Replacing the Guaiac Fecal Occult Blood Test With the Fecal Immunochemical Test Increases Proportion of Individuals Screened in a Large Healthcare Setting

Akram, Ali; Juang, Derek; Bustamante, Ranier; Li, Lin; Earles, Ashley; Ho, Samuel B.; Wang‐Rodriguez, Jessica; Allison, James E.; Gupta, Samir

doi:10.1016/j.cgh.2017.01.025

Cited by 33 publications

(38 citation statements)

References 18 publications

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“…This rate is similar to that determined from a large database of Veteran's Affairs data in the US (42.6%). [46] Based on meta-analysis data, annual HSgFOBT is ~16% [29] to 21% [38] relatively lower than FIT, thus, HSgFOBT adherence rates of 16% lower relative to FIT were assumed.…”

Section: Discussionmentioning

confidence: 99%

Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

Piscitello¹,

Saoud

Fendrick

et al. 2020

Preprint

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BackgroundReal-world adherence to colorectal cancer (CRC) screening strategies is imperfect. The CRC-AIM microsimulation model was used to estimate the impact of imperfect adherence on the relative benefits and burdens of guideline-endorsed, stool-based screening strategies.MethodsPredicted outcomes of multi-target stool DNA (mt-sDNA), fecal immunochemical tests (FIT), and high-sensitivity guaiac-based fecal occult blood tests (HSgFOBT) were simulated for 40-year-olds free of diagnosed CRC. For robustness, imperfect adherence was incorporated in multiple ways and with extensive sensitivity analysis. Analysis 1 assumed adherence from 0%-100%, in 10% increments. Analysis 2 longitudinally applied real-world first-round differential adherence rates (base-case imperfect rates=40% annual FIT vs 34% annual HSgFOBT vs 70% triennial mt-sDNA). Analysis 3 randomly assigned individuals to receive 1, 5, or 9 lifetime (9=100% adherence) mt-sDNA tests and 1, 5, or 9 to 26 (26=100% adherence) FIT tests. Outcomes are reported per 1000 individuals compared with no screening.ResultsEach screening strategy decreased CRC incidence and mortality versus no screening. In individuals screened between ages 50-75 and adherence ranging from 10%-100%, the life-years gained (LYG) for triennial mt-sDNA ranged from 133.1-300.0, for annual FIT from 96.3-318.1, and for annual HSgFOBT from 99.8-320.6. At base-case imperfect adherence rates, mt-sDNA resulted in 19.1% more LYG versus FIT, 25.4% more LYG versus HSgFOBT, and generally had preferable efficiency ratios while offering the most LYG. Completion of at least 21 FIT tests is needed to reach approximately the same LYG achieved with 9 mt-sDNA tests.ConclusionsAdherence assumptions affect the conclusions of CRC screening microsimulations that are used to inform CRC screening guidelines. LYG from FIT and HSgFOBT are more sensitive to changes in adherence assumptions than mt-sDNA because they require more tests be completed for equivalent benefit. At imperfect adherence rates, mt-sDNA provides more LYG than FIT or HSgFOBT at an acceptable tradeoff in screening burden.

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Section: Discussionmentioning

confidence: 99%

Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

Piscitello¹,

Saoud

Fendrick

et al. 2020

Preprint

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“…Performing a probabilistic sensitivity analysis will also help demonstrate variation of estimated outcomes due to uncertainty in model input parameters. Finally, data on studies that have reported on adherence rates are limited and can vary across different populations, healthcare systems, and geographies . Given these caveats, we performed several sensitivity analyses and provided information on the clinical outcomes for each screening modality at different adherence rates.…”

Section: Discussionmentioning

confidence: 99%

“…One‐time adherence to colonoscopy was estimated at 38% . The one‐time adherence rates for FIT and HS‐gFOBT were modeled at 42.6% and 33.4%, respectively, based on an observational study of 7898 patients who were offered stool‐based CRC screening . We assumed that the adherence rate of FIT‐DNA was similar to that of FIT.…”

Section: Methodsmentioning

confidence: 99%

Quantifying the impact of adherence to screening strategies on colorectal cancer incidence and mortality

et al. 2019

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Current recommendations of The US Preventive Services Task Force (USPSTF) on colorectal cancer (CRC) screening strategies are based on models that assume 100% adherence. Since adherence can have a large effect on screening outcomes, we aimed to compare the effectiveness of CRC screening strategies under reported adherence rates at the population level. We developed and validated a microsimulation model to assess the effectiveness of colonoscopy (COL), flexible sigmoidoscopy (FS), highsensitivity guaiac fecal occult blood-test (HS-gFOBT), fecal immunochemical test (FIT), multitarget stool DNA test (FIT-DNA), computed tomography colonography (CTC), and methylated SEPT9 DNA test (SEPT9) in terms of CRC incidence and mortality, incremental life years gained (LYG), number of colonoscopies, and adverse events for men and women 50 years or older over their lifetime. We assessed outcomes under 100% adherence rates and reported adherence rates. We also performed sensitivity analyses to evaluate the impact of varying adherence levels on CRC outcomes. Assuming 100% adherence, FIT-DNA, FIT, HS-gFOBT, and SEPT9 averted 42-45 CRC cases and 25-26 CRC deaths, COL 46 cases and 26 deaths, CTC 39 cases and 23 deaths, FS 32 cases and 19 deaths per 1000 individuals. Assuming reported adherence, SEPT9 averted 37 CRC cases and 23 CRC deaths, COL 34 cases and 20 deaths, FIT-DNA, FIT, CTC and HS-gFOBT 16-25 cases and 10-16 deaths per 1000 individuals. LYG reflected the effectiveness of each strategy in reducing CRC cases and deaths. Adverse events were more common for COL (3.7 per 1000 screened) and annual SEPT9 (3.4 per 1000 screened), and proportional to the number of colonoscopies. Among the screening strategies recommended by USPSTF, colonoscopy results in the largest benefit when we account for adherence. Adherence rates higher than 65%-70% would be required for any stool or blood-based screening modality to match the benefits of colonoscopy. K E Y W O R D S adherence, colorectal cancer screening, compliance, simulation modeling | 825 D'ANDREA Et Al. F I G U R E 1 Structure of the screening strategy of colonoscopy every ten years (reference strategy) included in the microsimulation model.The diagram shows the structure of the model for colonoscopy offered every ten years. The yellow lines indicate the time between two subsequent screening referrals in which non-compliant patients can develop adenomas and/or cancer (COL 10 years). The dotted lines indicate the time to follow-up. When the time on the dotted lines is not specified in the diagrams, it corresponds to the time interval between two screening referrals of a specific strategy. COL, colonoscopy every ten years

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“…Although non-invasive screening tests provide options to individuals who do not want to be screened by more invasive methods, the efficacy of these tests is largely dependent upon consistently completing them when required. Relatively poor test completion rates are one reason why HSgFOBT has been suggested to be replaced by FIT in particular US settings where HSgFOBT is still used [38]. As demonstrated in this report, harm-benefit tradeoffs and optimal test selection directly depend upon particular adherence patterns.…”

Section: Discussionmentioning

confidence: 87%

Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

Piscitello¹,

Saoud

Fendrick

et al. 2020

PLoS ONE

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Background Real-world adherence to colorectal cancer (CRC) screening strategies is imperfect. The CRC-AIM microsimulation model was used to estimate the impact of imperfect adherence on the relative benefits and burdens of guideline-endorsed, stool-based screening strategies. Methods Predicted outcomes of multi-target stool DNA (mt-sDNA), fecal immunochemical tests (FIT), and high-sensitivity guaiac-based fecal occult blood tests (HSgFOBT) were simulated for 40-year-olds free of diagnosed CRC. For robustness, imperfect adherence was incorporated in multiple ways and with extensive sensitivity analysis. Analysis 1 assumed adherence from 0%-100%, in 10% increments. Analysis 2 longitudinally applied real-world first-round differential adherence rates (base-case imperfect rates = 40% annual FIT vs 34% annual HSgFOBT vs 70% triennial mt-sDNA). Analysis 3 randomly assigned individuals to receive 1, 5, or 9 lifetime (9 = 100% adherence) mt-sDNA tests and 1, 5, or 9 to 26 (26 = 100% adherence) FIT tests. Outcomes are reported per 1000 individuals compared with no screening. Results Each screening strategy decreased CRC incidence and mortality versus no screening. In individuals screened between ages 50–75 and adherence ranging from 10%a-100%, the life-years gained (LYG) for triennial mt-sDNA ranged from 133.1–300.0, for annual FIT from 96.3–318.1, and for annual HSgFOBT from 99.8–320.6. At base-case imperfect adherence rates, mt-sDNA resulted in 19.1% more LYG versus FIT, 25.4% more LYG versus HSgFOBT, and generally had preferable efficiency ratios while offering the most LYG. Completion of at least 21 FIT tests is needed to reach approximately the same LYG achieved with 9 mt-sDNA tests. Conclusions Adherence assumptions affect the conclusions of CRC screening microsimulations that are used to inform CRC screening guidelines. LYG from FIT and HSgFOBT are more sensitive to changes in adherence assumptions than mt-sDNA because they require more tests be completed for equivalent benefit. At imperfect adherence rates, mt-sDNA provides more LYG than FIT or HSgFOBT at an acceptable tradeoff in screening burden.

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Replacing the Guaiac Fecal Occult Blood Test With the Fecal Immunochemical Test Increases Proportion of Individuals Screened in a Large Healthcare Setting

Abstract: In a retrospective study of patients at a Veterans' administration healthcare system, replacing the gFOBT with the FIT increased the proportion of patients who completed CRC screening. Replacement of the gFOBT with the FIT should be strongly considered by all healthcare systems.

Cited by 33 publications

References 18 publications

Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

Quantifying the impact of adherence to screening strategies on colorectal cancer incidence and mortality

Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

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