Faecal immunochemical tests versus colonoscopy for post-polypectomy surveillance: an accuracy, acceptability and economic study

Atkin, W., et al | 2019|Faecal immunochemical tests versus colonoscopy for post-polypectomy surveillance: an accuracy, acceptability and economic study| Health Technology Assessment| Vol.23| 01| https://doi.org/10.3310/hta23010

 

A study which recruited male and female patients (aged between 60-72) from the Bowel Screening Programme between 30 January 2012 to 30 December 2013,  finds that annual faecal immunochemical testing, with colonoscopy in positive cases, was generally acceptable to patients and would be cost-saving compared to three-yearly colonoscopy, although it has lower sensitivity, resulting in missed lesions.

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Plain English Summary 

Bowel cancer typically develops from lesions called adenomas. Although common, most adenomas do not develop into cancer. Adenomas detected during a bowel examination, called a colonoscopy, are usually removed during this procedure. However, even after adenoma removal, some patients are still at greater risk of bowel cancer.

Depending on the number and size of adenomas found, patients are invited for a colonoscopy after 1, 3 or 5 years. Most of these additional colonoscopies will not detect cancer and they are expensive, often uncomfortable and can harm the bowel.

Both bowel cancer and adenomas can cause bleeding in the bowel. This study examined whether or not a test for blood in stool, completed at home [known as the faecal immunochemical test (FIT)], could be used instead of colonoscopy to monitor patients following adenoma removal. Colonoscopy would then be offered only to those who had a positive FIT result, indicating blood in the stool.

This study invited individuals for annual FITs for 3 years who, as part of the Bowel Cancer Screening Programme, had one or two large adenomas or three or four small adenomas removed. If a FIT detected blood in the stool at any of the tests, these individuals were immediately offered a colonoscopy. If a FIT did not detect blood in the stool at any test, these individuals were offered a colonoscopy 3 years after their adenomas were removed, as were participants who did not return their second or third FIT.

The study demonstrated that an annual FIT could identify 85 of every 100 cancers and 57 of every 100 patients with adenomas if repeated over 3 years. Annual FITs were considerably cheaper than colonoscopy after 3 years. Participants reported that the FIT was easy to use and provided reassurance. However, some were concerned that the FIT would not be as effective as colonoscopy.

Abstract

Background

In the UK, patients with one or two adenomas, of which at least one is ≥ 10 mm in size, or three or four small adenomas, are deemed to be at intermediate risk of colorectal cancer (CRC) and referred for surveillance colonoscopy 3 years post polypectomy. However, colonoscopy is costly, can cause discomfort and carries a small risk of complications.

Objectives

To determine whether or not annual faecal immunochemical tests (FITs) are effective, acceptable and cost saving compared with colonoscopy surveillance for detecting CRC and advanced adenomas (AAs).

Design

Diagnostic accuracy study with health psychology assessment and economic evaluation.

Setting

Participants were recruited from 30 January 2012 to 30 December 2013 within the Bowel Cancer Screening Programme in England.

Participants

Men and women, aged 60–72 years, deemed to be at intermediate risk of CRC following adenoma removal after a positive guaiac faecal occult blood test were invited to participate. Invitees who consented and returned an analysable FIT were included.

Intervention

We offered participants quantitative FITs at 1, 2 and 3 years post polypectomy. Participants testing positive with any FIT were referred for colonoscopy and not offered further FITs. Participants testing negative were offered colonoscopy at 3 years post polypectomy. Acceptibility of FIT was assessed using discussion groups, questionnaires and interviews.

Main outcome measures

The primary outcome was 3-year sensitivity of an annual FIT versus colonoscopy at 3 years for detecting advanced colorectal neoplasia (ACN) (CRC and/or AA). Secondary outcomes included participants’ surveillance preferences, and the incremental costs and cost-effectiveness of FIT versus colonoscopy surveillance.

Results

Of 8008 invitees, 5946 (74.3%) consented and returned a round 1 FIT. FIT uptake in rounds 2 and 3 was 97.2% and 96.9%, respectively. With a threshold of 40 µg of haemoglobin (Hb)/g faeces (hereafter referred to as µg/g), positivity was 5.8% in round 1, declining to 4.1% in round 3. Over three rounds, 69.2% (18/26) of participants with CRC, 34.3% (152/443) with AAs and 35.6% (165/463) with ACN tested positive at 40 µg/g. Sensitivity for CRC and AAs increased, whereas specificity decreased, with lower thresholds and multiple rounds. At 40 µg/g, sensitivity and specificity of the first FIT for CRC were 30.8% and 93.9%, respectively. The programme sensitivity and specificity of three rounds at 10 µg/g were 84.6% and 70.8%, respectively. Participants’ preferred surveillance strategy was 3-yearly colonoscopy plus annual FITs (57.9%), followed by annual FITs with colonoscopy in positive cases (31.5%). FIT with colonoscopy in positive cases was cheaper than 3-yearly colonoscopy (£2,633,382), varying from £485,236 (40 µg/g) to £956,602 (10 µg/g). Over 3 years, FIT surveillance could miss 291 AAs and eight CRCs using a threshold of 40 µg/g, or 189 AAs and four CRCs using a threshold of 10 µg/g.

Conclusions

Annual low-threshold FIT with colonoscopy in positive cases achieved high sensitivity for CRC and would be cost saving compared with 3-yearly colonoscopy. However, at higher thresholds, this strategy could miss 15–30% of CRCs and 40–70% of AAs. Most participants preferred annual FITs plus 3-yearly colonoscopy. Further research is needed to define a clear role for FITs in surveillance.

(Source: Health Technology Assessment (HTA)

 

The study can be read in full from HTA

National Bowel Cancer Audit

Health Quality Improvement Programme | December 2018 | Bowel Cancer Audit

The latest annual National Bowel Cancer Audit from the Health Quality Improvement Programme (HQIP) details data from over 30,000 patients diagnosed with bowel cancer between 01 April 2016 and 31 March 2017.

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Image source: hqip.org.uk

This  audit report describes some ongoing improvements such as mortality rates following both elective and emergency surgery falling over the past five years and increased numbers of operations being performed laparoscopically.

This year’s report has also described geographical variation in chemotherapy administration and further work is required to better describe and understand this. It is encouraging to see that there has been a reducing trend of deaths in hospital from 2011 to 2016 (46.2% – 34.6%) (Source: HQIP) .

2018 Annual Report 

Patient Report 2018 

Bowel cancer waiting times figures revealed

University of Edinburgh | November 2018| Bowel cancer waiting times figures revealed

Bowel cancer is the fourth most common cancer type, now researchers from the University of Edinburgh have shown that it takes 10% of  patients in England and Wales more than a year from recognising the symptoms to receiving treatment for their bowel cancer. They found that 10% of people with bowel cancer in Scotland waited more than 8 months to start treatment. 

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This international study included anonymised medical data from 3000 patients and their doctors in Australia, and Canada alongside the UK. Among their findings people in Wales took the longest to contact their GP once they had a health concern. Patients in Wales also waited the longest time (168 days)  to commence treatment,  which contrasts with Denmark (77 days. Researchers found that men and women in Wales took the longest to contact their doctor once they had noticed a health concern or symptom (Source: University of Edinburgh).

Full details from University of Edinburgh 

Bowel screening to start at 50

Public Health England & Steve Brine MP | August 2018 | Bowel screening to start at 50

The independent expert screening committee has recommended that bowel cancer screening in England should in future start 10 years earlier at age 50.

Currently, men and women, aged 60 to 74, are invited for bowel screening and are sent a home test kit every 2 years to provide stool samples.

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Following a comprehensive review of the evidence, the committee recommends that screening should be offered from aged 50 to 74 using the faecal immunochemical home test kit (FIT).

The full press release can be viewed at Public Health England 

Related: National Bowel Cancer Audit: The feasibility of reporting patient outcome measures

National Bowel Cancer Audit: The feasibility of reporting patient outcome measures

Health Quality Improvement Programme | August 2018| National Bowel Cancer Audit: The feasibility of reporting patient outcome measures as part of  of a national colorectal cancer audit

Health Quality Improvement Programme  (HQIP)  has published the National Bowel Cancer Audit: The feasibility of reporting patient outcome measures

NHS England’s National Cancer PROMs Programme of the National Survivorship Initiative2 collected Patient Reported Outcome Measures (PROMs) for colorectal cancer patients in a one-off study in 2013. Patients were between one- and three-years from diagnosis at the point of being surveyed.

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The aim of this study was to link the Patient Reported Outcome Measures (PROMs) for colorectal cancer patients in a one-off study in 2013, survey data to the National Bowel Cancer Audit (NBOCA) data to establish the feasibility of reporting PROMs as part of a national clinical audit. This was assessed according to i) the characteristics of responders compared to all eligible patients ii) the representativeness of the responders at different points along their pathway from diagnosis, iii) hospital trust variation in response rate, and iv) the validity of the measures in comparison to NBOCA measures (Source: HQIP).

The full report is available from HQIP here 
Of interest:

Public Health England & Steve Brine MP Bowel screening to start at 50

Bowel cancer screening

Guidance for providers of bowel scope screening within the NHS Bowel Cancer Screening Programme in England | Public Health England

The UK National Screening Committee recommended the addition of bowel scope screening alongside the existing guaiac faecal occult blood test (gFOBT) following a clinical trial and 11 years of follow-up. These standard operating procedures (SOPs) help commissioners and providers in establishing and implementing bowel scope screening.

Full detail at Public Health England

Aspirin: a cure for bowel cancer?

University of Edinburgh |  June 2018 | Aspirin’s anti-cancer effects revealed

Researchers at the University of Edinburgh have discovered aspirin blocks a key process linked to tumour formation. Although aspirin  is recognised for its ability to reduce an individual’s risk of developing colon cancer-if taken regularly- its tumour fighting properties have been little understood. The team looked at the impact of taking aspirin to fight bowel cancer; focusing on a structure found inside cells called the nucleolus. They tested aspirin tumour biopsies removed from patients with colon cancer, and cells grown in the lab. Their research discovered that aspirin blocks TIF-IA a key molecule essential to the functioning of the nucleolus (via University of Edinburgh).
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Full press release from University of Edinburgh here 

The full article is available to read from Nucleic Acids Research

Chen, J. et al |2018|  Identification of a novel TIF-IA–NF-κB nucleolar stress response pathway| Nucleic Acids Research| gky455| https://doi.org/10.1093/nar/gky455

In the media:

BBC News Aspirin ‘helps block tumour formation’