Use Of Fecal Occult Blood Testing Research Articles

De-implementation of Fecal Occult Blood Testing in the Emergency Department and Hospital Units: A Quality Improvement Project.

Fecal occult blood tests (FOBT) are inappropriately used in patients with melena, hematochezia, coffee ground emesis, iron deficiency anemia, and diarrhea. The use of FOBT for reasons other than screening for colorectal cancer is considered low-value and unnecessary. Quality Improvement Project that utilized education, Best Practice Advisory (BPA) and modification of order sets in the electronic health record (EHR). The interventions were done in a sequential order based on the Plan-Do-Study-Act (PDSA) method. An annotated run chart was used to analyze the collected data. Education and Best Practice Advisory within the EHR led to significant reduction in the use of FOBT in the ED. The interventions eventually led to a consensus and removal of FOBT from the order set of the EHR for patients in the ED and hospital units. The use of electronic BPA, education and modification of order sets in the EHR can be effective at de-implementing unnecessary tests and procedures like FOBT in the ED and hospital units.

S706 Assessing the Use of the Fecal Occult Blood Tests in a Community Hospital

Introduction: Fecal occult blood tests (FOBTs) have been used as a tool for detecting occult blood in stool for colon cancer screening. Increasingly, FOBT has been utilized by clinicians to detect gastrointestinal (GI) bleeding in the hospital setting without evidence supporting its use. Furthermore, a false positive FOBT can lead to excessive patient harm in the form of unnecessary testing, patient anxiety, prolonged hospital stay, and financial hardship. In this study, we looked at the use of FOBTs, relevant specialist consults, and further endoscopic interventions in the inpatient setting. Methods: Our search criteria included patient demographics, length of stay, admission diagnosis, specialty consulted, FOBT ordering provider, FOBT results, intervention performed, and total blood volume ordered. Patient data was gathered using Epic Workbench. Data were analyzed using SPSS. Frequencies of age, sex, race, and length of stay were calculated. Descriptive statistics were obtained to compare FOBT results with the number of procedures and specialist consults. Pearson chi-square was used in the analysis of statistical significance. Results: Over one year, a total of 742 patients received a FOBT while inpatient: 411 females and 333 males; predominantly white (97.3%) with a median age of 71. A total of 433 FOBTs were positive, of which 27 resulted in a colonoscopy and 46 in gastroscopy. Consults to specialty services were placed on 222 positive FOBT results and 187 negative FOBT results. Overall, FOBT did have a significant impact on whether an invasive intervention, such as colonoscopy or gastroscopy, was performed (p < 0.001). FOBT results were not statistically associated with consults placed (p < 0.5). (Figure) Conclusion: Despite questionable benefits, the use of FOBTs has extended to inpatient and emergency department settings. Reasons for use included anemia, GI bleeds, abdominal pain, melena, and emesis. Two studies looked at the use of FOBTs in the community hospital setting and both found that FOBTs were used for non-evidence-based indications and did not offer any clinical benefit. Data analysis from our study revealed that of the 433 patients with a positive FOBT, only 73 did underwent an intervention. Consequently, the results of a FOBT do not appear to play a large role in deciding further intervention. In order to increase patient benefit and decrease healthcare burden, we plan to further this work by implementing provider education on the uses of FOBT and reporting on the color of stool samples. (Table)Figure 1.: Graphical representation of specialist consults placed compared with positive and negative FOBT results. Blue bars represent number of FOBTs with a consult and orange bars represent number of FOBTs without a consult. Table 1. - Comparison of FOBT with procedures completed Colonoscopy Esophagogastroduodenoscopy No scope Total Occult blood Positive 27 46 360 433 Negative 5 7 297 309 Total 32 53 657 742

S1508 Pathway to Eliminating Fecal Occult Blood Testing at a Tertiary Care Center

Introduction: The United States Preventive Services Task Force (USPSTF) recommends fecal occult blood testing as one method for colorectal cancer screening in average risk people. However, the test is often used inappropriately for other indications in admitted patients, leading to unnecessary procedures, false reassurance, and wasted health care dollars. We performed a retrospective review to determine the indications for inpatient fecal occult blood tests (FOBT) and their impact on clinical outcomes at a tertiary care center. Methods: Our goal was to characterize the current inpatient FOBT ordering patterns at our tertiary care center. We reviewed all the inpatient FOBT ordered between Jan 2018 and Jan 2021 and characterized them based on the ordering department. Internal Medicine (IM) was the most common ordering department. We then conducted a chart review of every fourth IM patient that had an FOBT ordered during the study period. We identified characteristics such as chief complaint, ordering team, indication, the result of the test, if a patient went on to endoscopy, and hemoglobin at the time of test. Results: Out of 1,446 total orders, IM ordered the most FOBT with 632 tests, followed by family medicine at 369 tests, and cardiology with 135 tests. Among the 158 IM charts reviewed, the most common ordering team was the admission triage team. Ninety percent of tests were ordered by non-teaching teams vs 10% ordered by teaching teams. The IM-ordered tests had a positivity rate of 54% and anemia was the most common indication. The average hemoglobin at time of testing was 8.5 g/dl. Twenty four percent of patients had signs of overt GI bleeding. In the absence of overt GI bleeding, only 23% of positive FOBT tests led to an inpatient endoscopy (Figure 1). The proportion of those who underwent endoscopy was higher in those who presented with symptoms of overt GI bleeding than those who did not (56% vs 10%). Conclusion: Our retrospective study highlights that inpatient FOBT are often utilized in the management of anemia in hospitalized patients. Most tests were ordered by non-teaching teams. In the absence of overt bleeding, a positive inpatient FOBT rarely led to endoscopy. Use of FOBT in the inpatient setting is a low value practice. We plan to conduct a further root cause analysis using physician interviews to understand reasoning for inpatient use of this test and design interventions to eliminate inpatient FOBT at our hospital.Figure 1.: Flow diagram detailing which patients went on to endoscopy.

Utilization of a Colorectal Cancer Screening Test Among Individuals With Average Risk

Colorectal cancer (CRC) screening reduces CRC incidence and mortality. It is important to examine screening patterns over time, including after the introduction of new screening modalities. To compare use of CRC screening tests before and after the availability of the multitarget stool DNA (mt-sDNA) test, given that endorsed options have changed. This longitudinal cohort study used administrative claims data to examine CRC screening use in 2 discrete periods: before (August 1, 2011, to July 31, 2014) and after (August 1, 2016, to July 31, 2019) the mt-sDNA test became available. The MarketScan Commercial and Medicare Supplemental databases were queried for individuals aged 45 to 75 years between August 1, 2011, and July 31, 2019, with average risk of CRC and with continuous enrollment in the databases from August 1, 2001, to July 31, 2019. The proportion of individuals up to date or not due for CRC screening during each measurement year and the type of screening test used among individuals due for screening. Data were reported overall and among individuals aged 45 to 49 or 50 years and older on August 1, 2011. A total of 97 776 individuals with average risk were identified. Individuals had a mean (SD) age of 50.8 (3.5) years, and 54 227 (55.5%) were women. The proportion of individuals with average risk aged 50 to 75 years with commercial or Medicare supplemental insurance who were up to date with CRC screening increased from 50.4% in 2011 (30 605 of 60 770) to 69.7% in 2019 (42 367 of 60 770). Among individuals due for screening and screened, the use of high-sensitivity fecal occult blood test (FOBT) decreased between 2011 (1088 of 6241 eligible individuals [17.7%]) and 2019 (195 of 2943 eligible individuals [6.6%]), and the use of mt-sDNA increased between 2016 (58 of 3014 eligible individuals [1.9%]) and 2019 (418 of 2943 eligible individuals [14.2%]). No consistent trends were observed with fecal immunochemical test (FIT) or screening colonoscopy. Computed tomography colonography, double-contrast barium enema, and flexible sigmoidoscopy were rarely performed. In this cohort study, the proportion of individuals with average risk who were up to date with CRC screening increased between 2011 and 2019 but remained suboptimal. There were no substantial changes in the use of the colonoscopy or FIT; however, there was an increase in the adoption of mt-sDNA and a decrease in the use of FOBT during the study period.

S1228 Fecal Occult Blood Testing Associated With Delayed Hospital Discharge: A Quality Improvement Study

INTRODUCTION: Fecal occult blood testing (FOBT) is a cheap test that is commonly used in outpatient and inpatient settings. The primary purpose of FOBT is to screen for colorectal cancer in an outpatient setting, as recommended by the US preventive services task force. FOBT inpatient use has not been validated. On the contrary, many reports advise against the inpatient use of FOBT. The impact of performing FOBT on hospitalization outcomes such as length of stay has (LOS) been sufficiently studied in literature. We aimed to assess whether our inpatient use of FOBT is associated with increased LOS in hospitalized patients with GI bleeding or iron deficiency anemia. METHODS: Adult inpatients from January 2016 until June 2020 with ICD-10-CM diagnoses pertaining to GI bleeding and/or iron deficiency anemia were included. The primary outcome was LOS. The secondary outcome was mortality. Variables were compared between FOBT ordered VS not ordered and FOBT positive VS negative. Standard statistical tests using Chi-square, Student t-test, Mann-Whitney U test, survival analysis, and multivariate linear regression were used. RESULTS: 4401 hospitalizations with GI bleeding and/or iron deficiency anemia were included. Mean age was 66 ± 16 years. Females represented 56.4%. GI bleeding was present in 2551 (58%) hospitalizations while iron deficiency anemia in 2256 (51.3%). FOBT was ordered in 832 (18.9%) and performed in 540 (12.3%). Ordering FOBT was associated with increased LOS (median 5.5 VS 4.4, P < 0.01) and no reduction in inpatient mortality (Table 1). Figure 1 illustrates that patients with FOBT-ordered stay longer in hospital prior to discharge. Positive FOBT occurred in 401 (74%) of performed tests. Patients with positive FOBT had higher mortality compared to negative FOBT (3.7% VS 0%, P = 0.02) (Table 2). CONCLUSION: FOBT is not indicated for inpatient settings. Although a positive FOBT result is associated with higher mortality, ordering FOBT should not delay obtaining early gastroenterology consultation and endoscopic treatment if indicated. Educational interventions should be implemented to decrease inappropriate inpatient use of FOBT testing.Table 1.: Comparison of baseline characteristics and outcomes based on FOBT order statusFigure 1.: A survival analysis plot comparing hospital discharges based on FOBT order status.Table 2.: Comparison of hospitalization outcomes based on FOBT test results

Fecal Occult Blood Tests in Colorectal Cancer Screening: Systematic Review and Meta-analysis of Traditional and New-generation Fecal Immunochemical Tests.

Noninvasive fecal occult blood tests (FOBTs) are recommended by current guidelines for colorectal cancer (CRC) screening. Our aim was to assess the diagnostic performance of traditional guaiac-based FOBTs (gFOBT) and new-generation immunochemical FOBTs (iFOBT) in CRC screening by carrying out a systematic review and meta-analysis. PubMed, Embase, Cochrane Library, and Web of Science were searched for eligible articles published before February 17, 2020. Three independent investigators conducted study assessment and data extraction. Diagnosis-related indicators for use of FOBTs in the detection of CRC (as the endpoint) in a screening setting were summarized, and further stratified by the type of FOBT (gFOBT vs. iFOBT). STATA software was used to conduct the meta-analysis. Pooled sensitivities and specificities were calculated using a random-effects model. Hierarchical summary receiver operating characteristic curves were plotted and area under the curves (AUC) were calculated. The electronic search identified 573 records after duplicates were removed, of which 75 full-text articles were assessed for eligibility. Finally, a total of 31 studies were eligible for the meta-analysis. In the ROC comparison test, there was a statistically significant difference in the performance of gFOBT and iFOBT tests, with AUC=0.77 (95% confidence intervaI=0.75-0.79) and AUC=0.87 (95% confidence intervaI=0.85-0.88), respectively (p=0.0017). In formal meta-regression, test brand did not prove to be a significant study-level covariate that would explain the observed heterogeneity between the studies. New-generation iFOBTs were found to have a significantly higher diagnostic performance as compared with gFOBTs, advocating the use of only fecal immunochemical tests in all newly implemented CRC screening programs.

Changes in colorectal cancer screening use after introduction of alternative screening offer in Germany: Prospective cohort study.

In October 2002, screening colonoscopy was added to the German colorectal cancer (CRC) screening program as an alternative to fecal occult blood test (FOBT). We aimed to evaluate the change in CRC screening use after introduction of the dual screening offer and to assess determinants of screening use. Data were drawn from a population-based cohort study initiated during 2000-2002 in Germany (n = 5,845, age range at recruitment: 50-75 years). We conducted both cross-sectional and longitudinal analyses to obtain uptake rates of CRC screening based on four waves of data. Age-group specific proportions of participants having had FOBT within 2 years remained essentially unchanged at 61-67% between 2000 and 2002 (1st wave) and 2005-2007 (3rd wave). The proportions of participants having undergone screening colonoscopy within 10 years increased from 23-29% to 46-57%, leading to a substantial overall increase in being up-to-date with CRC screening from 66-68% to 77-80%. In 2008-2010 (4th wave), FOBT use declined and colonoscopy use continued to increase. Obesity was significantly associated with lower prevalence of being up-to-date with FOBT (odds ratio [OR] at 8-year follow-up 0.68; 95% confidence interval [CI], 0.58-0.80) and screening colonoscopy (OR, 0.73; 95% CI, 0.62-0.86). Also, smokers were less likely to have ever used FOBT (OR, 0.54; 95% CI, 0.40-0.75) or colonoscopy (OR, 0.75; 95% CI, 0.63-0.90) compared to nonsmokers. After the introduction of dual screening offer, the overall adherence to CRC screening steeply increased, mainly due to an increase in screening colonoscopy uptake. Screening tests kept being underused by obese people and smokers who are at elevated CRC risk.

Fecal Occult Blood Tests

Purpose/Objectives The purpose of this program was to deimplement the use of fecal occult blood tests (FOBTs) for hospitalized patients. Description of the Project/Program We used a multipronged multidisciplinary approach to deimplement the use of FOBT, including physician-nurse collaborations, data-based poster displays, and a review of test utilization and patient cost throughout all facilities. Outcome Despite a downward trend in FOBT orders for hospitalized patients over 3 years, the inappropriate use of FOBT remains a cause of unnecessary delays of diagnostic workups and patient care and excess costs ranging from US $22 000 to $41 000 annually for each hospital. Conclusion Clinical nurse specialists can question the empirical origin and patient outcomes associated with clinical practice and are positioned to assess and champion deimplementation processes.

Trends in colonoscopy and fecal occult blood test use after the introduction of dual screening offers in Germany: Results from a large population-based study, 2003–2016

An increasing number of countries have recently introduced colorectal cancer (CRC) screening programs. Typically, one specific screening exam, such as fecal occult blood test (FOBT) or flexible sigmoidoscopy, is offered as a primary screening test. We aimed to assess trends in FOBT and colonoscopy use in Germany following the introduction of the offer of screening colonoscopy as an alternative to FOBT in 2002. We used data from 4052 control participants aged 50–79 years recruited during 2003–2016 for a population-based case-control study in Germany. Prevalence of FOBT and colonoscopy lifetime and recent use was analyzed and trends over time were examined. The percentage of all respondents who had ever undergone a colonoscopy (for either screening or diagnostic purpose) increased markedly over time from 44.6% in 2003–2005 to 57.5% in 2013–2016 (p < 0.0001). Large increases were also observed for colonoscopy use within 10 years (from 38.0% to 52.8%, p < 0.0001), whereas FOBT uptake within one to two years declined from 54.0% to 33.3%. By 2013–2016, 67.2% of respondents either had an FOBT within one to two years or a colonoscopy within 10 years, and this percentage had remained relatively stable over time. This study demonstrates a large increase in colonoscopy utilization since colonoscopy was included as an alternative primary screening test, which was accompanied by a substantial decline in FOBT use. Although the overall adherence to CRC screening recommendations remained stable, the substantial shift of share from FOBT to colonoscopy is expected to yield more protection against CRC incidence and mortality.

Utilization of Colorectal Cancer Screening among Saudi Elderly Population: A Study from the Saudi National Survey for Elderly Health

Objective:The goal of this study was to measure colorectal cancer screening (CRCS) utilization in Saudi Arabia ’s elderly population and to assess the factors associated with CRCS.Methods:The Saudi National Survey for Elderly Health was used to examine CRCS utilization. It is a nationally representative population-based cross-sectional survey that was conducted between 2006-2007. Utilization of CRCS was defined as any colonoscopy during the last five years or fecal occult blood test (FOBT) during the twelve months before the interview. Multivariable logistic regression was used to assess patients’ demographics, co-morbidities, number of visits to primary health clinics, and hospital availability and accessibility impact on CRCS.Results:The prevalence of CRCS utilization among Saudi elderly population was 5.64%. The fecal occult blood test was done in 4.4% of subjects while scope use was performed in 0.55%. In addition, 0.69% of patients have gone through both FOBT and scope use. Having blood in stools (OR=2.80; 95%CI: 1.3-6.00), Self-drivers (OR= 2.52) private driver (OR=2.1; 95%CI: 1.15-3.7) having 4 or more visits to primary care centers 1.81 (95%CI: 1.14-2.86) were positively associated with CRCS utilization. On the other hand, being single was negatively associated with CRCS utilization.Conclusion:In this nationally representative sample CRCS prevalence was very low. According to our findings and in the context of the burden of colorectal cancer on the population, we recommend developing national evidence-based policies and programs that take in consideration easiness of transportation and the availability of primary care centers near to Saudi elderly population.

Estudio de validez diagnóstica de la prueba de hemorragia oculta fecal en lactantes con proctocolitis alérgica inducida por proteína alimentaria

Food protein-induced allergic proctocolitis (FPIAP) is the most frequent presenta tion of non-IgE mediated food allergy (FA). The diagnosis is made by oral food challenge, however, non-invasive diagnostic tests are not available. In Chile, the fecal occult blood test (FOBT) is fre quently used to confirm FPIAP, however, there are no studies that support this practice. To establish the diagnostic validity of FOBT in the evaluation of infants with FPIAP. Case-control study with prospective recruitment of infants with rectal bleeding and suspicion of FPIAP, and controls were healthy infants, in whom the FOBT was conducted. All cases underwent an elimination diet, after which the diagnosis of FPIAP was confirmed by oral food cha llenge. 25 cases and 29 controls were included without significant differences in age, gen der, type of delivery, feeding, and maternal age. The cases had higher rates of allergic comorbidities, medication use, and family history of allergy. The FOBT was positive in 84% of cases and in 34% of controls (p < 0.001). The sensitivity of the FOBT for the diagnosis of FPIAP was 84%, specificity was 66%, positive predictive value 68%, and the negative predictive value 83%. The area under the ROC curve was 0.75 (CI 95% 0.61-0.88). Although the FOBT has an adequate sensitivity to diagnose FPIAP in infants with rectal bleeding, this test had abnormal results in more than a third of healthy infants. Therefore, the routine use of FOBT is not recommended for the diagnosis of FPIAP.

Utilization of fecal occult blood test in the acute hospital setting and its impact on clinical management and outcomes.

Background:Despite lack of evidence supporting the use of fecal occult blood test (FOBT) in the acute hospital setting, FOBT is commonly used in the inpatient setting for reasons other than colorectal cancer (CRC) screening.Aims:To evaluate practice trends in utilizing FOBT on inpatients and its impact on affecting clinical management and outcomes.Materials and Methods:A cross-sectional study of consecutive adult patients undergoing FOBT from January 1, 2011 to December 31, 2011 during an acute medical admission at a large urban safety net hospital was performed. Indications for FOBT, and the impact of FOBT results on endoscopic procedures performed and clinical outcomes were assessed. The number of inpatient endoscopic procedures before and after discontinuing inpatient FOBT was also assessed.Results:A total of 207 inpatient FOBTs were performed in 2011. The most common reason cited for FOBT was anemia (36%, n = 74) followed by gastrointestinal (GI) bleeding (27%, n = 55). Interestingly, 23% (n = 47) of the patients undergoing inpatient FOBT had overt GI bleeding. As expected, patients with positive FOBT were significantly more likely to undergo endoscopic examinations (P < 0.01). After discontinuing the availability of inpatient FOBT, patients were less likely to undergo endoscopic examinations [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.75-0.85].Conclusion:Inappropriate utilization of FOBT in the inpatient setting is common, even when the indication does not support its use. Setting limitations on inpatient FOBT may reduce the inappropriate utilization of inpatient FOBT. Quality improvement initiatives are needed to educate clinicians on the appropriate use of FOBT, which is primarily for average risk CRC screening.

Longitudinal Rates of Colon Cancer Screening Use in Winnipeg, Canada: The Experience of a Universal Health-Care System with an Organized Colon Screening Program.

OBJECTIVES:We examined trends in colorectal cancer (CRC) screening (fecal occult blood test (FOBT), colonoscopy, and flexible sigmoidoscopy (FS)) and differences in CRC screening by income in a population with an organized CRC screening program and universal health-care coverage.METHODS:Individuals who had an FOBT, colonoscopy, or FS were identified from the provincial Physician Claims database and the population-based colon cancer screening registry. Trends in age-standardized rates were determined. Logistic regression was performed to explore the association between CRC screening and income quintiles by year.RESULTS:Up-to-date CRC screening (FOBT, colonoscopy, or FS) increased over time for men and women, all age groups, and all income quintiles. Up-to-date CRC screening was very high among 65- to 69- and 70- to 74-year-olds (70% and 73%, respectively). There was a shift toward the use of an FOBT for CRC screening for individuals in the lower income quintiles. The disparity in colonoscopy/FS coverage by income quintile was greater in 2012 than in 1995. Overall, there was no reduction in disparities by income in up-to-date CRC screening nor did the rate of increase in up-to-date CRC screening or FOBT use change after the introduction of the organized provincial CRC screening program.CONCLUSIONS:CRC screening is increasing over time for both men and women and all age groups. However, a disparity in up-to-date CRC screening by income persisted even with an organized CRC screening program in a universal health-care setting.

Sa1513 Evaluation of Fecal Occult Blood Testing in the Acute Hospital Setting

Despite lack of evidence supporting the use of fecal-occult blood testing (FOBT) in the acute hospital setting, FOBT is commonly used for reasons other than colorectal cancer screening.

Rates and correlates of potentially inappropriate colorectal cancer screening in the Veterans Health Administration.

Inappropriate use of colorectal cancer (CRC) screening procedures can inflate healthcare costs and increase medical risk. Little is known about the prevalence or causes of inappropriate CRC screening. Our aim was to estimate the prevalence of potentially inappropriate CRC screening, and its association with patient and facility characteristics in the Veterans Health Administration (VHA) . We conducted a cross-sectional study of all VHA patients aged 50 years and older who completed a fecal occult blood test (FOBT) or a screening colonoscopy between 1 October 2009 and 31 December 2011 (n = 1,083,965). Measures included: proportion of patients whose test was classified as potentially inappropriate; associations between potentially inappropriate screening and patient demographic and health characteristics, facility complexity, CRC screening rates, dependence on FOBT, and CRC clinical reminder attributes. Of 901,292 FOBT cases, 26.1 % were potentially inappropriate (13.9 % not due, 7.8 % limited life expectancy, 11.0 % receiving FOBT when colonoscopy was indicated). Of 134,335 screening colonoscopies, 14.2 % were potentially inappropriate (10.4 % not due, 4.4 % limited life expectancy). Each additional 10 years of patient age was associated with an increased likelihood of undergoing potentially inappropriate screening (ORs = 1.60 to 1.83 depending on screening mode). Compared to facilities scoring in the bottom third on a measure of reliance on FOBT (versus screening colonoscopy), facilities scoring in the top third were less likely to conduct potentially inappropriate FOBTs (OR = 0.,78) but more likely to conduct potentially inappropriate colonoscopies (OR = 2.20). Potentially inappropriate colonoscopies were less likely to be conducted at facilities where primary care providers were assigned partial responsibility (OR = 0.74) or full responsibility (OR = 0.73) for completing the CRC clinical reminder. A substantial number of VHA CRC screening tests are potentially inappropriate. Establishing processes that enforce appropriate screening intervals, triage patients with limited life expectancies, and discourage the use of FOBTs when a colonoscopy is indicated may reduce inappropriate testing.

Use of Biomarkers in Screening for Cancer.

Screening for premalignant lesions or early invasive disease has the potential to reduce mortality from cancer. Because of their ease of measurement, several biomarkers have been evaluated or are currently undergoing evaluation as screening tests for early malignancy. These include the use of AFP in screening for hepatocellular cancer in high-risk subjects, CA 125 in combination with transvaginal ultrasound (TVU) in screening for epithelial ovarian cancer, PSA in screening for prostate cancer, faecal occult blood testing (FOBT) in screening for colorectal cancer (CRC) and vanillymandelic acid and homovanillic acid in screening for neuroblastoma in newborn infants, Of these biomarkers, only the use of FOBT in screening for CRC has unequivocally been shown to reduce mortality from cancer. Although 2 large randomized prospective trials have evaluated PSA as a screening test for prostate cancer, it is still unclear whether the benefits outweigh the harms in this setting. Although biomarkers have many attractive features as cancer screening tests, lack of sensitivity and specificity, when combined with the low prevalence of specific cancer types in asymptomatic subjects, limit their application for the early detection of malignancy.

Cost-effectiveness of colorectal cancer screening protocols in urban Chinese populations.

Colorectal cancer (CRC) takes a second and fourth position in the incidence and mortality lists respectively among all malignant tumors in urban populations in China. This study was designed to evaluate the cost-effectiveness of two different CRC screening protocols: faecal occult blood test (FOBT) alone, and FOBT plus a high-risk factor questionnaire (HRFQ) as the respective initial screens, followed by colonoscopy. We developed a Markov model to simulate the progression of a cohort of 100,000 average risk asymptomatic individuals moving through a defined series of states between the ages of 40 to 74 years. The parameters used for the modeling came from the CESP (Comparison and Evaluation of Screening Programs for Colorectal Cancer in Urban Communities in China) study and published literature. Eight CRC screening scenarios were tested in the Markov model. The cost-effectiveness of CRC screening under each scenario was measured by an incremental cost-effectiveness ratio (ICER) compared with a scenario without CRC screening. The study revealed that a combined use of FOBT and HRFQ is preferable in CRC screening programs as an initial screening instrument. Annual FOBT+HRFQ screening is recommended for those who have a negative initial result and those who have a positive result but have failed to continue to colonoscopic examination. Repeated colonoscopy (for those with a positive result in initial screening but a negative colonoscopy result) should be performed at a ten-year interval instead of one-year. Such a protocol would cost 7732 Yuan per life year saved, which is the most cost-effective option. In conclusion, the current Chinese Trial Version for CRC Screening Strategy should be revised in line with the most cost-effective protocol identified in this study.

More on Fecal Occult Blood Test Misuse

The current issue of the Journal includes a study by Narula et al (1) (pages 421–426) that nicely demonstrates the numerous reasons why fecal occult blood test (FOBT) use outside of screening purposes should be considered inappropriate and how it may, in fact, negatively impact patient care. The authors performed a chart review of all FOBTs ordered in Hamilton Health Sciences’ (Hamilton, Ontario) acute care campuses over a three-month period in 2011, combined with a survey of health care providers on their practices regarding the use of FOBT. Use of point-of-care FOBT was not included. The clinical presentations were anemia, overt or suspected gastrointestinal (GI) bleeding, diarrhea, iron deficiency and dyspepsia. Thirty-four percent of patients underwent ≥2 FOBTs, and the majority of tested patients were either on medications or on a diet that could interfere with the test. Only 50% of the FOBT positives were ever referred for a GI consultation and, most importantly, 27% of patients presenting with overt GI bleeding in whom an FOBT was ordered experienced a delay in the GI referral because of the FOBT process. The survey included 67 health care professionals (mainly primary care physicians and nurses); the most common reasons for ordering an FOBT were: symptoms potentially consistent with GI bleeding (84%); anemia (53%); iron deficiency with or without anemia (31%); overt GI blood loss (26%); and nonbloody diarrhea (10%). Interestingly, screening for colorectal cancer was a cited reason in only 25% of the cases.

Effectiveness of an organized colorectal cancer screening program on increasing adherence in asymptomatic average-risk Canadians

BackgroundColorectal cancer (CRC) is the third most commonly diagnosed cancer and second highest cause of cancer-related mortality in Canada. Despite the availability of screening services and establishment of guidelines, utilization of colorectal cancer screening in Canada remains low. In 2008, the province of Ontario launched ColonCancerCheck, an organized colorectal cancer screening program aimed at increasing CRC screening adherence. In this study, we adopt a quasi-experimental approach to estimate and describe the impact of ColonCancerCheck on screening behavior in the asymptomatic average risk population.MethodsAnnual screening rates from the target population were estimated using five cycles of the Canadian Community Health Survey, a cross-sectional nationally representative survey of health status, healthcare use, and determinants of health in the Canadian population. We used a difference-in-differences design to measure the overall impact of ColonCancerCheck on past-year fecal occult blood testing (FOBT) and endoscopy in Ontario relative to the rest of Canada. Several verification tests validated the suitability of our model specification.ResultsThe difference-in-differences analysis shows that ColonCancerCheck increased FOBT screening in the average risk population by 5.2 percentage points (95% CI [3.2, 7.2]), an increase of 33% relative to pre-program screening rates. The program had no observed effect on endoscopy screening and we found no evidence that ColonCancerCheck differentially altered the screening practices of population sub-groups.ConclusionsOur findings suggest ColonCancerCheck has been successful at increasing use of FOBT in the asymptomatic average risk population.

Limited Clinical Utility of the Fecal Occult Blood Test for Evaluation of Gastrointestinal Bleed in Hospitalized Patients

Purpose: Fecal occult blood test (FOBT) is widely used for colorectal cancer screening in an outpatient setting. There is little data on whether an inpatient FOBT will guide clinical management. This is a study evaluating the clinical effectiveness of an inpatient FOBT to predict significant endoscopic lesions in the setting of a gastrointestinal (GI) bleed. Methods: We reviewed laboratory and endoscopic reports from hospitalized patients with FOBT performed over one year at a single university-based medical center. Statistical analysis was performed using the Chi Square test and multivariate regression analysis to determine whether the use of inpatient FOBT can predict significant endoscopic lesions. Results: A total of 575 anemic patients were checked for a guaiac-based FOBT during admission. Patient characteristics included ages 19-94 years (mean 58), 327 men, and 248 women. A total of 167 GI consults were placed and 119 patients underwent 182 endoscopies (89 EGD, 63 colonoscopy, and 30 flexible sigmoidoscopy). Among 67 overt GI bleeding patients, 79% were found to have positive endoscopic findings predominantly with high risk stigmata. Of those with positive endoscopic findings, 60.5% were FOBT positive and 41.5% were FOBT negative, clinically non-significant between the two groups (p=0.52). Among 52 suspected occult GI bleeding patients, FOBT and iron deficiency anemia status were not significantly different in predicting a clinically significant endoscopic lesion. On multivariate regression analysis, the strongest predictor for an endoscopic lesion was the presence of a low hemoglobin (OR 1.67; 95% CI 1.08-2.56; p<0.05). On the other hand, a positive FOBT correlated with an 80% probability of less positive endoscopic lesions (OR 0.20; 95% CI 0.04-0.95; p<0.05). Regardless of the FOBT status, the presence of GI symptoms coupled with abnormal imaging has a high predictive value of 64% for clinically significant endoscopic lesions. Conclusion: In our study, there is limited utility of checking FOBT in the inpatient setting. It is potentially harmful in a clinically overt GI bleeding patient. Thus, inpatient FOBT should not be checked in an overt GI bleeding patient with the potential for false negatives which may delay endoscopic intervention. Limitations of checking an inpatient FOBT in a suspected occult GI bleeding patient stem from high rates of false positives due to lack of strict dietary and medication adherence. Nonetheless, gastrointestinal symptoms coupled with an abnormal imaging and severe anemia is the most important predictor of a clinically significant endoscopic finding. Future prospective and randomized controlled trials are needed to determine if there is any role for FOBT in an inpatient setting.