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Patricia L. Raymond MD FACG 
Assistant Professor of Clinical Internal Medicine, 
Eastern Virginia Medical School 
what the...
Sponsored by an educational grant from Hemosure Inc.
We will cover: 
… and perhaps change the tools you use 
to detect blood in stool & colorectal cancer. 
Screening 
verses 
...
On the road to poopville
-rationale for screening for colorectal cancer 
-the polyp-cancer sequence 
-American College of Gastroenterology 
2008 gu...
We do a poor job preventing colorectal cancer. 
142,820 dx in 2013 
American Cancer Society estimates
Colon Cancer 
Statistics 
Second leading cause of cancer deaths in the US 
142,820 diagnosed, 50,830 deaths estimated for ...
Polyp-Cancer Sequence 
8-12 years 
estimated for 
polyp to 
become cancer 
Already a cancer: 
Stage 0 Carcinoma in situ 
S...
Stage= Survival 
Early detection = 5 year survival 
>90% if local stage 
69% if to regional lymph nodes 
20% if to distant...
ACG 2008 guidelines – it’s been five years, people! 
Changes in 2008 guidelines from the 2000 ACG 
recommendations for scr...
ACG 2008 : Preferred CRC screening recommendations 
• Cancer prevention tests should be 
offered first. The preferred CRC ...
Time to discard stool guaiac? 
“ ACG supports the joint guideline recommendation that 
older guaiac-based fecal occult blo...
I’ve got job security. Detection verses prevention. 
FIT for those who 
refuse colonoscopy.
ACS guidelines on colorectal cancer screening & surveillance 
Starting at age 50 years, men and women should 
undergo one ...
American Cancer Society guidelines 
Method DescriptionNotes 
Flexible sigmoidoscopy 
Flexible, lighted, tubelike video cam...
ACS guidelines on increased CRC risk 
US Pharmacist. 2012;37(12):22-26. 
Colorectal Cancer Screening Guidelines Update M S...
ACS guidelines on high CRC risk 
US Pharmacist. 2012;37(12):22-26. 
Colorectal Cancer Screening Guidelines Update M Steinb...
It’s working!
More uninsured, so they get stool testing 
at least, right? 
http://www.examiner.com/article/free-health-care-101-where-to...
-causes of false-positives with guaiac-based 
FOBT(gFOBT) 
- how immunochemical FOBT (iFOBT 
or FIT) works 
-the future of...
Albert Einstein 
Everything should be made as 
simple as possible, but not simpler.
Standard Guaiac testing 
Peroxidase reaction with hemoglobin 
turns guaiac impregnated paper blue 
Hemoccult sensa is more...
Dietary restrictions– who actually follows them? 
Restrictive diet advised 
• high fiber diet x 2 days 
• no red meat 
• n...
Food peroxidases & guaiac testing 
In vivo study, N = 61 
Peroxidase challenge diet for three days 
with 750 g of raw pero...
If it is human blood, where from? 
• Mouth and dental 
• Esophagus 
• Stomach 
• Small intestine 
• Colon 
• Anal 
Image f...
CRC mortality reduced by 33% at 13 
years (annual gFOBT)and 21 % at 18 
years (biennial gFOBT) 
2% Guaiac + patients had c...
Modern stool testing today: iFOBT (FIT) 
More specific than guaiac testing 
Respond only to human globin 
• No false + for...
iFOBT (FIT) major advantages over traditional gFOBT 
No diet or medication restrictions 
Increased specificity with high 
...
Using stool guaiac (gFOBT) is like using 
Laennec’s stethoscope (1819)… 
Image from http://www.homeopathyworldcommunity.co...
Future fecal DNA testing (sDNA) 
• CRC sheds DNA, mutations may be 
tested 
• Commercially available sDNA test off 
market...
-logistics of iFOBT (FIT) 
testing 
-compliance 
-outcomes in population-based 
prevention studies 
How does this work?
How FIT testing is done
How FIT testing is done: poking the poop
In your office
Positive: Occult blood is detected in the 
stool sample. Please consult a doctor 
Negative: No occult blood is detected in...
Compliance with FIT 
• No diet change 
• No multiple samples 
• No chasing stool in toilet with 
popsicle stick 
Now you c...
Sealed with a iFOBT 
Belgium 2009, N=19,542 
Random mailings verses GP advice 
42.1% overall participation (8229 fecal sam...
Sealed with a iFOBT (2) 
• Women > Men (OR 1.22, p<0.001) 
• Residential (OR=1.98) and rural 
(OR=2.90) > urban 
– 8229 se...
Population based studies 
Belgium 
Mail compliance vs. GP 
Brazil 
Population screening 
Netherlands 
Higher participation...
IMMUNOLOGICAL FECAL OCCULT BLOOD 
TEST ON THE SCREENING FOR 
COLORECTAL CANCER IN A BRAZILIAN 
TOWN – PRELIMINARY RESULTS ...
FIT Brazilians 
FIT positive in 390 (10.7%) 
exams 
Out of the 245 patients with 
positive result and referred to 
colonos...
Participation rate FIT > gFOBT 
In a randomized trial in 
the Netherlands 
comparing Hemoccult 
II (guaiac-based), a 
quan...
gFOBT + 2.8% 
FIT + 4.8% 
FFS + 10.2%. 
Detection of 
advanced neoplasia 
was significantly 
higher in the FIT 
(2.4%; OR,...
FIT: More sensitive with less bleeding lesions 
N=20 322 , tested with gFOBT and 
FIT 
At least 1 positive test in 1615, 
...
“…use of low-dose aspirin compared with no 
aspirin was associated with a markedly higher 
sensitivity for detecting advan...
INVITING TRAGEDY
Remember: + FIT needs colonoscopy
? Questions… 
Please ask! 
Patricia Raymond MD FACG
Learn more: Resources 
» Guidelines for Colorectal Cancer Screening 2008 - 
American College of Gastroenterology 
» www.s3...
Learn more: Selected Resources 
» ACG & Cancer Detection Testing with FIT 
Nakajima M , Saito H , Soma Y et al. Prevention...
Patricia L. Raymond MD FACG 
Assistant Professor of Clinical Internal Medicine, 
Eastern Virginia Medical School 
what the...
Just what is their stool telling you?
What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
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What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm

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Everyone needs a colonoscopy at 50 for colorectal cancer prevention, but what if…they simply refuse? They can’t afford it due to insurance issues? We seem to have forgotten that the updated ACG guidelines of 2009 for first time recommend use of annual stool FIT testing as “the preferred cancer detection test” if colonoscopy was not available or refused. How does FIT differ from our venerable stool guaiac testing? And is it finally time to discard gFOBT (AKA guaiac testing) as an insensitive and nonspecific diagnostic tool? Join our conversation and see how FIT testing fits our current screening guidelines, your patients’ financial limitations, and your excellent medical care.

Published in: Health & Medicine
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What Their Poo Can Tell You: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm

  1. 1. Patricia L. Raymond MD FACG Assistant Professor of Clinical Internal Medicine, Eastern Virginia Medical School what their stool can tell you: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
  2. 2. Sponsored by an educational grant from Hemosure Inc.
  3. 3. We will cover: … and perhaps change the tools you use to detect blood in stool & colorectal cancer. Screening verses detection gFOBT, iFOBT, & the future iFOBT compliance & outcomes
  4. 4. On the road to poopville
  5. 5. -rationale for screening for colorectal cancer -the polyp-cancer sequence -American College of Gastroenterology 2008 guidelines -screening (colonoscopy) -detection (FIT test) -American Cancer Society 2012 guidelines
  6. 6. We do a poor job preventing colorectal cancer. 142,820 dx in 2013 American Cancer Society estimates
  7. 7. Colon Cancer Statistics Second leading cause of cancer deaths in the US 142,820 diagnosed, 50,830 deaths estimated for 2013 Early detection = 5 year survival >90% if local stage 69% if to regional lymph nodes 20% if to distant organs We don’t detect it early enough 39% local 37% regional 20% distant organs 6% of average risk Americans will get colon cancer ACS 2012 Cancer Facts and Figures, Colorectal Cancer Facts & Figures 2011-2013 Image from http://www.danielwagner.com/how-the-guru-send-me-traffic/
  8. 8. Polyp-Cancer Sequence 8-12 years estimated for polyp to become cancer Already a cancer: Stage 0 Carcinoma in situ Stage 1 Mucosal Stage 2 To muscularis Stage 3 To lymph nodes Stage 4 To distant organs
  9. 9. Stage= Survival Early detection = 5 year survival >90% if local stage 69% if to regional lymph nodes 20% if to distant organs We don’t detect it early enough 39% local 37% regional 20% distant organs
  10. 10. ACG 2008 guidelines – it’s been five years, people! Changes in 2008 guidelines from the 2000 ACG recommendations for screening 1. Screening tests are divided into cancer prevention and cancer detection tests. Cancer prevention tests are preferred over detection tests. 2. Screening is recommended in African Americans beginning at age 45 years. 3. CT colonography every 5 years replaces double contrast barium enema as the radiographic screening alternative, when patients decline colonoscopy. 4. FIT replaces older guaiac-based fecal occult blood testing. FIT is the preferred cancer detection test. 5. Annual Hemoccult Sensa and fecal DNA testing every 3 years are alternative cancer detection tests. 6. A family history of only small tubular adenomas in first-degree relatives is not considered to increase the risk of CRC. 7. Individuals with a single first-degree relative with CRC or advanced adenomas diagnosed at age ≥60 years can be screened like average-risk persons.
  11. 11. ACG 2008 : Preferred CRC screening recommendations • Cancer prevention tests should be offered first. The preferred CRC prevention test is colonoscopy every 10 years, beginning at age 50. (Grade 1 B) • Screening should begin at age 45 years in African Americans (Grade 2 C) • Cancer detection test should be offered to patients who decline colonoscopy or another cancer prevention test. The preferred cancer detection test is annual FIT for blood (Grade 1 B)
  12. 12. Time to discard stool guaiac? “ ACG supports the joint guideline recommendation that older guaiac-based fecal occult blood testing be abandoned as a method for CRC screening.”
  13. 13. I’ve got job security. Detection verses prevention. FIT for those who refuse colonoscopy.
  14. 14. ACS guidelines on colorectal cancer screening & surveillance Starting at age 50 years, men and women should undergo one of the following screening tests (average risk): US Pharmacist. 2012;37(12):22-26. Colorectal Cancer Screening Guidelines Update M Steinberg. • Flexible sigmoidoscopy every 5 y • Colonoscopy every 10 y • Double-contrast barium enema every 5 y • CT colonography every 5 y • FOBT annually (take-home, multiple-sample method) • FIT annually (take-home, multiple-sample method)
  15. 15. American Cancer Society guidelines Method DescriptionNotes Flexible sigmoidoscopy Flexible, lighted, tubelike video camera inserted into rectum allows visualization of entire rectum, but less than half of colon Requires bowel preparation Colonoscopy Flexible, lighted, tubelike video camera inserted into rectum allows visualization of entire rectum and colon; has ability to remove any identified polyps Requires bowel preparation; use of sedation requires patient to rely on another person to drive him/her home after the procedure Double-contrast barium enema Barium sulfate suspension is injected with air into rectum via flexible tube; x-ray images are taken Requires bowel preparation; colonoscopy may be performed to evaluate/remove any suspicious polyps CT colonography Patient lies within scanning machine, which rotates around him/her taking cross-sectional images that enable 2-or 3-dimensional visualization of colon and rectum Requires bowel preparation; may require drinkable contrast solution, as well as insertion of air into colon to improve visualization; colonoscopy may be performed to evaluate/remove any suspicious polyps FOBT Patient applies stool sample (usually 3 consecutive bowel movements) to test-kit cards and returns/mails completed kit to medical office/laboratory Requires colonoscopy for positive test to determine cause of bleeding; NSAIDs, aspirin, vitamin C (>250 mg/day), or red meat ≤3 days before testing interacts with accuracy; may not detect nonbleeding tumors FIT or iFOBT Patient applies stool sample (usually 2–3 consecutive bowel movements) to test-kit cards and returns/mails completed kit to medical office/laboratory Requires colonoscopy for positive test to determine cause of bleeding; no dietary limitations; may not detect nonbleeding tumors US Pharmacist. 2012;37(12):22-26. Colorectal Cancer Screening Guidelines Update M Steinberg.
  16. 16. ACS guidelines on increased CRC risk US Pharmacist. 2012;37(12):22-26. Colorectal Cancer Screening Guidelines Update M Steinberg. Increased Risk (due to FH of colorectal cancer) Risk Category Age/Time to Begin Recommended Test Colorectal cancer or adenomatous polyps in any 1st-degree relative <60 y or ≥2 1st-degree relatives at any age Age 40 y, or 10 y before youngest immediate-family case Colonoscopy every 5 y Colorectal cancer or adenomatous polyps in any 1st-degree relative ≥60 y or ≥2 2nd-degree relatives at any age Age 40 y Colonoscopy every 10 y
  17. 17. ACS guidelines on high CRC risk US Pharmacist. 2012;37(12):22-26. Colorectal Cancer Screening Guidelines Update M Steinberg. Risk Category Age to Begin Recommended Test(s) FAP diagnosed by genetic testing, or suspected without genetic testing Age 10–12 y Yearly flexible sigmoidoscopy; genetic testing HNPCC or FH of condition Age 20–25 y or 10 y before youngest immediate-family case Colonoscopy every 1–2 y; genetic testing Inflammatory bowel disease Unclear, but cancer risk begins ≤8 y after Colonoscopy with biopsy pancolitis onset or 12–15 y after LC onset every 1–2 y
  18. 18. It’s working!
  19. 19. More uninsured, so they get stool testing at least, right? http://www.examiner.com/article/free-health-care-101-where-to-find-chicago-s-low-and-no-cost-health-care
  20. 20. -causes of false-positives with guaiac-based FOBT(gFOBT) - how immunochemical FOBT (iFOBT or FIT) works -the future of & development of fecal DNA testing
  21. 21. Albert Einstein Everything should be made as simple as possible, but not simpler.
  22. 22. Standard Guaiac testing Peroxidase reaction with hemoglobin turns guaiac impregnated paper blue Hemoccult sensa is more sensitive than Hemoccult, Hemoccult-II or Hemoccult-R • hydrogen peroxide is dripped onto the guaiac paper • oxidizes the alpha-guaiaconic acid to a blue colored quinone • occurs very slowly when no blood (& no peroxidases or catalases from vegetables) are present • Heme catalyzes this reaction, giving a result in about two seconds • positive test result is one where there is a quick and intense blue color change of the film. Your Meemaw’s gFOBT Image from http://digital-photography-school.com/forum/how-i-took/59938-chuck-norris-eyedrops.html Kratochvil JF, et al. (1971). "Isolation and characterization of alpha-guaiaconic acid and the nature of guiacum blue". Phytochem 10: 2529.
  23. 23. Dietary restrictions– who actually follows them? Restrictive diet advised • high fiber diet x 2 days • no red meat • no vitamin C or citrus fruits • false negatives due to anti-oxidant properties inhibiting the color reaction • no gastric irritant medications • includes iron • no peroxidase containing vegetables (cucumber, cauliflower, horseradish) • Reduced compliance with screening Biennial (every 2 years) screening with non-rehydrated specimens Beg M, et al. (2002). "Occult Gastrointestinal Bleeding: Detection, Interpretation, and Evaluation" JIACM 3 (2): 153–8.
  24. 24. Food peroxidases & guaiac testing In vivo study, N = 61 Peroxidase challenge diet for three days with 750 g of raw peroxidase-rich fruits and vegetables daily 160–180 g of broccoli 160–180 g of cauliflower 40–50 g of red radish 110–120 g of turnip 250–280 g of cantaloupe “… ingested plant peroxidases are capable of surviving transit through the gut and that, in the feces, they can cause positive guaiac-based FOBT reactions… the ability of plant peroxidases to cause false-positive reactions decreases rapidly as the time between fecal smearing and development increases.” Clinical Chemistry January 1999 vol. 45 no. 1 123-126. Interference of Plant Peroxidases with Guaiac-based Fecal Occult Blood Tests Is Avoidable
  25. 25. If it is human blood, where from? • Mouth and dental • Esophagus • Stomach • Small intestine • Colon • Anal Image from http://www.uofmmedicalcenter.org/healthlibrary/Article/40233 and http://1.bp.blogspot.com/-Nxq4Bx0WK3k/T1zdJcnEh0I/AAAAAAAABUg/WArnSc1PgCg/s1600/Funny+joke+picture+on+Apple+iPhone+Ambulance+bleeding+help+humor+image.jpg
  26. 26. CRC mortality reduced by 33% at 13 years (annual gFOBT)and 21 % at 18 years (biennial gFOBT) 2% Guaiac + patients had cancer = 50 colonoscopies to detect 1 cancer • Single FOBT sensitivity for CRC 30% • Program of repeated testing sensitivity 80-92% • High false positive rate • ? Chance detection of cancers verses specific effect of gFOBT • Does not detect polyps which do not bleed, many false positive results More on gFOBT Image from http://www.sciencemuseum.org.uk/hommedia.ashx?id=91853&size=Inline Mandel JS, Church TR, Ederer F, Bond JH. Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst 1999; 91:434. Allison JE, Sakoda LC, Levin TR, et al. Screening for colorectal neoplasms with new fecal occult blood tests: update on performance characteristics. J Natl Cancer Inst 2007; 99:1462. Lang CA, Ransohoff DF. Fecal occult blood screening for colorectal cancer. Is mortality reduced by chance selection for screening colonoscopy? JAMA 1994; 271:1011. Ederer F, Church TR, Mandel JS. Fecal occult blood screening in the Minnesota study: role of chance detection of lesions. J Natl Cancer Inst 1997; 89:1423.
  27. 27. Modern stool testing today: iFOBT (FIT) More specific than guaiac testing Respond only to human globin • No false + for UGI bleed (globin digested in transit) • No false + for foods with peroxidase activity • Sensitivity does degrade in mailing delay (degradation of hemoglobin) • >5 days post sample verses no delay with decrease in adenoma detection (OR 0.6) Qualitative and quantitative testing available, with adjustment of cut-off Image from http://ncmuseumofhistory.org/exhibits/healthandhealing/topic/36/, http://dsc.discovery.com/tv-shows/curiosity/topics/modern-medicine-pictures.htm van Rossum LG, van Rijn AF, van Oijen MG, et al. False negative fecal occult blood tests due to delayed sample return in colorectal cancer screening. Int J Cancer 2009; 125:746.
  28. 28. iFOBT (FIT) major advantages over traditional gFOBT No diet or medication restrictions Increased specificity with high sensitivity Specific to lower GI bleeding -improved compliance (10-12%) -DOUBLE detection advanced lesions with little loss of PPV Better patient return rate Fewer false-positives for CRC Ideal CRC screening product Fewer false positives and needless colonoscopies
  29. 29. Using stool guaiac (gFOBT) is like using Laennec’s stethoscope (1819)… Image from http://www.homeopathyworldcommunity.com/forum/topics/rene-theophile-hyacinthe
  30. 30. Future fecal DNA testing (sDNA) • CRC sheds DNA, mutations may be tested • Commercially available sDNA test off market 2012, new panels under development • False negatives (unidentified genetic abnormality), false + (upper GI malignancy or premalignant genetic abnormalities elsewhere in GI tract) Cost analysis 2010 pricing • $350 per test • sDNA every 3-5 years more costly than other screening per year of life saved. • Could be cost effective at $40-60 Image from http://inside-the-brain.com/tag/future-of-medicine/ Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med 2004; 351:2704.
  31. 31. -logistics of iFOBT (FIT) testing -compliance -outcomes in population-based prevention studies How does this work?
  32. 32. How FIT testing is done
  33. 33. How FIT testing is done: poking the poop
  34. 34. In your office
  35. 35. Positive: Occult blood is detected in the stool sample. Please consult a doctor Negative: No occult blood is detected in the stool sample. Invalid: This may be due to inadequate/excessive sample being collected or delay in sample transportation to the clinic. In your office
  36. 36. Compliance with FIT • No diet change • No multiple samples • No chasing stool in toilet with popsicle stick Now you can make fun craft projects! Image from http://www.mycafelove.com/2012/01/funny-face-made-from-vegetables-funny.html
  37. 37. Sealed with a iFOBT Belgium 2009, N=19,542 Random mailings verses GP advice 42.1% overall participation (8229 fecal samples) – 52.3% mail, 27.7% GP (p<0.001) – 26.5% mail, 16.6% GP prior to reminder letter and other invitation strategy Odds of participation almost 3 x higher (OR= 2.96) for people invited by mail than invited by their physician
  38. 38. Sealed with a iFOBT (2) • Women > Men (OR 1.22, p<0.001) • Residential (OR=1.98) and rural (OR=2.90) > urban – 8229 sent sample – 435 of 8229 (5.3%) positive iFOBT – CRC in 18/317 scoped (5.7%) Compliance for follow up colonoscopy 72.9%, did not differ in mail verses GP groups Van Roosbroek S, Hoeck S, Van Hal G. Population-based screening for colorectal cancer using an immunochemical faecal occult blood test: a comparison of two invitation strategies. Cancer Epidemiol. 2012 Oct; 36(5):e317-24.
  39. 39. Population based studies Belgium Mail compliance vs. GP Brazil Population screening Netherlands Higher participation rate & improved detection verses gFOBT France Better than gFOBT with lesions that bleed less Germany Enhanced detection despite/due to low dose aspirin use FIT around the globe (in developed countries)
  40. 40. IMMUNOLOGICAL FECAL OCCULT BLOOD TEST ON THE SCREENING FOR COLORECTAL CANCER IN A BRAZILIAN TOWN – PRELIMINARY RESULTS Angelita HABR-GAMA, M.D.; Rodrigo Oliva PEREZ, M.D., Igor PROSCURSHIM, M.D., Guilherme Pagin SÃO JULIÃO, M.D., Mauro PICOLO, M.D., Joaquim GAMA-RODRIGUES, M.D., Project carried out in Santa Cruz das Palmeiras municipality, São Paulo state, Brazil, sponsored by ABRAPRECI – Brazilian Association for Colorectal Cancer Prevention 4,567 FIT tests 54.8% of the local population over 40 years • 905 (19.8%) were not returned • 22 (0.5%) could not be analyzed. • 3,640 tests, 43.7% of the target population, were analyzed • Results were positive in 390 (10.7%) exams
  41. 41. FIT Brazilians FIT positive in 390 (10.7%) exams Out of the 245 patients with positive result and referred to colonoscopy, 33 (13.5%) refused to undergo the exam. The results of the 212 performed colonoscopies were: • 53 patients with diverticular disease, • 59 with polyps • 9 with adenocarcinoma • 91 normal. 32% yield of polyps and cancer Out of the patients with adenocarcinoma, three were treated endoscopically since lesions were small and detected at an early stage.
  42. 42. Participation rate FIT > gFOBT In a randomized trial in the Netherlands comparing Hemoccult II (guaiac-based), a quantitative fecal immunochemical test (FIT), and flexible sigmoidoscopy for screening, the participation rate was higher for the FIT compared to the guaiac test (61.5% versus 49.5%) Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy. Hol L, van Leerdam ME, van Ballegooijen M, van Vuuren AJ, van Dekken H, Reijerink JC, van der Togt AC, Habbema JD, Kuipers EJ Gut. 2010;59(1):62. Image from http://www.123rf.com/photo_6011092_windmill-with-tulip-field-near-schermerhorn-netherlands.html
  43. 43. gFOBT + 2.8% FIT + 4.8% FFS + 10.2%. Detection of advanced neoplasia was significantly higher in the FIT (2.4%; OR, 2.0; CI, 1.3 to 3.1) and the FS arm (8.0%; OR, 7.0; CI, 4.6 to 10.7) than the gFOBT arm (1.1%) Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy. Hol L, van Leerdam ME, van Ballegooijen M, van Vuuren AJ, van Dekken H, Reijerink JC, van der Togt AC, Habbema JD, Kuipers EJ Gut. 2010;59(1):62. Image from http://www.123rf.com/photo_6011092_windmill-with-tulip-field-near-schermerhorn-netherlands.html
  44. 44. FIT: More sensitive with less bleeding lesions N=20 322 , tested with gFOBT and FIT At least 1 positive test in 1615, colonoscopy results were available for 1277 43 invasive cancers and 270 high-risk adenomas were detected. The gain in sensitivity associated with the I-FOBT was calculated using the ratio of sensitivities (RSN) according to type and location of lesions, and amount of bleeding. The gain in sensitivity by using I-FOBT increased from invasive cancers (RSN=1.48 (1.16-4.59)) to high-risk adenomas (RSN=3.32 (2.70-4.07)), and was inversely related to the amount of bleeding. Comparison of a guaiac and an immunochemical faecal occult blood test for the detection of colonic lesions according to lesion type and location. Guittet L, Bouvier V, Mariotte N, Vallee JP, Levillain R, Tichet J, Launoy G Br J Cancer. 2009;100(8):1230.
  45. 45. “…use of low-dose aspirin compared with no aspirin was associated with a markedly higher sensitivity for detecting advanced colorectal neoplasms, with only a slightly lower specificity.” 2 different FIT tests in 1979 patients (mean age, 62.1 years): • 233 regular users of low-dose aspirin • 1746 who never used low-dose aspirin • Advanced neoplasms were found in 24 users (10.3%) and 181 nonusers (10.4%) of low-dose aspirin Low-dose aspirin use and performance of immunochemical fecal occult blood tests. Brenner H, Tao S, Haug JAMA. 2010;304(22):2513.
  46. 46. INVITING TRAGEDY
  47. 47. Remember: + FIT needs colonoscopy
  48. 48. ? Questions… Please ask! Patricia Raymond MD FACG
  49. 49. Learn more: Resources » Guidelines for Colorectal Cancer Screening 2008 - American College of Gastroenterology » www.s3.gi.org/media/ACG2009CRCGuideline.pdf » Review slides wherever you are » Slideshare.net/PatriciaRaymond
  50. 50. Learn more: Selected Resources » ACG & Cancer Detection Testing with FIT Nakajima M , Saito H , Soma Y et al. Prevention of advanced colorectal cancer by screening using the immunochemical faecal occult blood test: a case-control study . Br J Cancer 2003 ; 89 : 23 – 8 . Lee KJ , Inoue M , O tani T et al. C olorectal cancer screening using fecal occult blood test and subsequent risk of colorectal cancer: a prospective cohort study in Japan . Cancer Detect Prev 2007 ; 31 : 3 – 11 . Zappa M , Csatiglione G , rGazzini G et al. E7 ect of faecal occult blood testing on colorectal mortality: results of a population-based case-control study in the district of Florence, Italy . Int J Cancer 1997 ; 73 : 208 – 10 . van Rossum LG , van Rijn AF , Laheij RJ et al. Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population . Gastroenterology 2008 ; 135 : 82 – 90 . Hol L , van Leerdam ME , van Ballegooijen M et al. Attendance to screening for colorectal cancer in the Netherlands; randomized controlled trial comparing two different forms of faecal occult blood tests and sigmoidoscopy . Gastroenterology 2008 ; 134 : A87 .
  51. 51. Patricia L. Raymond MD FACG Assistant Professor of Clinical Internal Medicine, Eastern Virginia Medical School what their stool can tell you: How FIT (iFOBT) Fits Your Colorectal Cancer Algorithm
  52. 52. Just what is their stool telling you?

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