One-Time Fecal Immunochemical Screening for Advanced Colorectal Neoplasia in Patients with CKD (DETECT Study)

Abstract

BackgroundIn patients with CKD, the risk of developing colorectal cancer is high and outcomes are poor. Screening using fecal immunochemical testing (FIT) is effective in reducing mortality from colorectal cancer, but performance characteristics of FIT in CKD are unknown.MethodsTo determine the detection rates and performance characteristics of FIT for advanced colorectal neoplasia (ACN) in patients with CKD, we used FIT to prospectively screen patients aged 35–74 years with CKD (stages 3–5 CKD, dialysis, and renal transplant) from 11 sites in Australia, New Zealand, Canada, and Spain. All participants received clinical follow-up at 2 years. We used a two-step reference standard approach to estimate disease status.ResultsOverall, 369 out of 1706 patients who completed FIT (21.6%) tested positive; 323 (87.5%) underwent colonoscopies. A total of 1553 (91.0%) completed follow-up; 82 (4.8%) had died and 71 (4.2%) were lost. The detection rate of ACN using FIT was 6.0% (5.6%, 7.4%, and 5.6% for stages 3–5 CKD, dialysis, and transplant). Sensitivity, specificity, and positive and negative predictive values of FIT for ACN were 0.90, 0.83, 0.30, and 0.99, respectively. Of participants who underwent colonoscopy, five (1.5%) experienced major colonoscopy-related complications, including bowel perforation and major bleeding.ConclusionsFIT appears to be an accurate screening test for patients with CKD, such that a negative test may rule out the diagnosis of colorectal cancer within 2 years. However, the risk of major complications from work-up colonoscopy are at least ten-fold higher than in the general population.

Assessment of kidney transplant suitability for patients with prior cancers: is it time for a rethink?

“…Similar magnitude of benefits and uncertainties have been shown in a model of implementing routine ultrasound screening to detect asymptomatic renal cell cancer in kidney transplant recipients . One recent prospective cohort study showed that faecal occult blood testing (FOBT) was an accurate screening test to detect advanced colorectal neoplasia in kidney transplant recipients; with test sensitivity, specificity, positive predictive value and negative predictive value of 97%, 82%, 26% and 98%, respectively . Nevertheless, there are continuing uncertainties relating to the diagnostic test performance of other population‐based cancer screening techniques including cervical cancer screening test and mammography; the competing risks of cardiovascular and infection‐related mortality; the projected reduced survival of patients with ESKD; and the beliefs and concerns of patients regarding cancer screening relative to their health needs and priorities, and therefore, the strengths of the current recommendations for cancer screening in the kidney transplant recipients remain indeterminate .…”

“…In the absence of adequate clinical evidence to support the recommendations of transplant eligibility or waiting time across all cancer types, the creation of a global repository of patients with all cancer types (including accurate records of the updated histology, prognostic factors, staging and classification and response to treatment) for patients with EKSD (dialysis and transplantation) will help inform future clinical guidelines. There continues to be uncertainty as to the applicability of age‐ and gender‐specific general population cancer screening guidelines to patients with ESKD pre‐ and post‐transplantation and future research examining the test performance of cancer screening in this population should be prioritized , including the appropriateness and cost‐effectiveness of screening renal tract ultrasound (to detect renal cell carcinoma) and lung imaging (to detect lung cancer particularly in higher risk population such as former/current smokers) given the higher incidence of these cancers in patients with ESKD . In addition, a greater emphasis on attaining effective consumer engagement along with a transparent public consultative process in clinical practice guideline development is critical, particularly on the standpoints of eligibility and ‘acceptable’ waiting times for patients with prior cancers (for both potential live and deceased donor kidney transplantation).…”

KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantation

“…A recent study of screening colorectal cancer using one-time fecal immunochemical diagnostic tests in patients with CKD (including kidney transplant recipients) has shown favorable performance, but major complications from workup colonoscopies are high. 72 There are also considerable variations in screening practices across major transplant centers worldwide. Population-based screening programs for cervical, colorectal, breast, and prostate cancers are universal in most high-income countries.…”

Post-transplant cancer: An epidemiological evaluation

“…[57][58][59] The Detecting Bowel Cancer in Chronic Kidney Disease (CKD) (DETECT) study examined the test performance characteristic of screening bowel cancer using fecal immunochemical testing (FIT) in patients across the full spectrum of CKD (stages 3-5, dialysis and transplant). 60 The study found that the prevalence of advanced colorectal neoplasia is high (approx. 2 times higher than the general population) and the test accuracy of FIT is also high.…”