Interval cancers in a FOBT-based colorectal cancer population screening programme: implications for stage, gender and tumour site

Steele, Robert; McClements, Paula L.; Watling, Christopher; Libby, Gillian; Weller, David; Brewster, David H.; Black, Robert B.; Carey, Francis A.; Fraser, Callum G.

doi:10.1136/gutjnl-2011-300535

Cited by 133 publications

(169 citation statements)

References 26 publications

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“…Since then, recent findings at two academic endoscopy units in North America have indicated that the prevalence of proximal colon serrated lesions in patients undergoing screening colonoscopy in a clinical setting may be higher than previously reported [63] and a significant proportion of proximal serrated lesions may be missed during colonoscopy [64]. Interval cancers have also been associated with proximal location in a population-based screening setting in Europe [65]. These findings also illustrate the importance of the recommendations in the guidelines for routine documentation of the morphology and topography of lesions detected in CRC screening [19,21].…”

Section: Author Manuscriptmentioning

confidence: 95%

European guidelines for quality assurance in colorectal cancer screening and diagnosis: Overview and introduction to the full Supplement publication

Karsa¹,

Patnick²,

Segnan³

et al. 2012

Endoscopy

249

187

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Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines. IntroductionAccording to recent estimates by the International Agency for Research on Cancer [1], colorectal cancer (CRC) is the most common cancer in Europe with 432 000 new cases reported annually in men and women combined. It is the second most common cause of cancer deaths in Europe with 212 000 deaths reported in 2008.Worldwide, CRC ranks third in incidence and fourth in mortality with an estimated 1.2 million cases and 0.6 million deaths annually. In the 27 Member States of the European Union (EU), CRC ranks first in incidence and second in mortality, with approximately 334000 new cases and 149000 deaths estimated in 2008.Even in those Member States in the lower range for age-standardized rates of CRC, the burden of disease is significantly greater when compared with many other HHS Public Access Author Manuscript Author ManuscriptAuthor ManuscriptAuthor Manuscript regions of the world (see reference [1]). CRC is therefore an important health problem across the EU.Screening can be effective in cancer control in populations with a significant burden of CRC, provided the services are of high quality [2]. The aim of CRC screening is to lower the burden of cancer in the population by discovering disease in its early, latent stages [3]. Evidence-based methods permit treatment that is more effective than if disease is diagnosed later when symptoms have occurred. Early treatment of invasive lesions, for example by endoscopic resection of early CRC, can also be less detrimental for quality of life. The endoscopic removal of pre-malignant lesions also reduces the incidence of CRC by avoiding the progression to cancer. Randomized trials in people of average risk invite...

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Section: Author Manuscriptmentioning

confidence: 95%

European guidelines for quality assurance in colorectal cancer screening and diagnosis: Overview and introduction to the full Supplement publication

Karsa¹,

Patnick²,

Segnan³

et al. 2012

Endoscopy

249

187

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“…This raises some concern as it has been found that more women have interval cancers than men in Scotland. 15 Because this is the fourth screening round in NHS Tayside, and most who participate in screening do so regularly 16 , this implies that the current screening strategy misses significant neoplasia and it might be that evolution to an approach that uses an automated quantitative FIT would be of advantage in this regard. 11 Men did, however, have more adenomas of all types than did women.…”

Section: Discussionmentioning

confidence: 99%

Experience with a two-tier reflex gFOBT/FIT strategy in a national bowel screening programme

Fraser

Digby²,

McDonald³

et al. 2011

J Med Screen

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Objectives To evaluate a two-tier reflex guaiac-based faecal occult blood test (gFOBT)/faecal immunochemical test (FIT) algorithm in screening for colorectal cancer. Setting Fourth screening round in NHS Tayside (Scotland). Methods gFOBT were sent to 50-74-year-olds. Participants with five or six windows positive were offered colonoscopy. Participants with one to four windows positive were sent a FIT and, if positive, were offered colonoscopy. Participants providing an untestable gFOBT were sent a FIT and, if positive, were offered colonoscopy. Outcomes following positive results, cancer stages and key performance indicators were assessed. Results Of 131,885 invited, 73,315 (55.6%) responded. There were 66,957 (91.3%) negative, 241 (0.3%) strong positive, 5230 (7.1%) weak positive and 887 (1.2%) untestable results. The 241 participants who had five or six windows positive had more cancers than those positive by other routes: only 3 of the 30 cancers (9.7%) were Dukes' A. Among the 983 positive results from the weak positive gFOBT then positive FIT route, there were fewer cancers and more normal colonoscopies, but more adenomas than in the group with a strong positive gFOBT. In those with an untestable gFOBT, 77 had a positive FIT result, with fewer true and more false positive results than in the other groups. Fewer males had cancer and stages were earlier than in females, but more had adenoma. The detection rate for cancer was 0.18% and the PPV for cancer and all adenomas was 41.3%. Conclusions The algorithm and FIT following a weak positive gFOBT have advantages. FIT following an untestable gFOBT warrants review.

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“…There are few publications on interval cancers but a recent study showed that, of the cancers diagnosed in the screened population, interval cancers comprised 31.2% in the first round, 47.7% in the second and 58.9% in the third: the number of interval cancers increased slightly over screening rounds and, as expected, there was a concomitant decline in the numbers of screen-detected cancers. 47 Thus, gFOBT screening was associated with substantial interval cancer rates that increased with screening round and appears to preferentially detect cancers in men and the left side of the colon at the expense of cancers in women and in the right colon and rectum. Interval cancers are thus commoner in women and it may be that women are considerably disadvantaged by the use of currently available gFOBT.…”

Section: Fraser Faecal Haemoglobin Measurementsmentioning

confidence: 99%

“…50 A number of possible explanations for the gender difference have been postulated. 46,47 Men have higher blood haemoglobin concentrations than women in their reproductive years of life but most women who are screened are probably postmenopausal when such differences are less. It might be that men take more medicines that inhibit clotting or cause gastrointestinal tract bleeding than women.…”

Section: Fraser Faecal Haemoglobin Measurementsmentioning

confidence: 99%

A future for faecal haemoglobin measurements in the medical laboratory

Fraser

2012

Ann Clin Biochem

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Guaiac-based faecal occult blood tests (gFOBT) are still used in asymptomatic population bowel screening programmes but are being replaced by faecal immunochemical tests (FIT) for haemoglobin. gFOBT have many well-documented disadvantages and there is little evidence for their use in assessment of the symptomatic. Many laboratories have eliminated gFOBT from their approved repertoires by invoking the authoritative published guidelines. Data continue to accumulate that gFOBT are obsolete. FIT are available in two formats, qualitative and quantitative, the latter having advantages that the faecal haemoglobin concentrations are measured and cut-off concentrations that stimulate further investigation can be user-defined. There is growing evidence that FIT would be useful in a spectrum of clinical settings in addition to screening. All laboratories should have FIT in their existing repertoire. For some uses, qualitative FIT would be adequate. However, much evidence has accumulated that measurements of faecal haemoglobin concentrations are beneficial for the assessment of both disease severity and the future risk of colorectal neoplasia. Interpretation requires appreciation that faecal haemoglobin concentrations are higher in men than women and rise with age. It might well be that risk scoring systems that take gender and age into account, possibly with other factors including symptoms, will benefit individuals. Laboratories should consider how quantitative faecal haemoglobin measurements could be brought into routine practice and included in their forward planning. External quality assessment is needed. Specialists in laboratory medicine are urged to play a significant role in the research and development still required to make this a truly mature investigation.

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Interval cancers in a FOBT-based colorectal cancer population screening programme: implications for stage, gender and tumour site

Cited by 133 publications

References 26 publications

European guidelines for quality assurance in colorectal cancer screening and diagnosis: Overview and introduction to the full Supplement publication

European guidelines for quality assurance in colorectal cancer screening and diagnosis: Overview and introduction to the full Supplement publication

Experience with a two-tier reflex gFOBT/FIT strategy in a national bowel screening programme

A future for faecal haemoglobin measurements in the medical laboratory

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