Refinement and validation of the IDIOM score for predicting the risk of gastrointestinal cancer in iron deficiency anaemia

Almilaji, Orouba; Smith, Carla; Surgenor, Susan L; Clegg, Andrew; Williams, E.; Thomas, Peter; Snook, Jonathon

doi:10.1136/bmjgast-2020-000403

Cited by 12 publications

(17 citation statements)

References 32 publications

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“…47 The overall prevalence of significant underlying GI pathology, and in particular of GI malignancy, is low in NAID. 25 In the absence of other pointers, GI investigation generally is not warranted in premenopausal women since the cause is likely to be menstrual blood loss and/or recent pregnancy (see the Special situations section). The threshold for investigation of NAID should however be low in men, postmenopausal women, and those with GI symptoms or a family history of GI pathology.…”

Section: Non-anaemic Iron Deficiencymentioning

confidence: 99%

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British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

Snook

Bhala

Beales

et al. 2021

Gut

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159

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Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA—for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease— with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.

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Section: Non-anaemic Iron Deficiencymentioning

confidence: 99%

“…Further refinement of the risk stratification process with the incorporation of additional clinical variables may allow the identification of sizeable subgroups who can safely avoid invasive procedures altogether. 25…”

Section: Who To Investigatementioning

confidence: 99%

British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

Snook

Bhala

Beales

et al. 2021

Gut

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159

111

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“…The full IDIOM model was almost identical to the original model using only the training dataset [ 4 ]. Statistical assessment of the validity and goodness of fit of the logistic regression model (smoothed scatter plot, deviance and residual test, Cook’s distance and standardised residual errors, variance inflation factor, Akaike information criterion, analysis of variance χ 2 test, pseudo R 2 ) was satisfactory.…”

Section: Methodsmentioning

confidence: 99%

“…With the aim of risk stratification, we have previously built and internally validated a binary multivariable logistic model to predict the risk of GI cancer in patients with confirmed IDA, based on four simple variables: age, sex, haemoglobin concentration (Hb) and mean cell volume (MCV)—the IDIOM model (iron deficiency as an indicator of malignancy) [ 4 ]. Identifying subgroups of IDA patients who are at increased/reduced risk of GI cancer might lead to (a) accelerating the investigation of those at high predicted risk, with potential prognostic implications, and (b) helping those at low predicted risk to avoid unnecessary invasive procedures.…”

Section: Introductionmentioning

confidence: 99%

Broad external validation of a multivariable risk prediction model for gastrointestinal malignancy in iron deficiency anaemia

et al. 2021

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Background Using two large datasets from Dorset, we previously reported an internally validated multivariable risk model for predicting the risk of GI malignancy in IDA—the IDIOM score. The aim of this retrospective observational study was to validate the IDIOM model using two independent external datasets. Methods The external validation datasets were collected, in a secondary care setting, by different investigators from cohorts in Oxford and Sheffield derived under different circumstances, comprising 1117 and 474 patients with confirmed IDA respectively. The data were anonymised prior to analysis. The predictive performance of the original model was evaluated by estimating measures of calibration, discrimination and clinical utility using the validation datasets. Results The discrimination of the original model using the external validation data was 70% (95% CI 65, 75) for the Oxford dataset and 70% (95% CI 61, 79) for the Sheffield dataset. The analysis of mean, weak, flexible and across the risk groups’ calibration showed no tendency for under or over-estimated risks in the combined validation data. Decision curve analysis demonstrated the clinical value of the IDIOM model with a net benefit that is higher than ‘investigate all’ and ‘investigate no-one’ strategies up to a threshold of 18% in the combined validation data, using a risk cut-off of around 1.2% to categorise patients into the very low risk group showed that none of the patients stratified in this risk group proved to have GI cancer on investigation in the validation datasets. Conclusion This external validation exercise has shown promising results for the IDIOM model in predicting the risk of underlying GI malignancy in independent IDA datasets collected in different clinical settings.

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“…They are also strongly associated with the finding of iron deficiency anaemia (IDA) at presentation 19 – 23 , believed to be due to chronic low-grade loss of (iron-rich) blood from the tumour bed, resulting in the slowly progressive depletion of body iron stores. IDA often occurs before any other clinical manifestations of CRC 24 , and as the development of IDA is gradual it may precede the diagnosis of CRC by up to 2 years 25 . This provides a window of opportunity for the detection of CRC earlier in the disease course, particularly for tumours of the right colon, and is the basis of the recommendation for urgent investigation of unexplained IDA in the at-risk population 26 , 27 .…”

Section: Introductionmentioning

confidence: 99%

Evidence for improved prognosis of colorectal cancer diagnosed following the detection of iron deficiency anaemia

Almilaji

Parry

Docherty

et al. 2021

Sci Rep

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Iron deficiency anaemia (IDA) is common in colorectal cancer (CRC), especially, in right-sided CRC which is known to have an overall worse prognosis. The associations between diagnostic pathway (Bowel Cancer Screening Programme (BCSP), IDA, symptomatic) and tumour side/stage was assessed using logistic regression models in 1138 CRC cases presenting during 2010–2016 at a single secondary-care centre in the UK. In the IDA sub-group, the relationship between CRC stage and the event of having a blood count prior to CRC diagnosis was examined using Bayesian parametric survival model. IDA was found as the only significant predictor of right-sided CRC (OR 10.61, 95% CI 7.02–16.52). Early-stage CRC was associated with both the IDA (OR 1.65, 95% CI 1.18–2.29) and BCSP pathway (OR 2.42, 95% CI 1.75–3.37). At any age, the risk of detecting CRC at late-stage was higher in those without a previous blood count check (hazard ratio 1.53, 95% credibility interval 1.08–2.14). The findings of this retrospective observational study suggest a benefit from diagnosing CRC through the detection of IDA, and warrant further research into the prognosis benefit of systematic approach to blood count monitoring of the at-risk population.

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Refinement and validation of the IDIOM score for predicting the risk of gastrointestinal cancer in iron deficiency anaemia

Cited by 12 publications

References 32 publications

British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults

Broad external validation of a multivariable risk prediction model for gastrointestinal malignancy in iron deficiency anaemia

Evidence for improved prognosis of colorectal cancer diagnosed following the detection of iron deficiency anaemia

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