A large proportion of fecal immunochemical test-positive participants in colorectal cancer screening is symptomatic

Abstract

BackgroundSymptomatic invitees are advised not to participate in colorectal cancer (CRC) screening but to directly consult their general practitioner (GP), because fecal immunochemical test (FIT) sensitivity for cancer is not optimal. This recommendation may not always be followed in daily practice. We evaluated how many FIT-positive participants had CRC-related symptoms and whether the presence of symptoms was associated with the presence and location of CRC/advanced neoplasia.MethodsWe prospectively collected data on CRC-related symptoms in all FIT-positive participants in the Dutch CRC screening program, referred to our endoscopy centers between 2014 and 2016, and evaluated whether symptoms were associated with detected CRC/advanced neoplasia at colonoscopy.ResultsOf 527 FIT-positive participants, 314 had advanced neoplasia, of which 41 had CRC. Overall, 246 (47%; 95% confidence interval (CI) 0.42–0.51) reported CRC-related symptoms. A change in bowel habits (odds ratio (OR) 2.86, CI 1.23–6.62) and visible blood in stool (OR 8.65, CI 2.34–32.0) were associated with the detection of CRC at colonoscopy. We did not observe significant associations between evaluated symptoms and advanced neoplasia.ConclusionsA large proportion of FIT-positive screening participants have CRC-related symptoms. This suggests that current instructions do not retain symptomatic screening invitees from participation and awareness of CRC-related symptoms is inadequate.

Detection of cancers and advanced adenomas in asymptomatic participants in colorectal cancer screening: a cross-sectional study

“…This implies that almost one out of five not detected with CRC would report rectal bleeding, while still only every fourth case of CRC would be identified by a history of rectal bleeding. A similar association between change in bowel habit and rectal bleeding with CRC was observed in the Dutch screening programme 18 while no association was found between symptoms and findings in the English and Scottish guaiac based FOBT screening programme. [19][20][21] Better sensitivity and specificity of FIT compared with guaiac based FOBT may be one reason for this difference.…”

“…In FOBT screening populations, the association between bowel symptoms and the detection of CRC or advanced adenomas is conflicting. [17][18][19][20][21] In FIT positive attenders, change in bowel habits had the strongest association with detection of CRC. However, the sensitivity was low, indicating that only a minority of individuals with CRC would be identified by change in bowel habits.…”

“…17 In FOBT positive screening populations, the prevalence of bowel symptoms is reported to be between 47% and 78%. [18][19][20][21] Systematic reviews and meta-analyses provide evidence for an association between rectal bleeding and CRC in primary and secondary care, 3 4 22 while other 'alarm symptoms' such as change in bowel habits, abdominal pain and bloating have uncertain diagnostic value. 5 23 The usefulness of symptoms in predicting CRC or advanced adenomas in screening populations is contradictory.…”

“…5 23 The usefulness of symptoms in predicting CRC or advanced adenomas in screening populations is contradictory. [17][18][19][20][21] In addition, there is limited attention on the detection rates among truly asymptomatic individuals in these screening populations.…”

The use of electronic healthcare records for colorectal cancer screening referral decisions and risk prediction model development

“…Studies have suggested that large proportions of colorectal cancer screening participants have underlying symptoms [26][27][28] despite recommendations and campaigns for symptomatic individuals to visit their GP. Some of these symptoms can be considered 'low risk, but not no risk' [29] and are often self-limiting but in combination can indicate underlying disease [13,14].…”