Fecal Hemoglobin Concentration Predicts Risk of Interval Cancers
abstract
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Interval colorectal cancer (CRC) after colonoscopy may affect effectiveness and cost-effectiveness of screening programmes. We aimed to investigate whether and how faecal haemoglobin concentration (FHbC) of faecal immunochemical testing (FIT) affected the risk prediction of interval cancer (IC) caused by inadequate colonoscopy quality in a FIT-based population screening programme.
DESIGN
From 2004 to 2009, 29 969 subjects underwent complete colonoscopy after positive FIT in the Taiwanese Nationwide CRC Screening Program. The IC rate was traced until the end of 2012. The incidence of IC was calculated in relation to patient characteristics, endoscopy-related factors (such adenoma detection rate (ADR)) and FHbC. Poisson regression analysis was performed to assess the potential risk factors for colonoscopy IC.
RESULTS
One hundred and sixty-two ICs developed after an index colonoscopy and the estimated incidence was 1.14 per 1000 person-years of observation for the entire cohort. Increased risk of IC was most remarkable in the uptake of colonoscopy in settings with ADR lower than 15% (adjusted relative risk (aRR)=3.09, 95% CI 1.55 to 6.18) and then higher FHbC (μg Hb/g faeces) (100-149: aRR=2.55, 95% CI 1.52 to 4.29, ≥150: aRR=2.74, 95% CI 1.84 to 4.09) with adjustment for older age and colorectal neoplasm detected at baseline colonoscopy. Similar findings were observed for subjects with negative index colonoscopy.
CONCLUSIONS
Colonoscopy ICs arising from FIT-based population screening programmes were mainly influenced by inadequate colonoscopy quality and independently predicted by FHbC that is associated with a priori chance of advanced neoplasm. This finding is helpful for future modification of screening logistics based on FHbC.
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Additional Info
Faecal Haemoglobin Concentration Influences Risk Prediction of Interval Cancers Resulting From Inadequate Colonoscopy Quality: Analysis of the Taiwanese Nationwide Colorectal Cancer Screening Program
Gut 2015 Oct 29;[EPub Ahead of Print], SY Chiu, SL Chuang, SL Chen, AM Yen, JC Fann, DC Chang, YC Lee, MS Wu, CK Chou, WF Hsu, ST Chiou, HM ChiuFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The United States is one of the few places in the world where colonoscopy is the preferred method for colorectal cancer screening. Over the past few years, with the publication of large, mostly non–United States based studies showing encouraging results using fecal immunochemical tests (FIT) for screening, there has been renewed interest in better understanding the usefulness of that approach. There are quantitative and qualitative FIT tests, although there is a great variability among the latter. Thus, there is growing evidence that high-quality quantitative FIT is the best option. Taking advantage of the use of quantitative FIT tests in the Taiwanese Nationwide Colorectal Cancer Screening Program, and with preliminary data showing that concentrations of fecal hemoglobin (FHb) may correlate with histologic severity of colorectal neoplasms, the authors hypothesized that concentrations of FHb could affect risk prediction of interval cancers caused by inadequate colonoscopy in a FIT-based population screening program. The study confirmed previous findings showing that inadequate quality of colonoscopy, as indicated by a low adenoma detection rate by endoscopists, was the factor most associated with interval cancers. It also showed that higher FHb concentration was also associated with interval cancers and that the higher the concentrations, the more likely the lesions would be advanced. The authors urge us to take these data into consideration and perhaps consider a repeat colonoscopy when high FHb concentrations are found. We may eventually accept that FIT-based screening programs are quite effective, although this may require a more complex algorithm for colorectal cancer screening.