Comparing Attendance and Detection Rate of Colonoscopy With Sigmoidoscopy and FIT for Colorectal Cancer Screening

doi:10.1053/j.gastro.2007.03.030

Gastroenterology

Volume 132, Issue 7, June 2007, Pages 2304-2312

https://doi.org/10.1053/j.gastro.2007.03.030 Get rights and content

Background & Aims: We conducted a study to estimate population coverage and detection rate (DR) achievable through different strategies of colorectal cancer (CRC) screening. Methods: A population-based multicenter randomized trial comparing 3 strategies was used: (1) biennial immunologic fecal occult blood test (FIT), (2) “once only” sigmoidoscopy (FS), and (3) “once only” colonoscopy (TC). A random sample of men and women, aged 55 to 64 years, was drawn from general practitioners’ (GP) rosters. Eligible subjects, randomized within GP, were mailed a personal invitation. Nonresponders in groups 2 and 3 were invited again at 12 and 24 months. Screenees with “high-risk” distal polyps (villous component >20%, high-grade dysplasia, CRC, size ≥10 mm, >2 adenomas) at FS, or with positive FIT, were referred for TC. Results: The attendance rate was 32.3% (1965/6075) for FIT, 32.3% (1944/6018) for FS, 26.5% (1597/6021) for TC. FIT detected 2 patients with CRC (0.1%) and 21 with an advanced adenoma (1.1%). The corresponding figures were as follows: 12 (0.6%) and 86 (4.5%) patients, respectively, for FS; 13 (0.8%) and 100 (6.3%) patients, respectively, for TC. To detect 1 advanced neoplasm, it would be necessary to invite 264 people with FIT, 60 with FS, 53 with TC. FS would have detected 27.3% of the proximal advanced neoplasms detected at TC. Assuming the same participation rate at TC as at FS, 48 TCs would be necessary to detect 1 additional advanced neoplasm missed by FS. Conclusions: When participants are offered 1 screening test, participation is lower in a TC than in an FS program. However, DR of advanced neoplasia is higher with TC.

Section snippets

Study Design

The study was conducted between October 2002 and January 2004 in 6 centers in Italy (Biella, Firenze, Milano, Rimini, Torino, and Verona), following the same design adopted in a previous population-based, multicenter, randomized, controlled trial of different screening strategies.¹⁶ Approval of the study was obtained by the local ethics review committees. Briefly, in each participating center, we draw a population sample from the general practitioners’ (GP) rosters or the population registers,

Recruitment and Randomization

Of 20,042 subjects aged 55 to 64 years listed in the rosters of the 172 GPs included in the study, 1595 (8.0%) were excluded and 18,447 were randomized (Figure 1). The proportion of randomized subjects by gender in each group corresponded to the demographic structure of the source population.²⁵ On the contrary, the age distribution is shifted toward the younger age group.

Attendance

The attendance rate was calculated over the 18,114 persons who received the invitation letter, after excluding 333 subjects

Discussion

This is the first large trial comparing uptake and neoplasia yield of TC with other recommended screening methods—FS and FIT—in an average risk population. Overall, approximately 30% of the people invited were screened. To increase the participation in screening programs, time is needed to allow for the diffusion of the reputation of the program and of the awareness of the advantages and disadvantages of the proposed intervention at the community level. On the other hand, the degree of GPs’

References (30)

S.J. Winawer et al.
Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society
Gastroenterology
(2006)
D.K. Rex et al.
Prospective determination of distal colon findings in average risk patients with proximal colon cancer
Gastrointest Endosc
(1999)
W.S. Atkin et al.
Prevention of colorectal cancer by once-only sigmoidoscopy
Lancet
(1993)
H. Nakama et al.
A cost-effective analysis of the optimum number of stool specimens collected for immunochemical occult blood screening for colorectal cancer
Eur J Cancer
(2000)
A.R. Neilson et al.
Determinants of persistent compliance with screening for colorectal cancer
Soc Sci Med
(1995)
Ministero della sanità. Linee Guida elaborate dalla Commissione Oncologica Nazionale, in applicazione di quanto...
M. Zorzi et al.
Screening for colorectal cancer in Italy: survey 2004
Epidemiol Prev
(2006)
P. Rozen et al.
Comparative screening with a sensitive guaiac and specific immunochemical occult blood test in an endoscopy study
Cancer
(2000)
D.A. Aalquist et al.
Stool screening for colorectal cancer: evolution from occult blood to molecular markers
Clin Chim Acta
(2002)
D.A. Lieberman et al.
One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon
N Engl J Med
(2001)

D.A. Lieberman et al.

Use of colonoscopy to screen asymptomatic adults for colorectal cancer

N Engl J Med

(2000)

T.F. Imperiale et al.

Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings

N Engl J Med

(2000)

D.K. Podolsky

Going the distance—the case for true colorectal cancer screening

N Engl J Med

(2000)

J.C. Clark et al.

Prevalence of polyps in an autopsy series from areas with varying incidence of large-bowel cancer

Int J Cancer

(1985)

Cited by (237)

Cost Effectiveness of Mailed Outreach Programs for Colorectal Cancer Screening: Analysis of a Pragmatic, Randomized Trial
2022, Clinical Gastroenterology and Hepatology
Clinical guidelines for colorectal cancer (CRC) screening suggest use of either stool-based tests or colonoscopy – modalities that differ in recommended screening intervals, adherence, and costs. We know little about the long-term cost differences in population-health outreach strategies to promote these strategies.
We conducted a cost-effectiveness analysis to compare 2 mailed outreach strategies to increase CRC screening from a pragmatic, randomized clinical trial: mailed fecal immunochemical test (FIT) kits vs invitations to complete a screening colonoscopy. We built a 10-year Markov chain Monte Carlo microsimulation model to account for differences in screening intervals, adherence, and costs.
Mailed FIT kits had a lower 10-year average per-person cost of screening relative to colonoscopy invitations ($1139 vs $1725) but with 10.89 fewer months of compliance and 60 fewer advanced neoplasia detected (37 advanced adenomas and 23 CRC). Incremental cost effectiveness ratios for colonoscopy invitations compared with mailed FIT kits were $55.23, $15.84, and $25.48 per additional covered month, advanced adenoma, and CRC, respectively. Although FIT was the preferred strategy at low willingness-to-pay thresholds, the 2 strategies were equal at a willingness-to-pay threshold of $41.31 per covered month gained.
Mailed FIT or colonoscopy invitations are both options to improve CRC screening completion and advanced neoplasia detection, and the choice of outreach strategy may differ by a health system’s willingness-to-pay threshold. Mailed FIT kits are less expensive than colonoscopy invitations but result in fewer months of screening compliance and advanced neoplasia detected.
Pooled rates of adenoma detection by colonoscopy in asymptomatic average-risk individuals with positive fecal immunochemical test: a systematic review and meta-analysis
2022, Gastrointestinal Endoscopy
Current adenoma detection rate (ADR) benchmarks for colonoscopy in individuals positive for a fecal immunochemical test (FIT) are ≥45% in men and ≥35% in women. These are based on weak, low-quality evidence. We performed a meta-analysis to ascertain the pooled ADR in FIT-positive colonoscopy.
Major databases like PubMed, EMBASE, and Web of Science were searched in October 2021 for studies reporting on ADR of colonoscopy in a FIT-positive population. Meta-analysis was performed by standard methodology using the random-effects model. Heterogeneity was assessed by I² and 95% prediction interval statistics.
Thirty-four high-quality studies that included more than 6 million asymptomatic average-risk individuals were analyzed; 2,655,345 individuals completed a screening FIT test. The pooled FIT screening rate was 69.8% (95% CI, 62.8-76.1), the pooled FIT positivity rate was 5.4% (95% CI, 4.3-6.9), and the colonoscopy completion rate was 85% (95% CI, 82.8-86.9). The pooled ADR was 47.8% (95% CI, 44.1-51.6), pooled advanced ADR was 25.3% (95% CI, 22-29), and the pooled colorectal cancer detection rate was 5.1% (95% CI, 4.4-5.9). The pooled ADR in men was 58.3% (95% CI, 52.8-63.6) and in women was 41.9% (95% CI, 36.4-47.6). The pooled ADR with qualitative FIT assessment was 67.7% (95% CI, 50.7-81), with 1-stool sample FIT was 52.8% (95% CI, 48.8-56.8), and at a cutoff threshold of 100 ng hemoglobin/mL was 52.1% (95% CI, 47-57.1). Based on time-period cumulative analysis, the ADR improved over time from 30.5% (95% CI, 24.6-37.2) to 47.8% (95% CI, 44.1-51.6).
This meta-analysis supports the current ADR benchmarks for colonoscopy in FIT-positive individuals. Excellent pooled ADR parameters were demonstrated with qualitative assessment of 1 stool sample at a test cutoff value of 100 ng hemoglobin/mL, and ADR per endoscopist improved over time.
Novel Quality Measure Set: Closing the Completion Loop on Radiology Follow-up Recommendations for Noncritical Actionable Incidental Findings
2022, Journal of the American College of Radiology
Care gaps occur when radiology follow-up recommendations are poorly communicated or not completed, resulting in missed or delayed diagnosis potentially leading to worse patient outcomes. This ACR-led initiative assembled a technical expert panel (TEP) to advise development of quality measures intended to improve communication and drive increased completion rates for radiology follow-up recommendations.
A multistakeholder TEP was assembled to advise the development of quality measures. The project scope, limited to noncritical actionable incidental findings (AIFs), encourages practices to develop and implement systems ensuring appropriate communication and follow-up to completion.
A suite of nine measures were developed: four outcome measures include closing the loop on completion of radiology follow-up recommendations for nonemergent AIFs (with pulmonary nodule and abdominal aortic aneurysm use cases) and overall cancer diagnoses. Five process measures address communication and tracking of AIFs: inclusion of available evidence or guidelines informing the recommendation, communication of AIFs to the practice managing ongoing care, identifying when AIFs have been communicated to the patient, and employing tracking and reminder systems for AIFs.
This ACR-led initiative developed a measure set intended to improve patient outcomes by ensuring that AIFs are appropriately communicated and followed up. The intent of these measures is to focus improvement on specific areas in which gaps in communication and AIF follow-up may occur, prompting systems to devote resources that will identify and implement solutions to improve patient care.
Effectiveness and Harms of Colorectal Cancer Screening Strategies
2022, Gastrointestinal Endoscopy Clinics of North America
Evaluating key characteristics of ideal colorectal cancer screening modalities: the microsimulation approach
2021, Gastrointestinal Endoscopy
Screening for colorectal cancer (CRC) can effectively reduce CRC incidence and mortality. Besides colonoscopy, tests for the detection of biomarkers in stool, blood, or serum, including the fecal immunochemical test (FIT), ColoGuard, Epi proColon, and PolypDx, have recently been advanced. We aimed to identify the characteristics of theoretic, highly efficient screening tests and calculated the effectiveness and cost effectiveness of available screening tests.
Using the microsimulation-based colon modeling open-source tool (CMOST), we simulated 142,501 theoretic screening tests with variable assumptions for adenoma and carcinoma sensitivity, specificity, test frequency, and adherence, and we identified highly efficient tests outperforming colonoscopy. For available screening tests, we simulated 10 replicates of a virtual population of 2 million individuals, using epidemiologic characteristics and costs assumptions of the United States.
Highly efficient theoretic screening tests were characterized by high sensitivity for advanced adenoma and carcinoma and high patient adherence. All simulated available screening tests were effective at 100% adherence to screening and at expected real-world adherence rates. All tests were cost effective below the threshold of 100,000 U.S. dollars per life year gained. With perfect adherence, FIT was the most effective and cost-efficient intervention, whereas Epi proColon was the most effective at expected real-world adherence rates. In our sensitivity analysis, assumptions for patient adherence had the strongest impact on effectiveness of screening.
Our microsimulation study identified characteristics of highly efficient theoretic screening tests and confirmed the effectiveness and cost-effectiveness of colonoscopy and available urine-, blood-, and stool-based tests. Better patient adherence results in superior effectiveness for CRC prevention in the whole population.
Participation in Competing Strategies for Colorectal Cancer Screening: A Randomized Health Services Study (PICCOLINO Study)
2021, Gastroenterology
Primary colonoscopy and fecal immunochemical testing (FIT) are considered first-tier tests for colorectal cancer (CRC) screening. Although colonoscopy is considered the most efficacious test, FIT might achieve higher participation rates. It is uncertain what the best strategy is for offering population-wide CRC screening.
This was a multicenter randomized health services study performed within the framework of the Polish Colonoscopy Screening Program between January 2019 and March 2020 on screening-naïve individuals. Eligible candidates were randomly assigned in a 1:1:1 ratio to participate in 1 of 3 competing invitation strategies: control (invitation to screening colonoscopy only); sequential (invitation to primary colonoscopy and invitation for FIT for initial nonresponders); or choice (invitation offering a choice of colonoscopy or FIT). The primary outcome was participation in CRC screening within 18 weeks after enrollment into the study. The secondary outcome was diagnostic yield for advanced neoplasia.
Overall, 12,485 individuals were randomized into the 3 study groups. The participation rate in the control group (17.5%) was significantly lower compared with the sequential (25.8%) and choice strategy (26.5%) groups (P < .001 for both comparisons). The colonoscopy rates for participants with positive FITs were 70.0% for the sequential group and 73.3% for the choice group, despite active call-recall efforts. In the intention-to-screen analysis, advanced neoplasia detection rates were comparable among the control (1.1%), sequential (1.0%), and choice groups (1.1%).
Offering a combination of FIT and colonoscopy as a sequential or active choice strategy increases participation in CRC screening. Increased participation in strategies with FIT do not translate into higher detection of advanced neoplasia. ClinicalTrials.gov, Number NCT03790475.

View all citing articles on Scopus

: Supported by a grant from the Italian League against Cancer (LILT); and by the Istituto Oncologico Romagnolo (IOR), the Fondo “E Tempia,” the University of Milan, the ULSS 20, and the Piedmont Regional Health Authority for implementation of the study in Rimini, Biella, Milan, Verona, and Turin, respectively; and by SOFAR s.p.a. for providing the enemas for the bowel preparation.

: All authors declare that they have no conflict of interest to disclose.

View full text

Clinical–alimentary tractComparing Attendance and Detection Rate of Colonoscopy With Sigmoidoscopy and FIT for Colorectal Cancer Screening

Section snippets

Study Design

Recruitment and Randomization

Attendance

Discussion

Gastroenterology

Gastrointest Endosc

Lancet

Eur J Cancer

Soc Sci Med

Screening for colorectal cancer in Italy: survey 2004

Epidemiol Prev

Comparative screening with a sensitive guaiac and specific immunochemical occult blood test in an endoscopy study

Cancer

Stool screening for colorectal cancer: evolution from occult blood to molecular markers

Clin Chim Acta

One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon

N Engl J Med

Use of colonoscopy to screen asymptomatic adults for colorectal cancer

N Engl J Med

Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings

N Engl J Med

Going the distance—the case for true colorectal cancer screening

N Engl J Med

Prevalence of polyps in an autopsy series from areas with varying incidence of large-bowel cancer

Int J Cancer

Clinical–alimentary tract
Comparing Attendance and Detection Rate of Colonoscopy With Sigmoidoscopy and FIT for Colorectal Cancer Screening