Time from Positive Screening Fecal Occult Blood Test to Colonoscopy and Risk of Neoplasia
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Purpose: Fecal occult blood testing (FOBT) is accepted as one method of colon cancer screening, and a positive result is an indication for colonoscopy. However, the utility of FOBT in the inpatient setting is not clear. We sought to describe the yield of colonoscopy in inpatients whose sole pre-op indication was positive FOBT. Methods: This is a retrospective study. Using an electronic GI endoscopy database, we identified all inpatients who underwent colonoscopy from 2008-2013 with a positive FOBT listed as the indication on the order form. Patient charts were reviewed for demographics, clinical presentation, prep quality, and for colonoscopic findings including quality of bowel preparation and adverse events. The type of FOBT, location of testing and presence of iron-deficiency anemia were also recorded. Results: Five hundred twenty-five inpatients undergoing colonoscopy were identified. Of these, 96 (18%) had a positive FOBT as the sole indication for colonoscopy (median age 75; 43% female). Sixty-three patients (66%) had a normal colonoscopy, six were found to harbor colorectal cancer (6%), eight had one or more colonic adenomas ≥ 1cm (6%), 4 had angiodysplasia ≥ 5 in number and ≥ 8 mm in size (4%), five had active colitis (5%), 6 had one/more ulcers ≥ 1cm (6%) and 4 had an incomplete exam (4%). Only one patient experienced a procedural adverse event (sedation-related hypotension). Thirty-one patients (32%) were found to have a poor colonoscopic preparation. After chart review, we identified clinical indications for colonoscopy other than positive FOBT in nearly all patients (98%). These included anemia (65 patients; 68%), history of melena or hematochezia (28 patients; 29%) or concern for carcinoma (1 patient; 1%). Conclusion: Only 44% of inpatients undergoing colonoscopy with positive FOBT as the listed indication had clinically significant findings. However, nearly all patients had at least one other reason to undergo colonoscopy. We believe that FOBT should not be used to decide whether screening colonoscopy should be performed in inpatients.
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To evaluate gastroenterologists' use of esophagogastroduodenoscopy (EGD) for positive fecal occult blood test (FOBT).Colonoscopy is recommended when an FOBT performed for colorectal cancer screening is positive. Guidelines suggest no further evaluation if anemia and gastrointestinal (GI) symptoms are absent.Online surveys included 4 vignettes: positive FOBT in average-risk adults 50 years of age or older with/without iron-deficiency anemia and with/without upper GI symptoms. For each scenario, respondents were asked if they would perform colonoscopy only, EGD only, colonoscopy+EGD on same day, or colonoscopy followed by EGD on different day if colonoscopy was negative.Surveys were returned by 778 (11%) of 7094 potential responders. In patients without anemia or upper GI symptoms, 65% performed colonoscopy only; 35% added EGD (9% same day, 25% different day). EGD was added in 91% with anemia, 96% with symptoms, and 100% with anemia+symptoms. In patients with positive FOBT alone (no symptoms or anemia), multivariate analysis revealed fear of litigation as the primary factor associated with adding EGD to colonoscopy (odds ratio=4.1; 95% confidence interval, 2.3-7.3). When EGD+colonoscopy were planned for positive FOBT, private practice was associated with performing EGD on a different day (odds ratio=6.3; 95% confidence interval, 2.9-13.5 for private versus academic setting).One third of gastroenterologists perform EGD in addition to colonoscopy for a positive FOBT alone. Fear of litigation is the most important factor in deciding whether to add EGD to colonoscopy. When both procedures are planned, they are more likely to be performed on different days in a private practice setting than in an academic setting.
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Abstract BACKGROUND: Professional society guidelines recommend follow‐up colonoscopy for patients with resected colonic adenomas. However, adherence to guideline recommendations in routine clinical practice has not been well characterized. METHODS: The authors used a population‐based sample of Medicare beneficiaries to identify all patients aged ≥70 years who had a claim for colonoscopy with polypectomy or hot biopsy during the period from 2001 to 2004. Medicare claims through 2009 identified colonoscopy within the following 5 years as well as fecal occult blood testing, sigmoidoscopy, and barium enema. RESULTS: In total, 12,771 patients were included. At 5 years, 45.7% of patients underwent another colonoscopy, and 32.3% of procedures included a polypectomy. The rates of fecal occult blood testing, flexible sigmoidoscopy, and barium enema at 5 years were 54%, 3.8%, and 2.9%, respectively. There was a marked decrease in repeat colonoscopy at 1 year, 3 years, and 5 years with more recent years of index procedures. Other predictors of undergoing repeat colonoscopy were younger age, African American race, and a colonoscopy before the index examination. There was no association with physician specialty. The decreasing use of colonoscopy with time was maintained in a multivariable analysis. CONCLUSIONS: In a sample of elderly Medicare beneficiaries, there was under use of follow‐up colonoscopy at 5 years after polypectomy, and <50% of patients received a repeat examination. In particular, the use of this procedure decreased over the 4‐year study period. Coupled with other data indicating the overuse of follow‐up colonoscopy in patients without polyps, there appeared to be significant discordance between guidelines and actual practice. Cancer 2013. © 2013 American Cancer Society.
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Colorectal cancer (CRC) is preventable through screening, with colonoscopy and fecal occult blood testing comprising the two most commonly used screening tests. Given the differences in complexity, risk, and cost, it is important to understand these tests' comparative effectiveness.The CONFIRM Study is a large, pragmatic, multicenter, randomized, parallel group trial to compare screening with colonoscopy vs. the annual fecal immunochemical test (FIT) in 50,000 average risk individuals. CONFIRM examines whether screening colonoscopy will be superior to a FIT-based screening program in the prevention of CRC mortality measured over 10 years. Eligible individuals 50-75 years of age and due for CRC screening are recruited from 46 Veterans Affairs (VA) medical centers. Participants are randomized to either colonoscopy or annual FIT. Results of colonoscopy are managed as per usual care and study participants are assessed for complications. Participants testing FIT positive are referred for colonoscopy. Participants are surveyed annually to determine if they have undergone colonoscopy or been diagnosed with CRC. The primary endpoint is CRC mortality. The secondary endpoints are (1) CRC incidence (2) complications of screening colonoscopy, and (3) the association between colonoscopists' characteristics and neoplasia detection, complications and post-colonoscopy CRC. CONFIRM leverages several key characteristics of the VA's integrated healthcare system, including a shared medical record with national databases, electronic CRC screening reminders, and a robust national research infrastructure with experience in conducting large-scale clinical trials. When completed, CONFIRM will be the largest intervention trial conducted within the VA (ClinicalTrials.gov identifier: NCT01239082).
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One of the most critical factors determining survival in terms of colorectal cancers is diagnosis and treatment at an early stage. Diagnosis at an early stage is possible with screening programs carried out within preventive health services. In this study, we aimed to compare the results of patients who underwent colonoscopy due to fecal occult blood test (FOBT) positivity with those over 50 years of age who underwent colonoscopy with other complaints and to reveal whether FOBT test is still essential for screening programs.This study included patients who underwent colonoscopy between January 2016 and December 2021. Patients were analyzed in two groups according to colonoscopy reasons: group I (FOBT-positive) and group II (other reasons).A total of 3393 patients were included in the study. The patients were divided into two groups for evaluation. Patients who underwent colonoscopy for FOBT positivity (Group I) and patients over 50 years of age who underwent colonoscopy for other reasons (Group II). When the colonoscopy findings were compared between the groups' inflammatory bowel diseases (p=0,03) were higher in group I, while normal colonoscopy (p=0,03) was found to be more common in group II. Polyps, malignancy, diverticulosis, and perianal diseases seem similar between the groups statistically.FOBT can still be used in colorectal screening because it is inexpensive, widely available, has more participation due to non-invasiveness, and can be applied outside of clinical settings.
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Patients with positive fecal occult blood test and unrevealing colonoscopy are often advised to undergo esophago-gastro-duodenoscopy (EGD) to exclude a bleeding source in the upper gastrointestinal tract. In this study, we evaluated EGD findings in patients with positive immunochemical fecal occult blood test (I-FOBT) not explained by colonoscopy.Out of 1221 consecutive patients having total colonoscopy after preparing I-FOBT (OC-MICRO, with threshold of 75 or 100 ngHb/ml), we included only patients without colorectal cancer or advanced adenomatous polyp on colonoscopy, who also underwent EGD within 4 months of the fecal blood testing. Findings on EGD were classified as those lesions which are likely or unlikely to bleed.EGD was performed in 160 patients after a negative colonoscopy. The procedure was performed 1.6 ± 1.4 months after the I-FOBT. Lesion with a bleeding potential was found in 24 patients (15%). In three (12.5%) and two (8.3%) of these patients I-FOBT was positive at the 75 and 100 ngHb/ml threshold, respectively. In 136 patients EGD was normal, and I-FOBT was similarly positive in 16 (11.7%) and 13 patients (9.5%), respectively. The mean fecal hemoglobin was also similar between the groups.Immunological FOBT positivity was not correlated with the finding of lesions, which are likely to bleed on EGD. Thus, EGD is probably not indicated in patients with positive I-FOBT and unrevealing colonoscopy.
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Purpose: The American Cancer Society and the Multi-society Task Force for Colorectal Cancer (CRC) recommend yearly fecal occult blood test (FOBT) with any positive result followed by colonoscopy. However, FOBT requires the patient to collect stool on 3 occasions and observe dietary restriction. This can cause inconvenience and result in noncompliance, probably more so in a lower socioeconomic stratum. We, therefore, aimed to determine if underserved patients undergoing a colonoscopy for positive FOBT have clinically more significant endoscopic findings than those undergoing a screening colonoscopy only. Methods: We performed a retrospective electronic chart review of consecutive patients who underwent colonoscopy over a period of 10 months in 2009 in a county hospital serving largely resource-poor patients. From these, patients with positive FOBT done for CRC screening who were then referred for diagnostic colonoscopy (Group A) were compared with those referred for average risk CRC screening colonoscopy(Group B). Results: Out of 309 patients included in the study, 123 (39.8%) were African American (AA), 118 (38.8%) Hispanic, 39 (12.6%) Asian, 26 (8.4%) White and 3 (0.9%) of other races. Overall, 83 patients (26.8%) had one or more neoplastic lesions: tubular, tubulovillous or serrated adenoma; 32% were AA, 25% Hispanics, 28% Asians and 19% Whites. Group A had 126 patients with a mean age of 57 years and 36 (28.5%) of these had neoplastic lesions. Group B had 183 patients with a mean age of 59 and 47 of these (25.6%) had neoplastic lesions (p= 0.6) (Table 1). The most common lesion was tubular adenoma. Two patients had tubulovillous adenoma and both were AA (1 woman) in Group B. Three patients (2 women) had serrated adenoma, all AA and 2 from Group A. Eleven patients had polyp/s ≥ 10 mm, 5 in Group A and 6 in Group B. In most cases, the endoscopic findings could not explain the positive FOBT. No patient had villous adenoma or CRC.Table 1Conclusion: There was no difference in the diagnostic yield of a colonoscopy between those who had a positive FOBT versus those who underwent a screening colonoscopy. The high rate of FOBT false positive results may be due to multiple factors (test counseling, compliance, language barrier, etc) but as currently implemented, appears to be an ineffective step for CRC screening in the underserved population. This underlines the need for a cost effective CRC screening test for this population.
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OBJECTIVES: Follow-up colonoscopy rates among persons with positive fecal occult blood test results (FOBT + ) remain suboptimal in many jurisdictions. In Ontario, Canada, primary care providers (PCPs) are responsible for arranging follow-up colonoscopies. The objectives were to understand the reasons for a lack of follow-up colonoscopy and any action plans to address follow-up. METHODS: Semi-structured interviews were conducted with 30 FOBT+ persons and 30 PCPs in Ontario. Eligible FOBT+ persons were identified through administrative databases and included those aged 50-74, with a 6-12 month old FOBT+, no follow-up colonoscopy, and no prior colorectal cancer diagnosis or colectomy. Eligible PCPs had ≥1 rostered FOBT+ person without follow-up colonoscopy. Transcripts were analyzed inductively using Nvivo 11 (QSR International Pty Ltd., 2015). RESULTS: Reasons for lack of follow-up colonoscopy were: person and/or provider believed the FOBT + was a false positive; person was afraid of colonoscopy; person had other health issues; and breakdown in communication of FOBT+ results or colonoscopy appointments. PCPs who initially recommended follow-up colonoscopy did not change the minds of the persons who dismissed the FOBT+ as a false positive and/or who were afraid of the procedure. These FOBT+ persons negotiated an alternative follow-up action plan including repeating the FOBT or not following-up. CONCLUSIONS: PCPs may not adequately counsel FOBT+ persons who believe the FOBT+ is a false positive and/or fear colonoscopy. PCPs may lack fail-safe systems to communicate FOBT+ results and colonoscopy appointments. Using navigators may help address these barriers and increase follow-up rates.
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