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Increased Uptake and Improved Outcomes of Bowel Cancer Screening With a Fecal Immunochemical Test
TAKE-HOME MESSAGE
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Over a 6-month period, 1 in 28 individuals eligible for bowel cancer screening as part of the Bowel Cancer Screening Programme in England were sent a fecal immunochemical test (FIT) instead of a guaiac-based fecal occult blood test to evaluate the acceptability and performance of the FIT. Overall, uptake increased from 59.3% to 66.4%, and, in previous nonresponders, uptake almost doubled from 12.5% to 23.9%. The increase in uptake was significantly higher in men than in women. Overall FIT positivity was 7.8%. The rate of detection of cancer doubled, and there was a fivefold increase in the detection of advanced adenomas.
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The introduction of the FIT into the screening program led to markedly improved uptake in screening with improved detection of adenomas and cancers. The high rate of positivity will improve cancer detection but will demand more use of colonoscopy.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
The National Health Service Bowel Cancer Screening Programme (BCSP) in England uses a guaiac-based faecal occult blood test (gFOBt). A quantitative faecal immunochemical test (FIT) for haemoglobin (Hb) has many advantages, including being specific for human blood, detecting Hb at a much lower concentration with a single faecal sample and improved uptake.
METHODS
In 2014, a large comparative pilot study was performed within BCSP to establish the acceptability and diagnostic performance of FIT. Over a 6-month period, 40 930 (1 in 28) subjects were sent a FIT (OC-SENSOR) instead of a gFOBt. A bespoke FIT package was used to mail FIT sampling devices to and from FIT subjects. All participants positive with either gFOBt or FIT (cut-off 20 µg Hb/g faeces) were referred for follow-up. Subgroup analysis included cut-off concentrations, age, sex, screening history and deprivation quintile.
RESULTS
While overall uptake increased by over 7 percentage points with FIT (66.4% vs 59.3%, OR 1.35, 95% CI 1.33 to 1.38), uptake by previous non-responders almost doubled (FIT 23.9% vs gFOBt 12.5%, OR 2.20, 95% CI 2.10 to 2.29). The increase in overall uptake was significantly higher in men than women and was observed across all deprivation quintiles. With the conventional 20 µg/g cut-off, FIT positivity was 7.8% and ranged from 5.7% in 59-64-year-old women to 11.1% in 70-75-year-old men. Cancer detection increased twofold and that for advanced adenomas nearly fivefold. Detection rates remained higher with FIT for advanced adenomas, even at 180 µg Hb/g.
CONCLUSIONS
Markedly improved participation rates were achieved in a mature gFOBt-based national screening programme and disparities between men and women were reduced. High positivity rates, particularly in men and previous non-respondents, challenge the available colonoscopy resource, but improvements in neoplasia detection are still achievable within this limited resource.
Additional Info
Increased Uptake and Improved Outcomes of Bowel Cancer Screening With a Faecal Immunochemical Test—Results From a Pilot Study Within the National Screening Programme in England
Gut 2016 Jun 07;[EPub Ahead of Print], S Moss, C Mathews, TJ Day, S Smith, HE Seaman, J Snowball, SP HalloranFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
In spite of some unresolved challenges, particularly relating to the appropriate hemoglobin concentration cutoff for positivity, FIT testing has been proven to be superior to guaiac-based fecal occult blood testing (gFOBt) for colorectal cancer and advanced adenoma detection. Furthermore, some studies have shown more acceptance of FITt, which can result in higher screening rates. Thus, there is currently a movement among population-based colorectal cancer screening programs toward switching from gFOBTt to FITt.
This paper by Moss et al describes a comparative pilot study on participation rates and detection of advanced lesions between gFOBTt and FITt within the National Health Service Bowel Cancer Screening Programme (BCSP) in England. Uptake was on average 7 points higher with FITt, and, importantly, the highest increase was among individuals who had not responded to the invitation with gFOBTt. The final result was a significant increase in detection rate of advanced lesions. While compliance could have been facilitated because FITt is easier to administer, the overall process was also simplified, and this could also have contributed to this better uptake.
While all of this is good, the price to pay was a much higher number of colonoscopies to be performed. Thus, this circles back to the issue of determining a hemoglobin concentration cutoff that detects most advanced adenomas and early cancers without overwhelming the endoscopy capacity of an entire nation.