Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: a systematic review and cost-effectiveness analysis

BackgroundColorectal cancer (CRC) is the third most common cancer in the UK. Presenting symptoms that can be associated with CRC usually have another explanation. Faecal immunochemical tests (FITs) detect blood that is not visible to the naked eye and may help to select patients who are likely to benefit from further investigation.ObjectivesTo assess the effectiveness of FITs [OC-Sensor (Eiken Chemical Co./MAST Diagnostics, Tokyo, Japan), HM-JACKarc (Kyowa Medex/Alpha Laboratories Ltd, Tokyo, Japan), FOB Gold (Sentinel/Sysmex, Sentinel Diagnostics, Milan, Italy), RIDASCREEN Hb or RIDASCREEN Hb/Hp complex (R-Biopharm, Darmstadt, Germany)] for primary care triage of people with low-risk symptoms.MethodsTwenty-four resources were searched to March 2016. Review methods followed published guidelines. Summary estimates were calculated using a bivariate model or a random-effects logistic regression model. The cost-effectiveness analysis considered long-term costs and quality-adjusted life-years (QALYs) that were associated with different faecal occult blood tests and direct colonoscopy referral. Modelling comprised a diagnostic decision model, a Markov model for long-term costs and QALYs that were associated with CRC treatment and progression, and a Markov model for QALYs that were associated with no CRC.ResultsWe included 10 studies. Using a single sample and 10 µg Hb/g faeces threshold, sensitivity estimates for OC-Sensor [92.1%, 95% confidence interval (CI) 86.9% to 95.3%] and HM-JACKarc (100%, 95% CI 71.5% to 100%) indicated that both may be useful to rule out CRC. Specificity estimates were 85.8% (95% CI 78.3% to 91.0%) and 76.6% (95% CI 72.6% to 80.3%). Triage using FITs could rule out CRC and avoid colonoscopy in approximately 75% of symptomatic patients. Data from our systematic review suggest that 22.5–93% of patients with a positive FIT and no CRC have other significant bowel pathologies. The results of the base-case analysis suggested minimal difference in QALYs between all of the strategies; no triage (referral straight to colonoscopy) is the most expensive. Faecal immunochemical testing was cost-effective (cheaper and more, or only slightly less, effective) compared with no triage. Faecal immunochemical testing was more effective and costly than guaiac faecal occult blood testing, but remained cost-effective at a threshold incremental cost-effectiveness ratio of £30,000. The results of scenario analyses did not differ substantively from the base-case. Results were better for faecal immunochemical testing when accuracy of the guaiac faecal occult blood test (gFOBT) was based on studies that were more representative of the correct population.LimitationsOnly one included study evaluated faecal immunochemical testing in primary care; however, all of the other studies evaluated faecal immunochemical testing at the point of referral. Further, validation data for the Faecal haemoglobin, Age and Sex Test (FAST) score, which includes faecal immunochemical testing, showed no significant difference in performance between primary and secondary care. There were insufficient data to adequately assess FOB Gold, RIDASCREEN Hb or RIDASCREEN Hb/Hp complex. No study compared FIT assays, or FIT assays versus gFOBT; all of the data included in this assessment refer to the clinical effectiveness of individual FIT methods andnottheir comparative effectiveness.ConclusionsFaecal immunochemical testing is likely to be a clinically effective and cost-effective strategy for triaging people who are presenting, in primary care settings, with lower abdominal symptoms and who are at low risk for CRC. Further research is required to confirm the effectiveness of faecal immunochemical testing in primary care practice and to compare the performance of different FIT assays.Study registrationThis study is registered as PROSPERO CRD42016037723.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Model-based evaluation of the long-term cost-effectiveness of systematic case-finding for COPD in primary care

Thorax ◽

10.1136/thoraxjnl-2018-212148 ◽

2019 ◽

Vol 74 (8) ◽

pp. 730-739 ◽

Cited By ~ 7

Author(s):

Tosin Lambe ◽

Peymane Adab ◽

Rachel E Jordan ◽

Alice Sitch ◽

Alex Enocson ◽

...

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Natural History ◽

Cost Effective ◽

Case Finding ◽

Base Case ◽

Decision Analytic Model ◽

Screening Questionnaire ◽

History Of

Introduction‘One-off’ systematic case-finding for COPD using a respiratory screening questionnaire is more effective and cost-effective than routine care at identifying new cases. However, it is not known whether early diagnosis and treatment is beneficial in the longer term. We estimated the long-term cost-effectiveness of a regular case-finding programme in primary care.MethodsA Markov decision analytic model was developed to compare the cost-effectiveness of a 3-yearly systematic case-finding programme targeted to ever smokers aged ≥50 years with the current routine diagnostic process in UK primary care. Patient-level data on case-finding pathways was obtained from a large randomised controlled trial. Information on the natural history of COPD and treatment effects was obtained from a linked COPD cohort, UK primary care database and published literature. The discounted lifetime cost per quality-adjusted life-year (QALY) gained was calculated from a health service perspective.ResultsThe incremental cost-effectiveness ratio of systematic case-finding versus current care was £16 596 per additional QALY gained, with a 78% probability of cost-effectiveness at a £20 000 per QALY willingness-to-pay threshold. The base case result was robust to multiple one-way sensitivity analyses. The main drivers were response rate to the initial screening questionnaire and attendance rate for the confirmatory spirometry test.DiscussionRegular systematic case-finding for COPD using a screening questionnaire in primary care is likely to be cost-effective in the long-term despite uncertainties in treatment effectiveness. Further knowledge of the natural history of case-found patients and the effectiveness of their management will improve confidence to implement such an approach.

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Cost-effectiveness analysis of screening by faecal occult blood testing for colorectal cancer in Australia

Australian and New Zealand Journal of Public Health ◽

10.1111/j.1753-6405.1996.tb01807.x ◽

1996 ◽

Vol 20 (2) ◽

pp. 138-143 ◽

Cited By ~ 41

Author(s):

Glenn Salkeld ◽

Graeme Young ◽

Les Irwig ◽

Marion Haas ◽

Paul Glasziou

Keyword(s):

Colorectal Cancer ◽

Cost Effectiveness ◽

Occult Blood ◽

Cost Effectiveness Analysis ◽

Faecal Occult Blood Testing ◽

Blood Testing ◽

Faecal Occult Blood ◽

Effectiveness Analysis ◽

Faecal Occult

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Cost-Effectiveness of Pembrolizumab Plus Chemotherapy Versus Pembrolizumab Monotherapy in Metastatic Non-Squamous and Squamous NSCLC Patients With PD-L1 Expression ≥ 50%

Frontiers in Pharmacology ◽

10.3389/fphar.2021.803626 ◽

2022 ◽

Vol 12 ◽

Author(s):

Qiao Liu ◽

Zhen Zhou ◽

Xia Luo ◽

Lidan Yi ◽

Liubao Peng ◽

...

Keyword(s):

Cost Effectiveness ◽

Life Expectancy ◽

Cost Effective ◽

Base Case ◽

First Line ◽

Term Survival ◽

First Line Therapy ◽

Line Therapy ◽

Nsclc Patients

Objective To compare the cost-effectiveness of the combination of pembrolizumab and chemotherapy (Pembro+Chemo) versus pembrolizumab monotherapy (Pembro) as the first-line treatment for metastatic non-squamous and squamous non-small-cell lung cancer (NSCLC) with PD-L1expression ≥50%, respectively, from a US health care perspective.Material and Methods A comprehensive Makrov model were designed to compare the health costs and outcomes associated with first-line Pembro+Chemo and first-line Pembro over a 20-years time horizon. Health states consisted of three main states: progression-free survival (PFS), progressive disease (PD) and death, among which the PFS health state was divided into two substates: PFS while receiving first-line therapy and PFS with discontinued first-line therapy. Two scenario analyses were performed to explore satisfactory long-term survival modeling.Results In base case analysis, for non-squamous NSCLC patients, Pembro+Chemo was associated with a significantly longer life expectancy [3.24 vs 2.16 quality-adjusted life-years (QALYs)] and a substantially greater healthcare cost ($341,237 vs $159,055) compared with Pembro, resulting in an ICER of $169,335/QALY; for squamous NSCLC patients, Pembro+Chemo was associated with a slightly extended life expectancy of 0.22 QALYs and a marginal incremental cost of $3,449 compared with Pembro, resulting in an ICER of $15,613/QALY. Our results were particularly sensitive to parameters that determine QALYs. The first scenario analysis yielded lower ICERs than our base case results. The second scenario analysis founded Pembro+Chemo was dominated by Pembro.Conclusion For metastatic non-squamous NSCLC patients with PD-L1 expression ≥50%, first-line Pembro+Chemo was not cost-effective when compared with first-line Pembro. In contrast, for the squamous NSCLC patient population, our results supported the first-line Pembro+Chemo as a cost-effective treatment. Although there are multiple approaches that are used for extrapolating long-term survival, the optimal method has yet to be determined.

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Cost Analysis in a Population Based Screening Programme for Colorectal Cancer: Comparison of Immunochemical and Guaiac Faecal Occult Blood Testing

Journal of Medical Screening ◽

10.1177/096914139700400306 ◽

1997 ◽

Vol 4 (3) ◽

pp. 142-146 ◽

Cited By ~ 28

Author(s):

G Castiglione ◽

M Zappa ◽

G Grazzini ◽

C Sani ◽

A Mazzotta ◽

...

Keyword(s):

Colorectal Cancer ◽

Screening Programme ◽

Cost Effective ◽

Occult Blood ◽

Recall Rate ◽

Population Based ◽

Faecal Occult Blood Testing ◽

Faecal Occult Blood ◽

Blood Tests ◽

Faecal Occult

Objective— To compare the costs of colorectal cancer (CRC) screening by two faecal occult blood tests (FOBT)—namely, Hemoccult (guaiac based) and reversed passive haemagglutination (RPHA) tests. RPHA was interpreted according to two positivity thresholds (+ or +/-). Methods— Attenders performed both tests. Subjects with a positive FOBT test were invited to have a complete exploration of the colon. The total costs for every 10 000 screened subjects and costs for each unit of result (screened subject, or patient with adenoma/s or cancer detected) were calculated for both tests. Results— 8353 subjects were enrolled. A total of 2109 repeated screening after two years. RPHA(+ and +/-) showed the highest and RPHA(+) the lowest positivity rate at first screening. The Hemoccult positivity rate was highest at repeat screening. Total costs of screening by RPHA(+ and +/-) were highest as this method had the highest recall rate. Screening by RPHA(+) was the least costly. Costs for each screened subject were highest for RPHA(+ and +/-) and lowest for RPHA(+). Costs for each cancer detected were lowest for RPHA(+) and highest for Hemoccult or RPHA(+ and +/-) in subjects aged > 49 or < 50, respectively. Costs for subjects with detected adenoma/s of > 9 mm were lowest for RPHA(+ and +/-) and highest for Hemoccult. At repeat screening total costs of RPHA(+ and +/-) were lower than at first screening, whereas for each subject with cancer or adenoma/s costs were increased. Conclusions— Our data confirm that screening by RPHA is more cost effective than by Hemoccult.

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CS.3.7 COST-EFFECTIVENESS OF MEDICAL COUNSELLING IN FAECAL OCCULT BLOOD-POSITIVE SUBJECTS. EXPERIENCE OF TRENTINO SCREENING PROGRAM

Digestive and Liver Disease ◽

10.1016/s1590-8658(10)60022-9 ◽

2010 ◽

Vol 42 ◽

pp. S68-S69

Author(s):

R. Fasoli ◽

N. Pace ◽

G. de Pretis ◽

K. Faitini ◽

M. Mastromauro ◽

...

Keyword(s):

Cost Effectiveness ◽

Screening Program ◽

Occult Blood ◽

Faecal Occult Blood ◽

Faecal Occult

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Factors of Never Screened with Faecal Occult Blood Test in Public Primary Care Facilities

Asian Pacific Journal of Cancer Prevention ◽

10.31557/apjcp.2021.22.1.163 ◽

2021 ◽

Vol 22 (1) ◽

pp. 163-169

Author(s):

Mohd Fazeli Sazali ◽

Syed Sharizman Syed Abdul Rahim ◽

Richard Avoi ◽

Mohd Rohaizat Hassan ◽

Firdaus Hayati ◽

...

Keyword(s):

Primary Care ◽

Blood Test ◽

Occult Blood ◽

Faecal Occult Blood Test ◽

Occult Blood Test ◽

Faecal Occult Blood ◽

Faecal Occult ◽

Care Facilities ◽

Never Screened

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Experience of adopting faecal immunochemical testing to meet the NICE colorectal cancer referral criteria for low-risk symptomatic primary care patients in Oxfordshire, UK

Frontline Gastroenterology ◽

10.1136/flgastro-2018-101052 ◽

2018 ◽

Vol 10 (4) ◽

pp. 347-355 ◽

Cited By ~ 5

Author(s):

Brian D Nicholson ◽

Tim James ◽

James E East ◽

David Grimshaw ◽

Maria Paddon ◽

...

Keyword(s):

Primary Care ◽

Predictive Value ◽

Colorectal Adenocarcinoma ◽

Occult Blood ◽

Low Risk ◽

Colorectal Disease ◽

Care Practice ◽

Faecal Occult Blood ◽

Faecal Occult ◽

Gastrointestinal Pathology

ObjectiveTo compare the diagnostic performance of guaiac faecal occult blood (gFOB) testing with faecal immunochemical test (FIT) in a low-risk symptomatic primary care population to provide objective data on which to base local referral guidelines.DesignStool samples from routine primary care practice sent for faecal occult blood testing were analysed by a standard gFOB method and the HM-JACKarc FIT between January and March 2016. Symptoms described on the test request were recorded. Patients were followed up over 21 months for evidence of serious gastrointestinal pathology including colorectal adenocarcinoma.ResultsIn 238 patients, the sensitivity and specificity for colorectal adenocarcinoma detection using gFOB were 85.7% and 65.8%, respectively, compared with 85.7% and 89.2% for FIT. The positive predictive value (PPV) for gFOB was 7.1% and negative predictive value (NPV) was 99.3%. Comparatively, the PPV for FIT was 19.4% and NPV 99.5%. The improved performance of FIT over gFOB was due to a lower false positive rate (10.8 vs 34.2, p≤0.01) with no increase in the false negatives rate. For any significant colorectal disease, the PPV for FIT increased to 35.5% with a reduction in NPV to 95.7%.ConclusionIn this low-risk symptomatic patient group, the proportion of samples considered positive by FIT was considerably lower than gFOB with the same rate of colorectal adenocarcinoma detection. One in three of those with positive FIT had a significant colorectal disease. This supports National Institute of Health and Care Excellence recommendation that FIT can be reliably used as a triage test in primary care without overburdening endoscopy resources.

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Inability of a negative faecal occult blood test to rule out intussusception in children

Emergency Medicine Journal ◽

10.1136/emermed-2017-206911.2 ◽

2017 ◽

Vol 34 (7) ◽

pp. 489-490

Author(s):

Alvin Chin ◽

Kerstin De Wit

Keyword(s):

Patient Group ◽

Blood Test ◽

Occult Blood ◽

Faecal Occult Blood Test ◽

Clinical Question ◽

Occult Blood Test ◽

Faecal Occult Blood ◽

Faecal Occult ◽

Study Type ◽

Rule Out

A short cut review was carried out to establish whether a negative faecal occult blood test was sufficiently sensitive to rule out a diagnosis of intussusception in children. 5 papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that a negative faecal occult blood test cannot reliably rule out the diagnosis of intussusception .

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