High Rate of Advanced Adenoma Detection in 4 Rounds of Colorectal Cancer Screening With the Fecal Immunochemical Test

doi:10.1016/j.cgh.2012.02.030

Clinical Gastroenterology and Hepatology

Volume 10, Issue 6, June 2012, Pages 633-638

https://doi.org/10.1016/j.cgh.2012.02.030 Get rights and content

Background & Aims

Few data have been published on the performance of colorectal cancer (CRC) screens that use multiple rounds of the fecal immunochemical test (FIT). We evaluated outcomes of 4 screening rounds in over 7 years in an Italian population-based program.

Methods

We conducted a prospective cohort study of 2959 average-risk subjects, aged 50–74 years, who were invited for the first screening round in 2001. We assessed the participation rate, the yield of advanced adenomas and CRC detected in the screening examinations, and we collected information about interval CRCs, with a follow-up period of 8.5 years.

Results

Participation in each round varied from 56% to 63%; 48.1% of eligible subjects attended all 4 invitations. The positive predictive value of the FIT for advanced neoplasia (CRC or advanced adenoma) was 40% at the first round, and approximately 33% in the subsequent rounds. This decrease was attributable mainly to a decrease in the detection of CRC, although a high rate of advanced adenomas (range, 0.8%–1.7%) was observed over all rounds. To find one advanced neoplasia in the study period the number of people that needed to be screened was 28, and the number of tests needed was 74.

Conclusions

About 60% of invited individuals participated in every single round of FIT screening for CRC, but less than 50% attended all 4 tests. A high detection rate of advanced adenomas in all rounds indicates that FIT screening could have a higher impact on incidence of CRC than the guaiac fecal occult blood test.

Section snippets

Study Population

We conducted a prospective cohort study among people enrolled in a population-based screening program for CRC, in the municipalities of Chatillon and St. Vincent, in the Aosta Valley Region in Italy. In these two municipalities, a pilot study was started in 2001 and repeated in 2003, aimed at evaluating the feasibility of a program using biennial FIT.¹⁰ All subjects enrolled in the pilot study in 2001 and 2003 were invited again (if still eligible) in 2006 and 2008, in the context of the

Results

In October 2001, of 9800 inhabitants residing in the study area, 3145 people aged 50–74 years were identified through the Regional Health Service register. After excluding 186 subjects that GPs considered as being ineligible, 2959 people were invited to participate in the first screening round. As seen in Figure 1, 1862 people (62.9% of the initial cohort) were eligible to be invited in the fourth round in 2008. This reduction of the target population reflects mainly the progressive aging of

Discussion

The information concerning the performance of FIT screening over several rounds still is limited. We actively studied an average-risk population cohort, invited in 4 screening rounds, using an automated quantitative FIT. We observed a high response rate at each invitation, ranging between 56% and 63%, but the proportion of subjects who complied with all the recommended testing protocol was less than 50%. Fewer cases of CRCs were detected among people with previous negative test results, whereas

Acknowledgments

The authors are grateful to Guido Castiglione, Dario Conte, Grazia Grazzini, Ernst J. Kuipers, Roberto Penagini, and Manuel Zorzi for advice and discussion.

This was an observational study monitoring the quality indicators of a fecal occult blood screening program, according to the guidelines approved by the World Health Organization and the Italian Health Ministry. At a local level, organizational, logistic, and performance indicators are monitored by a Technical Committee (approved by Regione

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Cited by (107)

Benefit-Harm Analysis for Informed Decision Making on Participating in Colorectal Cancer Screening: A Modeling Study
2024, Value in Health
To facilitate informed decision making on participating in colorectal cancer (CRC) screening, we assessed the benefit-harm balance of CRC screening for a wide range of subgroups over different time horizons.
The study combined incidence proportions of benefits and harms of (not) participating in CRC screening estimated by the Adenoma and Serrated pathway to CAncer microsimulation model, a preference eliciting survey, and benefit-harm balance modeling combining all outcomes to determine the net health benefit of CRC screening over 10, 20, and 30 years. Probability of net health benefit was estimated for 210 different subgroups based on age, sex, previous participation in CRC screening, and lifestyle.
CRC screening was net beneficial in 183 of 210 subgroups over 30 years (median probability [MP] of 0.79, interquartile range [IQR] of 0.69-0.85) across subgroups. Net health benefit was greater for men (MP 0.82; IQR 0.69-0.89) than women (MP 0.76; IQR 0.67-0.83) and for those without history of participation in previous screenings (MP 0.84; IQR 0.80-0.89) compared with those with (MP 0.69; IQR 0.59-0.75). Net health benefit decreased with increasing age, from MP of 0.84 (IQR 0.80-0.86) at age 55 to 0.61 (IQR 0.56-0.71) at age 75. Shorter time horizons led to lower benefit, with MP of 0.70 (IQR 0.62-0.80) over 20 years and 0.54 (IQR 0.48-0.67) over 10 years.
Our benefit-harm analysis provides information about net health benefit of screening participation, based on important characteristics and preferences of individuals, which could assist screening invitees in making informed decisions on screening participation.
Socio-demographic and cultural factors related to non-participation in the Dutch colorectal cancer screening programme
2023, European Journal of Cancer
High participation rates are essential for a screening programme to be beneficial. To reach non-participants in a targeted manner, insight in characteristics of non-participants is needed. We investigated demographic differences between participants and non-participants in the Dutch faecal immunochemical test-based colorectal cancer (CRC) screening programme.
In this population-based cohort study, we included all invitees for CRC screening in 2018 and 2019. Participation status, birth year, and sex were extracted from the Dutch national screening information system and linked to demographic characteristics from Statistics Netherlands, including migration background, level of education, socioeconomic category, household composition, and household income. A multivariable logistic regression was used to assess the association between demographic factors and participation.
A total of 4,383,861 individuals were invited for CRC screening in 2018 and 2019, of which 3,170,349 (72.3%) participated. Individuals were less likely to participate when they were single and/or living with others (single with other residents versus couple: odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.31–0.38), had a migration background (e.g. Moroccan migrant versus Dutch background: OR 0.43, 95% CI: 0.42–0.44), or had a low income (lowest versus highest quintile: OR 0.45, 95% CI: 0.44–0.45). Although to a lesser extent, non-participation was also significantly associated with being male, being younger, receiving social welfare benefits and having a low level of education.
We found that individuals who were single and/or living with others, immigrants from Morocco or individuals with low income were the least likely to participate in the Dutch CRC screening programme. Targeted interventions are needed to minimise inequities in CRC screening.
Randomized Trial of Facilitated Adherence to Screening Colonoscopy vs Sequential Fecal-Based Blood Test
2023, Gastroenterology
Colorectal cancer (CRC) screening guidelines include screening colonoscopy and sequential high-sensitivity fecal occult blood testing (HSgFOBT), with expectation of similar effectiveness based on the assumption of similar high adherence. However, adherence to screening colonoscopy compared with sequential HSgFOBT has not been reported. In this randomized clinical trial, we assessed adherence and pathology findings for a single screening colonoscopy vs sequential and nonsequential HSgFOBTs.
Participants aged 40–69 years were enrolled at 3 centers representing different clinical settings. Participants were randomized into a single screening colonoscopy arm vs sequential HSgFOBT arm composed of 4–7 rounds. Initial adherence to screening colonoscopy and sequential adherence to HSgFOBT, follow-up colonoscopy for positive HSgFOBT tests, crossover to colonoscopy, and detection of advanced neoplasia or large serrated lesions (ADN-SERs) were measured.
There were 3523 participants included in the trial; 1761 and 1762 participants were randomized to the screening colonoscopy and HSgFOBT arms, respectively. Adherence was 1473 (83.6%) for the screening colonoscopy arm vs 1288 (73.1%) for the HSgFOBT arm after 1 round (relative risk [RR], 1.14; 95% CI, 1.10–1.19; P ≤ .001), but only 674 (38.3%) over 4 sequential HSgFOBT rounds (RR, 2.19; 95% CI, 2.05–2.33). Overall adherence to any screening increased to 1558 (88.5%) in the screening colonoscopy arm during the entire study period and 1493 (84.7%) in the HSgFOBT arm (RR, 1.04; 95% CI, 1.02–1.07). Four hundred thirty-six participants (24.7%) crossed over to screening colonoscopy during the first 4 rounds. ADN-SERs were detected in 121 of the 1473 participants (8.2%) in the colonoscopy arm who were adherent to protocol in the first 12 months of the study, whereas detection of ADN-SERs among those who were not sequentially adherent (n = 709) to HSgFOBT was subpar (0.6%) (RR, 14.72; 95% CI, 5.46–39.67) compared with those who were sequentially adherent (3.3%) (n = 647) (RR, 2.52; 95% CI, 1.61–3.98) to HSgFOBT in the first 4 rounds. When including colonoscopies from HSgFOBT patients who were never positive yet crossed over (n = 1483), 5.5% of ADN-SERs were detected (RR, 1.50; 95% CI, 1.15–1.96) in the first 4 rounds.
Observed adherence to sequential rounds of HSgFOBT was suboptimal compared with a single screening colonoscopy. Detection of ADN-SERs was inferior when nonsequential HSgFOBT adherence was compared with sequential adherence. However, the greatest number of ADN-SERs was detected among those who crossed over to colonoscopy and opted to receive a colonoscopy. The effectiveness of an HSgFOBT screening program may be enhanced if crossover to screening colonoscopy is permitted. ClinicalTrials.gov, Number: NCT00102011.
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.
Optimizing screening with faecal immunochemical test for both sexes - Cost-effectiveness analysis from Finland
2022, Preventive Medicine
A faecal immunochemical test (FIT) screening pilot was introduced in Finland in 2019 with sex-specific screening strategies. This study aims to model cost-effectiveness of sex-specific strategies for the whole population, and to assess whether the current strategies are optimal.
We developed separate MISCAN-Colon models, including different FIT performances, for the Finnish men and women using the first-year data of the FIT screening pilot. We evaluated 180 FIT strategies varying in FIT cut-off, screening interval, age to start, and age to stop screening, and compared them to no-screening by sex. We used incremental cost-effectiveness ratios (ICERs) to identify the optimal strategy after combining all male and female strategies and restricting the analysis by costs and referral rate to diagnostic colonoscopies.
Offering annual FIT screening with a cut-off of 25 μg/g at 50–79 years in men and with a cut-off of 10 μg/g at 55–69 years in women was optimal. This combined strategy prevented 28% of colorectal cancer (CRC) cases and 55% of CRC deaths with acceptable costs (ICER = 9000€/life-years gained). Screening at the current target age of 60–74 years was suboptimal for both sexes. Among strategies with the same target age and interval for both sexes, expected benefits from optimal screening were lower but still reasonable.
Our results support a wider age range of screening in men, and a lower cut-off for a positive test in women when restrictions on colonoscopy capacity and costs are in place. National FIT screening program should start at younger age.
Results of Compliant Participation in Five Rounds of Fecal Immunochemical Test Screening for Colorectal Cancer
2021, Clinical Gastroenterology and Hepatology
We investigated the magnitude and temporal patterns of the decreasing trend in main performance measures of fecal immunochemical test (FIT) screening for colorectal cancer (CRC) observed in second and subsequent rounds.
We followed up 494,187 participants from the first round of a regional biennial FIT screening program in Italy (cut-off value for positivity, 20 μg hemoglobin/g feces) for 5 total rounds (2005–2016). At each round, only compliant participants were eligible. Performance measures from the first, third, fourth, and fifth rounds were compared with those from the second round (the first incidence round) using rate ratios from multivariate Poisson regression models and relative risk ratios from multinomial logistic regression models.
Between the second and the third rounds, a significant 20% to 30% decrease was found in the proportion of men with a positive FIT result (from 5.2% to 4.3%) and in detection rates of advanced adenoma (from 13.4 to 10.2 per 1000), CRC (from 1.7 to 1.4 per 1000), and advanced neoplasia (from 15.1 to 11.6 per 1000). Positive predictive values (PPVs) decreased by 10% or less between the second and third rounds. Detection rates and PPVs for adenoma stabilized by the fourth and fifth rounds. The PPVs for advanced adenoma, CRC, and advanced neoplasia decreased slightly in men and women by the fourth and fifth rounds. The detection rate of proximal colon cancer stabilized after the second round, whereas the detection rate of distal colon cancer decreased until the fourth round in men (from 0.7 to 0.3 per 1000), and the fifth round in women.
These findings support the notion that FIT screening prevents progression of a subset of advanced adenomas. Screening intensity could be modulated based on results from previous rounds, with a risk-based strategy.

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: Conflicts of interest The authors disclose no conflicts.

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Original article—alimentary tractHigh Rate of Advanced Adenoma Detection in 4 Rounds of Colorectal Cancer Screening With the Fecal Immunochemical Test

Background & Aims

Methods

Results

Conclusions

Section snippets

Study Population

Results

Discussion

Acknowledgments

Gastroenterology

Gastroenterology

Lancet

Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update

Am J Gastroenterol

The effect of fecal occult-blood screening on the incidence of colorectal cancer

N Engl J Med

Screening for colorectal cancer in Italy: 2008 survey

Epidemiol Prev

A quantitative immunochemical fecal occult blood test for colorectal neoplasia

Ann Intern Med

Comparison of a guaiac based and an immunochemical faecal occult blood test in screening for colorectal cancer in a general average risk population

Gut

Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy

Gut

Screening for colorectal neoplasms with new fecal occult blood tests: update on performance characteristics

J Natl Cancer Inst

Original article—alimentary tract
High Rate of Advanced Adenoma Detection in 4 Rounds of Colorectal Cancer Screening With the Fecal Immunochemical Test