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Fecal immunochemical test good alternative when colonoscopy capacity limited
Wilschut JA. J Natl Cancer Inst. 2011;doi:10.1093/jnci/djr385.
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In situations when the ability to conduct colonoscopies was limited, the fecal immunochemical test using a higher hemoglobin cutoff was more effective compared with the fecal occult blood test.
This was true for both health outcomes and cost, according to the results of a recently published study.
There are many countries where colonoscopies are not readily available. In these situations, researchers need to know the most effective alternatives. To date, the fecal immunochemical test has been shown to have certain advantages over fecal occult blood testing.
The researchers used the MISCAN-Colon micro-simulation model, which simulates the relevant biographies of a large population from birth to death without screening, as well as with changes that would occur in screening programs.
They estimated the number of colonoscopies, costs and health effects of different screening strategies using both fecal occult blood testing and the fecal immunochemical test, various age ranges and multiple surveillance strategies.
Results indicated the best alternative to colonoscopy was an annual fecal immunochemical test with a 50 ng/mL hemoglobin cutoff. Colonoscopy surveillance should be offered to anyone with an adenoma.
For a scenario with limited colonoscopy capacity, a fecal immunochemical test with a higher hemoglobin cutoff of 200 ng /mL performed better than a fecal occult blood test and was more effective if the colonoscopy capacity was expanded.
In an accompanying editorial, Russell Harris, MD, MPH, of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill and Linda S. Kinsinger, MD, MPH, of the Department of Health Behavior and Health Education at the University of North Carolina School of Public Health wrote that aggressive colonoscopy screening, termed “going the distance,” in the United States has potential harms and costs that have not been fully explored. They wrote that the use of simulation models, such as the one described by Wilschut et al, could be useful to make real-world decisions about how intensive screening should be under different colonoscopy capacities by measuring clinical and cost effectiveness. Harris and Kinsinger suggest that outcomes tables are needed in addition to a simulation model to fully compare the benefits, harms and costs of screening strategies.
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We almost take for granted in the United States that every individual at average risk should undergo a screening colonoscopy beginning at age 50 years; however, in many parts of the world, there is limited accessibility to — and capacity for performing — colonoscopies. Thus, a more thoughtful and cost-conscious approach to screening needs to be developed when such situations arise. The authors of this study highlight the utility of fecal occult blood testing, in particular the use of quantitative fecal immunochemical testing, to define both the age range and the hemoglobin cutoff level at which colonoscopy should be recommended. While we think that perhaps such findings are not relevant to practice here in the United States, in this current era where health care economics and the need to contain costs are of great concern — not to mention issues of patient noncompliance and lack of accessibility to specialist care — it would be foolish to ignore the potential broader questions and implications that this study raises.
-Andrew H. Ko, MD
HemOnc Today
Editorial Board member
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