quantitative FIT-based colorectal cancer screening programme be enhanced by lowering the threshold and increasing the interval? Gut 2018; 67:993-994. [PMID: 28838973 DOI: 10.1136/gutjnl-2017-314862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/10/2017] [Accepted: 08/13/2017] [Indexed: 12/08/2022]
Affiliation(s)
- Jayne Digby
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, UK.,Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Callum G Fraser
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, UK.,Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Frank A Carey
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, UK
| | - Robert J C Steele
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, UK.,Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK.,Division of Cancer, Medical Research Institute, Ninewells Hospital and Medical School, Dundee, UK
| |
Collapse
|
18
|
Quyn AJ, Steele RJ, Digby J, Strachan JA, Mowat C, McDonald PJ, Carey FA, Godber IM, Younes HB, Fraser CG. Application of NICE guideline NG12 to the initial assessment of patients with lower gastrointestinal symptoms: not FIT for purpose? Ann Clin Biochem 2017; 55:69-76. [PMID: 28661203 DOI: 10.1177/0004563217707981] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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: 01/01/2023]
Abstract
Background The National Institute for Health and Care Excellence (NICE) published NG12 in 2015. The referral criteria for suspected colorectal cancer (CRC) caused controversy, because tests for occult blood in faeces were recommended. Faecal immunochemical tests for haemoglobin (FIT), which estimate faecal haemoglobin concentrations (f-Hb), might more than fulfil the intentions. Our aim was to compare the utility of f-Hb as the initial investigation with the NICE NG12 symptom-based guidelines. Methods Data from three studies were included. Patients had sex, age, symptoms, f-Hb and colonoscopy and histology data recorded. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of f-Hb and NG12 were calculated for all significant colorectal disease (SCD: CRC, higher risk adenoma and inflammatory bowel disease). Overall diagnostic accuracy was also estimated by the area under the receiver operating characteristic curve (AUC). Results A total of 1514 patients were included. At a cut-off of ≥10 µg Hb/g faeces, the sensitivity of f-Hb for CRC was 93.3% (95% confidence interval (CI): 80.7-98.3) with NPV of 99.7% (95%CI: 99.2-99.9). The sensitivity and NPV for SCD were 63.2% (95%CI: 56.6-69.4) and 96.0% (95%CI: 91.4-94.4), respectively. The NG12 sensitivity and NPV for SCD were 58.4% (95%CI: 51.8-64.8) and 87.6% (95%CI: 85.0-89.8), respectively. The AUC for CRC was 0.85 (95% CI: 0.87-0.90) for f-Hb versus 0.65 (95%CI: 0.58-0.73) for NG12 ( P < 0.005). For SCD, the AUC was 0.73 (95%CI: 0.69-0.77) for f-Hb versus 0.56 (95%CI: 0.52-0.60) for NG12 ( P < 0.0005). Conclusion f-Hb provides a good rule-out test for SCD and has significantly higher overall diagnostic accuracy than NG12.
Collapse
Affiliation(s)
- Aaron J Quyn
- 1 Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Robert Jc Steele
- 1 Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Jayne Digby
- 1 Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | | | - Craig Mowat
- 3 Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, UK
| | - Paula J McDonald
- 2 Blood Sciences, Ninewells Hospital and Medical School, Dundee, UK
| | - Francis A Carey
- 4 Department of Pathology, Ninewells Hospital and Medical School, Dundee, UK
| | - Ian M Godber
- 5 Department of Biochemistry, Monklands Hospital, Lanarkshire, UK
| | - Hakim B Younes
- 6 Department of Surgery, Wishaw General Hospital, Lanarkshire, UK
| | - Callum G Fraser
- 1 Centre for Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| |
Collapse
|
19
|
Cubiella J, Digby J, Rodríguez-Alonso L, Vega P, Salve M, Díaz-Ondina M, Strachan JA, Mowat C, McDonald PJ, Carey FA, Godber IM, Younes HB, Rodriguez-Moranta F, Quintero E, Álvarez-Sánchez V, Fernández-Bañares F, Boadas J, Campo R, Bujanda L, Garayoa A, Ferrandez Á, Piñol V, Rodríguez-Alcalde D, Guardiola J, Steele RJC, Fraser CG. The fecal hemoglobin concentration, age and sex test score: Development and external validation of a simple prediction tool for colorectal cancer detection in symptomatic patients. Int J Cancer 2017; 140:2201-2211. [PMID: 28187494 DOI: 10.1002/ijc.30639] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [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: 10/02/2016] [Revised: 01/22/2017] [Accepted: 01/30/2017] [Indexed: 12/15/2022]
Abstract
Prediction models for colorectal cancer (CRC) detection in symptomatic patients, based on easily obtainable variables such as fecal haemoglobin concentration (f-Hb), age and sex, may simplify CRC diagnosis. We developed, and then externally validated, a multivariable prediction model, the FAST Score, with data from five diagnostic test accuracy studies that evaluated quantitative fecal immunochemical tests in symptomatic patients referred for colonoscopy. The diagnostic accuracy of the Score in derivation and validation cohorts was compared statistically with the area under the curve (AUC) and the Chi-square test. 1,572 and 3,976 patients were examined in these cohorts, respectively. For CRC, the odds ratio (OR) of the variables included in the Score were: age (years): 1.03 (95% confidence intervals (CI): 1.02-1.05), male sex: 1.6 (95% CI: 1.1-2.3) and f-Hb (0-<20 µg Hb/g feces): 2.0 (95% CI: 0.7-5.5), (20-<200 µg Hb/g): 16.8 (95% CI: 6.6-42.0), ≥200 µg Hb/g: 65.7 (95% CI: 26.3-164.1). The AUC for CRC detection was 0.88 (95% CI: 0.85-0.90) in the derivation and 0.91 (95% CI: 0.90-093; p = 0.005) in the validation cohort. At the two Score thresholds with 90% (4.50) and 99% (2.12) sensitivity for CRC, the Score had equivalent sensitivity, although the specificity was higher in the validation cohort (p < 0.001). Accordingly, the validation cohort was divided into three groups: high (21.4% of the cohort, positive predictive value-PPV: 21.7%), intermediate (59.8%, PPV: 0.9%) and low (18.8%, PPV: 0.0%) risk for CRC. The FAST Score is an easy to calculate prediction tool, highly accurate for CRC detection in symptomatic patients.
Collapse
Affiliation(s)
- Joaquín Cubiella
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain.,Instituto de Investigación Biomedica (IBI) Ourense, Pontevedra y Vigo, Vigo, Spain
| | - Jayne Digby
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland, United Kingdom
| | - Lorena Rodríguez-Alonso
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Ciber de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Pablo Vega
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - María Salve
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Marta Díaz-Ondina
- Clinical Analysis Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Judith A Strachan
- Blood Sciences, Ninewells Hospital & Medical School, Dundee, Scotland, United Kingdom
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital & Medical School, Dundee, Scotland, United Kingdom
| | - Paula J McDonald
- Kings Cross Hospital, Scottish Bowel Screening Centre, Dundee, Scotland, United Kingdom
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital & Medical School, Dundee, Scotland, United Kingdom
| | - Ian M Godber
- Department of Biochemistry, Monklands Hospital, Airdrie, Lanarkshire, Scotland, United Kingdom
| | - Hakim Ben Younes
- Department of Surgery, Wishaw General Hospital, Wishaw, Lanarkshire, Scotland, United Kingdom
| | - Francisco Rodriguez-Moranta
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Ciber de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Enrique Quintero
- Gastroenterology Department, Hospital Universitario de Canarias, Instituto Universitario de Tecnologías Biomédicas (ITB) & Centro de Investigación Biomédica de Canarias (CIBICAN), Universidad de La Laguna, Tenerife, Spain
| | | | - Fernando Fernández-Bañares
- Gastroenterology Department, Hospital Universitari Mútua de Terrassa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa, Spain
| | - Jaume Boadas
- Gastroenterology Department, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - Rafel Campo
- Gastroenterology Department, Hospital de Sabadell, Corporació Sanitària i Universitària Parc Taulí, Sabadell, Spain
| | - Luis Bujanda
- Donostia Hospital, Biodonostia Institute, University of the Basque Country UPV/EHU (CIBERehd), San Sebastian, Spain
| | - Ana Garayoa
- Gastroenterology Department, Hospital de Sagunto, Sagunto, Valencia, Spain
| | - Ángel Ferrandez
- Servicio de Aparato Digestivo, Hospital Clínico Universitario, IIS Aragón, University of Zaragoza, (CIBERehd), Zaragoza, Spain
| | - Virginia Piñol
- Gastroenterology Department, Hospital Dr. Josep Trueta, Girona, Spain
| | | | - Jordi Guardiola
- Department of Gastroenterology and Hepatology, University Hospital of Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Ciber de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland, United Kingdom
| | - Callum G Fraser
- Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland, United Kingdom
| | | |
Collapse
|
20
|
Mowat C, Digby J, Strachan JA, Wilson R, Carey FA, Fraser CG, Steele RJC. Faecal haemoglobin and faecal calprotectin as indicators of bowel disease in patients presenting to primary care with bowel symptoms. Gut 2016; 65:1463-9. [PMID: 26294695 PMCID: PMC5036251 DOI: 10.1136/gutjnl-2015-309579] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [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: 03/12/2015] [Accepted: 06/06/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In primary care, assessing which patients with bowel symptoms harbour significant disease (cancer, higher-risk adenoma or IBD) is difficult. We studied the diagnostic accuracies of faecal haemoglobin (FHb) and faecal calprotectin (FC) in a cohort of symptomatic patients. DESIGN From October 2013 to March 2014, general practitioners were prompted to request FHb and FC when referring patients with bowel symptoms to secondary care. Faecal samples were analysed for haemoglobin (EIKEN OC-Sensor io) and calprotectin (BÜHLMANN Calprotectin ELISA). Patients triaged to endoscopy were investigated within 6 weeks. All clinicians and endoscopists were blind to the faecal test results. The diagnostic accuracies of FHb and FC for identification of significant bowel disease were assessed. RESULTS 1043 patients returned samples. FHb was detectable in 57.6% (median 0.4 µg/g, 95% CI 0.4 to 0.8; range 0-200). FC at 50 µg/g or above was present in 60.0%. 755 patients (54.6% women, median age 64 years (range 16-90, IQR 52-73)) returned samples and completed colonic investigations. 103 patients had significant bowel disease; the negative predictive values of FHb for colorectal cancer, higher-risk adenoma and IBD were 100%, 97.8% and 98.4%, respectively. Using cut-offs of detectable FHb and/or 200 µg/g FC detected two further cases of IBD, one higher-risk adenoma and no additional cancers. CONCLUSIONS In primary care, undetectable FHb is a good 'rule-out' test for significant bowel disease and could guide who requires investigation.
Collapse
Affiliation(s)
- Craig Mowat
- Department of Gastroenterology, Ninewells Hospital & Medical School, Dundee, UK
| | - Jayne Digby
- Centre for Research into cancer Prevention and Screening
| | - Judith A Strachan
- Department of Blood Sciences, Ninewells Hospital & Medical School, Dundee, UK
| | - Robyn Wilson
- Department of Blood Sciences, Ninewells Hospital & Medical School, Dundee, UK
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital & Medical School, Dundee, UK
| | | | | |
Collapse
|
21
|
Digby J, Fraser CG, Carey FA, Diament RH, Balsitis M, Steele RJC. Faecal haemoglobin concentration is related to detection of advanced colorectal neoplasia in the next screening round. J Med Screen 2016; 24:62-68. [DOI: 10.1177/0969141316653983] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective To examine associations between faecal haemoglobin concentrations below the cut-off used in colorectal cancer screening and outcomes in the next screening round. Methods In the Scottish Bowel Screening Programme, faecal haemoglobin concentrations and diagnostic outcomes were investigated for participants with a negative result (faecal haemoglobin concentrations < 80.0 µg Hb/g faeces), followed by a positive result within two years. Results Of 37,780 participants with negative results, at the next screening round, 556 (1.5%) screened positive and 30,293 (80.2%) negative. Initial median faecal haemoglobin concentrations (2.1 µg Hb/g faeces, IQR: 0.0–13.2) were higher in those with subsequent positive results than those with subsequent negative results (0.0 µg Hb/g faeces, IQR: 0.0–1.4; p < 0.0001). Using faecal haemoglobin concentrations 0.0–19.9 µg Hb/g faeces as reference, logistic regression analysis showed high adjusted odds ratios for advanced neoplasia (advanced neoplasia: colorectal cancer or higher risk adenoma) detection at the next round of 14.3 (95% CI: 8.9–23.1) in those with initial faecal haemoglobin concentrations 20.0–39.9 µg Hb/g faeces, and 38.0 (95% CI: 20.2–71.2) with 60.0–79.9 µg Hb/g faeces. Conclusions A higher proportion of participants with faecal haemoglobin concentrations of ≥ 20 µg Hb/g faeces had advanced neoplasia detected at the next round than participants with lower faecal haemoglobin concentrations. Although most relevant when using high faecal haemoglobin concentrations cut-offs, studies of faecal haemoglobin concentrations and outcomes over screening rounds may provide strategies to direct available colonoscopy towards those at highest risk.
Collapse
Affiliation(s)
- Jayne Digby
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, Scotland
- Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Callum G Fraser
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, Scotland
- Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Robert H Diament
- Department of Surgery, Crosshouse Hospital, Kilmarnock, Ayrshire, Scotland
| | - Margaret Balsitis
- Department of Pathology, Crosshouse Hospital, Kilmarnock, Ayrshire, Scotland
| | - Robert JC Steele
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, Scotland
- Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, Dundee, Scotland
- Medical Research Institute, Division of Cancer, Ninewells Hospital and Medical School, Scotland
| |
Collapse
|
22
|
Digby J, Fraser CG, Carey FA, Lang J, Stanners G, Steele RJ. Interval cancers using a quantitative faecal immunochemical test (FIT) for haemoglobin when colonoscopy capacity is limited. J Med Screen 2015; 23:130-4. [PMID: 26589788 DOI: 10.1177/0969141315609634] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [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: 04/16/2015] [Accepted: 09/11/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Quantitative faecal immunochemical tests (FIT) for faecal haemoglobin (f-Hb) in colorectal cancer (CRC) screening pose challenges when colonoscopy is limited. For low positivity rates, high f-Hb concentration cut-offs are required, but little is known about interval cancer (IC) proportions using FIT. We assessed IC proportions using an 80 µg Hb/g cut-off. METHODS In two NHS Boards in the Scottish Bowel Screening Programme, f-Hb was estimated for 30,893 participants aged 50-75, of whom 753 participants with f-Hb ≥ 80 µg Hb/g were referred for colonoscopy. ICs, defined as CRC within two years of a negative result, were identified from the Scottish Cancer Registry. RESULTS There were 31 ICs and 30 screen-detected (SD) CRCs, an IC proportion of 50.8% (48.4% for men, 53.3% for women). CRC site distribution was similar between ICs and SD, but ICs were later stage (46.7% and 33.3%, Dukes' stages C and D, respectively). Of 31 ICs, 23 had f-Hb < 10 µg Hb/g, including six with undetectable f-Hb. A f-Hb cut-off of 10 µg Hb/g would have raised the positivity rate from 2.4% to 9.4%, increased colonoscopy requirement from 753 to 2147, and reduced the IC proportion to 38.3%. CONCLUSIONS The IC proportion was similar to that seen with guaiac-based FOBT. The later stage distribution of ICs highlights the benefits of lower f-Hb cut-offs, but with 19.4% of ICs having undetectable f-Hb, some cancers would have been missed, even with drastic reduction in the f-Hb cut-off.
Collapse
Affiliation(s)
- Jayne Digby
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, Scotland Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Callum G Fraser
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, Scotland Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, Scotland
| | - Jaroslaw Lang
- Information Services Division, NHS National Services Scotland, Meridian Court, Glasgow, Scotland
| | - Greig Stanners
- Information Services Division, NHS National Services Scotland, Meridian Court, Glasgow, Scotland
| | - Robert Jc Steele
- Scottish Bowel Screening Research Unit, Ninewells Hospital and Medical School, Dundee, Scotland Centre for Research into Cancer Prevention and Screening, Ninewells Hospital and Medical School, Dundee, Scotland Medical Research Institute, Division of Cancer, Ninewells Hospital and Medical School, Scotland
| |
Collapse
|
23
|
Steele RJ, McDonald PJ, Digby J, Brownlee L, Strachan JA, Libby G, McClements PL, Birrell J, Carey FA, Diament RH, Balsitis M, Fraser CG. Clinical outcomes using a faecal immunochemical test for haemoglobin as a first-line test in a national programme constrained by colonoscopy capacity. United European Gastroenterol J 2014; 1:198-205. [PMID: 24917960 DOI: 10.1177/2050640613489281] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/10/2013] [Accepted: 04/15/2013] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Because of their many advantages, faecal immunochemical tests (FIT) are superseding traditional guaiac-based faecal occult blood tests in bowel screening programmes. METHODS A quantitative FIT was adopted for use in two evaluation National Health Service (NHS) Boards in Scotland using a cut-off faecal haemoglobin concentration chosen to give a positivity rate equivalent to that achieved in the Scottish Bowel Screening Programme. Uptake and clinical outcomes were compared with results obtained contemporaneously in two other similar NHS Boards and before and after the evaluation in the two evaluation NHS Boards. RESULTS During the evaluation, uptake was 58.5%. This was higher than in the same NHS Boards both before and after the evaluation, higher than in the other two NHS Boards and higher than the 53.7% achieved overall in Scotland. The overall positivity rate was higher in men than in women and increased with age in both genders. Positive predictive values for cancer (4.8%), high-risk adenoma (23.3%), all adenoma (38.2%) and all neoplasia (43.0%) in the two test NHS Boards were similar in all groups. CONCLUSIONS In summary, this evaluation of the FIT supports the introduction of FIT as a first-line test, even when colonoscopy capacity is limited.
Collapse
Affiliation(s)
- Robert Jc Steele
- Department of Surgery, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Jayne Digby
- Scottish Bowel Screening Centre, NHS Tayside, Dundee, UK
| | - Linda Brownlee
- Scottish Bowel Screening Centre, NHS Tayside, Dundee, UK
| | | | - Gillian Libby
- Scottish Bowel Screening Centre, NHS Tayside, Dundee, UK
| | - Paula L McClements
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Janice Birrell
- National Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, UK
| | | | | | - Callum G Fraser
- Centre for Research into Cancer Prevention & Screening, Ninewells Hospital and Medical School, Dundee, UK
| |
Collapse
|
24
|
Abstract
OBJECTIVE To investigate the relationship between deprivation and faecal haemoglobin concentration (f-Hb). SETTING Scottish Bowel Screening Programme. METHODS A total of 66725 men and women, aged 50 to 74, were invited to provide a single sample for a faecal immunochemical test. Deprivation was estimated using the Scottish Index of Multiple Deprivation quintiles: f-Hb was measured (OC-Sensor, Eiken, Japan) on 38439 participants. The relationship between deprivation quintiles and f-Hb was examined. RESULTS Median age was 60 years, 53.6% women, with 14.1%, 19.7%, 17.7%, 25.9% and 22.6% in the lowest to the highest deprivation quintiles respectively. No detectable f-Hb was found in 51.9%, ranging from 45.5% in the most deprived up to 56.5% in the least deprived. As deprivation increased, f-Hb increased (p < 0.0001). This trend remained controlling for sex and age (p < 0.001). Participants in the most deprived quintile were more likely to have a f-Hb above a cut-off of 80 µg Hb/g faeces compared with the least deprived, independent of sex and age (adjusted odds ratio 1.70, 95% confidence interval: 1.37 to 2.11). CONCLUSIONS Deprivation and f-Hb are related. This has important implications for selection of cut-off f-Hb for screening programmes, and supports the inclusion of deprivation in risk-scoring systems.
Collapse
Affiliation(s)
- Jayne Digby
- Scottish Bowel Screening Research Unit, University of Dundee, Dundee, Scotland
| | - Paula J McDonald
- Scottish Bowel Screening Centre Laboratory, Kings Cross, Dundee, Scotland
| | - Judith A Strachan
- Scottish Bowel Screening Centre Laboratory, Kings Cross, Dundee, Scotland
| | - Gillian Libby
- Scottish Bowel Screening Research Unit, University of Dundee, Dundee, Scotland
| | | | - Callum G Fraser
- Centre for Research into Cancer Prevention & Screening, University of Dundee, Dundee, Scotland
| |
Collapse
|
25
|
Antonopoulos A, Patel R, Demosthenous M, Margaritis M, Digby J, Sayeed R, Tousoulis D, Stefanadis C, Channon KM, Antoniades C. Differential responses of distinct adipose tissue depots to acute and chronic inflammation: novel insights into the complex mechanisms regulating adiponectin biosynthesis in humans. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht307.p725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
26
|
Digby J, McDonald PJ, Strachan JA, Libby G, Steele RJC, Fraser CG. Use of a faecal immunochemical test narrows current gaps in uptake for sex, age and deprivation in a bowel cancer screening programme. J Med Screen 2013; 20:80-5. [DOI: 10.1177/0969141313497197] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objectives To investigate the characteristics of participants screened for bowel cancer using a faecal immunochemical test for haemoglobin (FIT). Setting Scottish Bowel Screening Programme. Methods 65909 men and women in two NHS Boards, aged 50 to 74, were invited to participate in an evaluation of FIT as a first-line test. Uptake was calculated by sex, age in quintiles, and deprivation in quintiles, and compared with a group who had completed a guaiac faecal occult blood test (gFOBT) and for whom details of sex, age and deprivation were well documented. Results FIT kits from 38672 participants were tested. The overall uptake of 58.7% was significantly higher than the 53.9% for gFOBT (p < 0.0001). Uptakes in the two NHS Boards were 57.6% and 54.4% for men and 63.2% and 59.1% for women, higher than the 49.5% and 58.1% completing gFOBT. Uptake was higher for FIT than gFOBT in all age and deprivation quintiles for both men and women in both NHS Boards. The difference in uptake fell with age for men but rose for women; the increase in uptake was greater for men than women. Uptake fell as deprivation decreased for both sexes, and was similar in both NHS Boards. Conclusions Use of FIT increases uptake over gFOBT, and the greatest increases are seen in men, younger participants, and more deprived individuals, groups for which an increase in uptake is likely to be beneficial. The results support a move to FIT as a first-line screening test for those countries still using gFOBT.
Collapse
|
27
|
Ruparelia N, Digby J, Jefferson A, Medway D, Neubauer S, Lygate C, Choudhury R. 222 MYOCARDIAL INFARCTION CAUSES INFLAMMATION AND LEUKOCYTE RECRUITMENT AT REMOTE SITES IN THE MYOCARDIUM AND IN THE RENAL GLOMERULUS. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
28
|
Chai J, Digby J, Ruparelia N, Jefferson A, Handa A, Choudhury R. 167 NICOTINIC ACID RECEPTOR GPR109A IS DOWN-REGULATED IN HUMAN MACROPHAGE-DERIVED FOAM CELLS. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
29
|
McDonald PJ, Digby J, Innes C, Strachan JA, Carey FA, Steele RJC, Fraser CG. Low faecal haemoglobin concentration potentially rules out significant colorectal disease. Colorectal Dis 2013. [PMID: 23199241 DOI: 10.1111/codi.12087] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM The study aimed to determine whether faecal haemoglobin (Hb) concentration can assist in deciding who with lower abdominal symptoms will benefit from endoscopy. METHOD Faecal Hb concentrations were measured on single samples from 280 patients referred for lower gastrointestinal tract endoscopy from primary care in NHS Tayside who completed a faecal immunochemical test (FIT) for Hb and underwent subsequent endoscopy. RESULTS Among 739 invited patients, FIT and endoscopy were completed by 280 (median age 63 (18-84) years; 59.6% women), with a median time between FIT and endoscopy of 9 days. Six (2.1%) participants had cancer, 23 (8.2%) had high-risk adenoma (HRA) (more than three adenomas or any > 1 cm), 31 (11.1%) low-risk adenoma (LRA) and 26 (9.3%) inflammatory bowel disease (IBD) as the most serious diagnosis. Those with cancer had a median faecal Hb of > 1000 ng Hb/ml buffer. Those with cancer + HRA + IBD had a median faecal Hb concentration of 75 ng Hb/ml buffer (95% CI 18-204), which was significantly higher than that of all remaining participants without significant colorectal disease (P < 0.0001). Using a cut-off faecal Hb concentration of 50 ng Hb/ml buffer, negative predictive values of 100.0%, 94.4%, 93.4% and 93.9% were found for cancer, HRA, LRA and IBD. Patients with reasons for referral other than rectal bleeding and family history did not have high faecal Hb concentrations. CONCLUSION Faecal Hb concentration measurements have considerable potential to contribute to reducing unnecessary endoscopy for the majority of symptomatic patients.
Collapse
Affiliation(s)
- P J McDonald
- Scottish Bowel Screening Centre, Kings Cross Hospital, Dundee, UK
| | | | | | | | | | | | | |
Collapse
|
30
|
Digby J, Fraser CG, Carey FA, McDonald PJ, Strachan JA, Diament RH, Balsitis M, Steele RJC. Faecal haemoglobin concentration is related to severity of colorectal neoplasia. J Clin Pathol 2013; 66:415-9. [PMID: 23418340 DOI: 10.1136/jclinpath-2013-201445] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS Guaiac faecal occult blood tests are being replaced by faecal immunochemical tests (FIT). We investigated whether faecal haemoglobin concentration (f-Hb) was related to stage in progression of colorectal neoplasia, studying cancer and adenoma characteristics in an evaluation of quantitative FIT as a first-line screening test. METHODS We invited 66 225 individuals aged 50-74 years to provide one sample of faeces. f-Hb was measured on samples from 38 720 responders. Colonoscopy findings and pathology data were collected on the 943 with f-Hb ≥ 400 ng Hb/ml (80 µg Hb/g faeces). RESULTS Of the 814 participants with outcome data (median age: 63 years, range 50-75, 56.4% male), 39 had cancer, 190 high-risk adenoma (HRA, defined as ≥ 3 or any ≥ 10 mm) and 119 low-risk adenoma (LRA). 74.4% of those with cancer had f-Hb>1000 ng Hb/ml compared with 58.4% with HRA, and 44.1% with no pathology. Median f-Hb concentration was higher in those with cancer than those with no (p<0.002) or non-neoplastic (p<0.002) pathology, and those with LRA (p=0.0001). Polyp cancers had lower concentrations than more advanced stage cancers (p<0.04). Higher f-Hb was also found in those with HRA than with LRA (p<0.006), large (>10 mm) compared with small adenoma (p<0.0001), and also an adenoma displaying high-grade dysplasia compared with low-grade dysplasia (p<0.009). CONCLUSIONS f-Hb is related to severity of colorectal neoplastic disease. This has ramifications for the selection of the appropriate cut-off concentration adopted for bowel screening programmes.
Collapse
Affiliation(s)
- Jayne Digby
- Scottish Bowel Screening Centre, Kings Cross Hospital, Dundee, UK.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Steele RJC, Digby J. Critical considerations of fecal occult blood tests for colorectal cancer. Colorectal Cancer 2013. [DOI: 10.2217/crc.12.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
| | - Jayne Digby
- University of Dundee, Nethergate, Dundee, DD1 4HN, Scotland, UK
| |
Collapse
|
32
|
Fraser CG, Digby J, McDonald PJ, Strachan JA, Carey FA, Steele RJC. Experience with a two-tier reflex gFOBT/FIT strategy in a national bowel screening programme. J Med Screen 2011; 19:8-13. [DOI: 10.1258/jms.2011.011098] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives To evaluate a two-tier reflex guaiac-based faecal occult blood test (gFOBT)/faecal immunochemical test (FIT) algorithm in screening for colorectal cancer. Setting Fourth screening round in NHS Tayside (Scotland). Methods gFOBT were sent to 50–74-year-olds. Participants with five or six windows positive were offered colonoscopy. Participants with one to four windows positive were sent a FIT and, if positive, were offered colonoscopy. Participants providing an untestable gFOBT were sent a FIT and, if positive, were offered colonoscopy. Outcomes following positive results, cancer stages and key performance indicators were assessed. Results Of 131,885 invited, 73,315 (55.6%) responded. There were 66,957 (91.3%) negative, 241 (0.3%) strong positive, 5230 (7.1%) weak positive and 887 (1.2%) untestable results. The 241 participants who had five or six windows positive had more cancers than those positive by other routes: only 3 of the 30 cancers (9.7%) were Dukes' A. Among the 983 positive results from the weak positive gFOBT then positive FIT route, there were fewer cancers and more normal colonoscopies, but more adenomas than in the group with a strong positive gFOBT. In those with an untestable gFOBT, 77 had a positive FIT result, with fewer true and more false positive results than in the other groups. Fewer males had cancer and stages were earlier than in females, but more had adenoma. The detection rate for cancer was 0.18% and the PPV for cancer and all adenomas was 41.3%. Conclusions The algorithm and FIT following a weak positive gFOBT have advantages. FIT following an untestable gFOBT warrants review.
Collapse
Affiliation(s)
- Callum G Fraser
- Centre for Research into Cancer Prevention & Screening, University of Dundee, Dundee, Scotland
| | - Jayne Digby
- Scottish Bowel Screening Centre, Kings Cross, Dundee, Scotland
| | - Paula J McDonald
- Scottish Bowel Screening Centre Laboratory, Kings Cross, Dundee, Scotland
| | - Judith A Strachan
- Scottish Bowel Screening Centre Laboratory, Kings Cross, Dundee, Scotland
| | - Francis A Carey
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, Scotland
| | | |
Collapse
|
33
|
McDonald PJ, Strachan JA, Digby J, Steele RJC, Fraser CG. Faecal haemoglobin concentrations by gender and age: implications for population-based screening for colorectal cancer. Clin Chem Lab Med 2011; 50:935-40. [PMID: 22149740 DOI: 10.1515/cclm.2011.815] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [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: 10/03/2011] [Accepted: 11/11/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Faecal immunochemical tests (FIT) are becoming widely used in colorectal cancer screening. Estimation of faecal haemoglobin concentration in a large group prompted an observational study on gender and age. METHODS A single estimate of faecal haemoglobin concentration was made using quantitative automated immunoturbidimetry. Potential reference intervals were calculated for men and women and for age quintiles according to the Clinical and Laboratory Standards Institute Approved Guideline. The percentages of positive results were calculated at a number of concentrations. The percentages of individuals who fell into different risk groups were assessed. RESULTS The 97.5 percentiles, potential upper reference limits, were 519 ng haemoglobin/mL (90% CI: 468-575) for men and 283 ng haemoglobin/mL (90% CI: 257-316) for women. Concentrations increased with age in both genders. Decision limits have advantages over reference intervals. At any cut-off concentration, more men are declared positive than women and more older people are declared positive than younger people. Future risk of neoplasia is higher in men than in women and in older people. CONCLUSIONS Faecal haemoglobin concentrations vary with gender and age. More tailored strategies are needed in screening programmes. Faecal haemoglobin concentration could be included in individual risk assessment scores. These data should assist in screening programme design.
Collapse
Affiliation(s)
- Paula J McDonald
- Scottish Bowel Screening Centre, Kings Cross, Dundee, Scotland, UK
| | | | | | | | | |
Collapse
|
34
|
Lim C, van Gaal W, Burrell L, Testa L, Arnold R, Digby J, Neubauer S, Banning A. Does Troponin Elevation After Percutaneous Coronary Intervention Really Represent Myocardial Infarction? Insights from a Biomarker and MRI Study of Complex PCI. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
35
|
Chen J, Tan B, Karteris E, Zervou S, Digby J, Hillhouse EW, Vatish M, Randeva HS. Secretion of adiponectin by human placenta: differential modulation of adiponectin and its receptors by cytokines. Diabetologia 2006; 49:1292-302. [PMID: 16570162 DOI: 10.1007/s00125-006-0194-7] [Citation(s) in RCA: 187] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Accepted: 12/22/2005] [Indexed: 11/28/2022]
Abstract
AIMS/HYPOTHESIS Pregnancy, a state of insulin resistance, is associated with elevated levels of cytokines and profound alterations in metabolism. Serum adiponectin, an adipokine with anti-inflammatory and insulin-sensitising properties, has been shown to be lower in patients with gestational diabetes mellitus, a state of greater insulin resistance than normal pregnancies. Hypothesising that the human placenta is a source of adiponectin, we investigated its expression and secretion, and the regulation by cytokines of adiponectin and its receptors. METHODS Real-time RT-PCR, radioimmunoassay, Western blotting, radioligand binding and immunofluorescent analyses were applied to demonstrate the expression, secretion and functionality of placental adiponectin. RESULTS Adiponectin gene expression and protein were found in the human term placenta, with expression primarily in the syncytiotrophoblast. RIA of conditioned media from explant experiments revealed that the placenta can secrete adiponectin in vitro. Addition of conditioned media to HEK-293 cells transfected with the gene for adiponectin receptor-1 (ADIPOR1) altered the phosphorylation status of extracellular signal-regulated kinase 1/2 and p38 mitogen-activated protein kinase, an effect abolished after preabsorption with adiponectin antibody. Cytokines, including TNF-alpha, IFN-gamma, IL-6 and leptin, differentially modulated placental adiponectin receptors as well as adiponectin gene expression and secretion. Interestingly, in placentae from women with gestational diabetes mellitus, we observed significant downregulation of adiponectin mRNA, significant upregulation of ADIPOR1 expression, and a non-significant increase in ADIPOR2 expression. CONCLUSIONS/INTERPRETATION Our results indicate that the human placenta produces and secretes adiponectin, and that adiponectin and its receptors are differentially regulated by cytokines and their expression altered in women with gestational diabetes mellitus. Collectively, our novel data suggest that adiponectin may play a role in adapting energy metabolism at the materno-fetal interface.
Collapse
Affiliation(s)
- J Chen
- Biomedical Research Institute, Department of Biological Sciences, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
A study has been made of the means by which light influences the gravitropic set-point angle (GSA) of the nodes of Tradescantia and the hypocotyls of the lazy-2 mutant of tomato. In light-grown Tradescantia there is a light-regulated developmental change in the GSA with the magnitude of this change being dependent on the photon flux density of white light. The photosynthetic inhibitor DCMU abolished the effect of white light. Low fluence rates of red light had no significant effect on the GSA of Tradescantia: It was concluded that there is an interaction between photosynthesis and the GSA in Tradescantia: The light-induced reduction of the GSA of the hypocotyl of lazy-2 tomato has previously been assumed to be solely an action of light acting via phytochrome. However, it can be shown that the GSA of hypocotyls of lazy-2 seedlings grown in white light is sensitive to DCMU and norflurazon treatment, hence the light effects on the GSA of an organ can be mediated via both phytochrome and photosynthesis. The implication of these findings to the study of gravitropism is discussed.
Collapse
Affiliation(s)
- J Digby
- Department of Biology, University of York, PO Box 373, York YO1 5YW, UK.
| | | |
Collapse
|
37
|
Digby J, Sutterfield WC, Floresguerra C, Evans JR. Bilateral external iliac and common femoral artery disruptions after blunt trauma. South Med J 2000; 93:1120-1. [PMID: 11095568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Blunt trauma to the external iliac or common femoral artery is relatively rare. Since its original description as the "motor-scooter handlebar syndrome," this type of injury has been hypothesized as resulting from compression of the artery by the inguinal ligament. We report a case of mirror-image arterial injuries from blunt trauma. At operation, each distal external iliac and proximal common femoral artery was found to have large intimal flaps. Resection of the injured segments with bilateral saphenous vein interposition grafts led to a successful outcome.
Collapse
Affiliation(s)
- J Digby
- Department of Surgery, James H. Quillen College of Medicine, East Tennessee State University, Johnson City 37614-0575, USA
| | | | | | | |
Collapse
|
38
|
Digby J, Lewis JV. A case of traumatic fat embolism syndrome without long bone fracture. TENNESSEE MEDICINE : JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION 1999; 92:308-9. [PMID: 10437414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- J Digby
- Department of Surgery, Holston Valley Medical Center, Kingsport, USA
| | | |
Collapse
|
39
|
Affiliation(s)
- R Firn
- Biology Dept, University of York, UK
| | | | | |
Collapse
|
40
|
Abstract
Human omental adipocytes display a range of biochemical properties that distinguish them from adipocytes of subcutaneous origin. However, information about site-related gene expression in human fat cells is limited. We have previously demonstrated that leptin mRNA is markedly overexpressed in abdominal subcutaneous (SC) compared with omental (Om) adipocytes. To further investigate depot-specific differences in adipocyte gene expression, we have measured, in paired samples of isolated human adipocytes obtained from SC and Om fat depots, the expression of mRNAs encoding a number of proteins involved in the control of adipocyte metabolism. In contrast to the marked site-related expression of leptin, genes encoding lipoprotein lipase (LPL), hormone-sensitive lipase (HSL), peroxisome proliferator-activated receptor-gamma (PPAR-gamma), tumor necrosis factor-alpha (TNF-alpha), and adipsin were not consistently differentially expressed. Of note, a highly significant inverse correlation between adipocyte PPAR-gamma expression and BMI (r = -0.7, P = 0.0005) was found. In parallel experiments, differential display was used in an attempt to identify novel and/or unexpected adipocyte genes that were expressed in a site-related manner. No transcript that was unique to one or another depot was found, but cellular inhibitor of apoptosis protein-2 (cIAP2) mRNA, which has not previously been reported in adipocytes, was expressed at higher levels in Om than SC adipocytes (Om > SC in all eight subjects; mean Om:SC ratio 1.9 +/- 0.2, P < 0.01). Because cIAP2 may be involved in the regulation of TNF-alpha signaling, this raises the possibility that depot-specific differences may exist in the regulation of adipocyte apoptosis. Thus, of the mRNAs examined to date, only leptin and cIAP2 show consistent site-related expression, suggesting that these molecules may have important roles in determining functional properties particular to individual adipose depots. Given the importance of PPAR-gamma in adipocyte development and insulin sensitivity, the inverse correlation between adipocyte PPAR-gamma mRNA levels and adiposity may represent a local regulatory mechanism restraining fat accumulation and/or may be related to the reduction of insulin sensitivity that occurs with increasing fat mass.
Collapse
Affiliation(s)
- C T Montague
- Department of Medicine, University of Cambridge, England, UK.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
Two recently described proteins in the mitochondrial uncoupling protein (UCP) family, UCP-2 and UCP-3, have been linked to phenotypes of obesity and NIDDM. We determined the mRNA levels of UCP-2 and UCP-3 in skeletal muscle of NIDDM patients and of healthy control subjects. No difference in the mRNA levels or in the protein expression of UCP-2 was observed between the two groups. In contrast, mRNA levels of UCP-3 were significantly reduced in skeletal muscle of NIDDM patients compared with control subjects. In the NIDDM patients, a positive correlation between UCP-3 expression and whole-body insulin-mediated glucose utilization rate was also noted. These results suggest that UCP-3 regulation may be altered in states of insulin resistance.
Collapse
Affiliation(s)
- A Krook
- Department of Clinical Physiology, Karolinska Hospital, Stockholm, Sweden.
| | | | | | | | | |
Collapse
|
42
|
Abstract
Attempts to devise models to account for the gravitropic behaviour of plant organs have been limited conceptually by the predominance of studies on the gravitropic behaviour of organs of young seedlings. The dramatic growth responses induced by gravitropic stimulation of young shoots or roots, which rapidly restore the elongating axes to vertical, are experimentally convenient but theoretically limiting because gravitropism needs not simply restore an organ to vertical. Evidence is reviewed that suggests that plant organs must possess a mechanism which will allow them to attain a stable gravitropic position at any angle and that each organ has a characteristic gravitropic set-point angle (GSA). The GSA can be changed developmentally and is also regulated in a reversible manner by environmental parameters such as light. It is speculated that gravity may itself influence the GSA of an organ. The recognition that plant organs can grow at angles other than vertically up or down is not new, but previously it has been accepted that angles other than vertical were the consequence of the vectorial resultant effect of two different, opposing mechanisms. The new GSA concept proposes that a single mechanism might be sufficient to account for all forms of gravitropism in roots and shoots. This unifying concept proposes that the ability to change the angle of an organ with respect to the vertical is part of the basic gravitropic mechanism and that models of gravitropism must be able to account for this important feature.
Collapse
Affiliation(s)
- R D Firn
- Department of Biology, University of York, UK.
| | | |
Collapse
|
43
|
Digby J, Firn RD. The gravitropic set-point angle (GSA): the identification of an important developmentally controlled variable governing plant architecture. Plant Cell Environ 1995; 18:1434-40. [PMID: 11543210 DOI: 10.1111/j.1365-3040.1995.tb00205.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The angle at which an organ is maintained by gravitropism is characteristic of the organ, its developmental state and the prevailing environmental conditions. We propose that this angle be called the gravitropic set-point angle (GSA), defined as the angle with respect to the gravity vector (with a vertically downward orientation being 0 degrees) at which an organ is maintained as a consequence of gravitropism. Studies or the gravitropic behaviour of organs from trailing plants show that the GSA is subject to developmental regulation. Depending on the developmental age and prevailing environmental conditions, the GSA of an organ can be set at any value between 0 degrees and 180 degrees. The previously reported reversal of the sign of the gravitropic response in such organs, whether this is brought about developmentally or induced by light, represents the change from one common extreme (GSA = 180 degrees, conventionally referred to as negative orthogravitropism) to another (GSA = 0 degrees, or positive orthogravitropism). The concept of a variable gravitropic set-point offers a more unified view of all forms of gravitropic behaviour than has been advanced previously, and places a new constraint on models of gravitropism. Current models of gravitropism appear to be unable to explain either the ability of organs to change their orientation with respect to gravity as they develop, or the re-orientation that can be observed when some organs are exposed to new environmental conditions.
Collapse
Affiliation(s)
- J Digby
- Department of Biology, University of York, Heslington, UK
| | | |
Collapse
|
44
|
Digby J, Harrison R, Jehanli A, Lunt GG, Clifford-Rose F. Cultured rat spinal cord neurons: interaction with motor neuron disease immunoglobulins. Muscle Nerve 1985; 8:595-605. [PMID: 4047091 DOI: 10.1002/mus.880080709] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Conditions have been developed for the culture of rat spinal cord neurons in serum-free media supplemented with hormones and growth factors. Neurons were identified by immunofluorescence-labeled anti-neurofilament antibody, and their growth was monitored by assay of choline acetyltransferase and cholinesterase activities. Activities of these enzymes were considerably higher than those of comparable cultures in serum supplemented media in which there were visibly many more nonneuronal cells. Serum immunoglobulins from patients with motor neuron disease showed enhanced binding to rat spinal cord cells maintained in both serum-supplemented and serum-free media, as compared with those from normal healthy individuals. Enhanced binding was more marked with the latter cells, presumably because of the higher proportion of neuronal cells in these cultures. Serum immunoglobulins from patients with other neurologic disorders showed a similar binding to that of the normal controls. The results demonstrate the presence of an immune response to spinal cord cell membrane components in patients with motor neuron disease, although whether the response is primary or secondary in the disease process remains unclear.
Collapse
|
45
|
Franssen JM, Firn RD, Digby J. The role of the apex in the phototropic curvature of Avena coleoptiles: positive curvature under conditions of continuous illumination. Planta 1982; 155:281-286. [PMID: 24271860 DOI: 10.1007/bf00429452] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/1981] [Accepted: 03/23/1982] [Indexed: 06/02/2023]
Abstract
The differential growth causing second positive phototropic curvature in intact, black-capped and decapitated Avena coleoptiles has been measured. In all cases the curvature is brought about by a cessation in growth of the illuminated side. The fact that shading the apex does not significantly alter the initial steps of differential growth means that the subapical zones can perceive and respond to unilateral illumination. Decapitation significantly reduces coleoptile growth, especially in the most apical zone. However, the fact that differential growth is still evident in the other zones of decapitated coleoptiles within 30 min of unilateral illumination requires one to conclude that the apex cannot be controlling the differential growth in those basal zones.
Collapse
Affiliation(s)
- J M Franssen
- Department of Biology, University of York, YO1 5DD, York, UK
| | | | | |
Collapse
|
46
|
|
47
|
|
48
|
Firn R, Digby J, Pinsent C. Evidence Against the Involvement of Gibberellins in the Differential Growth which Causes Geotropic Curvature. ACTA ACUST UNITED AC 1977. [DOI: 10.1016/s0044-328x(77)80226-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
49
|
Cooper MJ, Digby J, Cooper PJ. Effects of plant hormones on the stomata of barley: A study of the interaction between abscisic acid and kinetin. Planta 1972; 105:43-49. [PMID: 24477701 DOI: 10.1007/bf00385162] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/1972] [Indexed: 06/03/2023]
Abstract
It is known that kinetin and abscisic acid affect stomatal aperture. A statistically significant interaction between kinetin and abscisic acid at concentrations of abscisic acid between 10(-5) and 10(-6)M is demonstrated for barley. It is suggested from this and other work that the results obtained may only be true for graminaceous species and not for other monocotyledons or for dicotyledons.
Collapse
|
50
|
Abstract
Bioassays of tissue extracts show that high (500-1000 mug/liter) kinetin concentrations which permit growth of tobacco callus cultures on media without added thiamine activate the biosynthesis of this vitamin by the tissues. Although the tissue concentration of thiamine may fall appreciably, it is maintained at a level adequate for survival and slow growth of the cultures, and there is a large net increase in total thiamine content per culture with time. In the second and subsequent passages of tissue on a thiamine free medium, growth is obtained only when high kinetin concentrations are maintained. Effective inhibition of growth by antithiamines suggests that thiamine is utilized by the high-kinetin tissue.In the presence of low (30-100 mug/liter) kinetin concentrations, which would be optimal for growth in the presence of thiamine, growth only occurs early in the first passage of tissue from a medium with the vitamin to one without it. The thiamine concentration in the tissues falls to low levels, and no net biosynthesis is apparent. The tissues turn dark and die after 2 to 3 weeks. In contrast with this, in the absence of both added thiamine and kinetin no appreciable growth occurs, but the tissues keep their normal appearance, retain their thiamine content, and may stay alive for several weeks.
Collapse
Affiliation(s)
- J Digby
- Department of Botany, University of Wisconsin, Madison, Wisconsin
| | | |
Collapse
|