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Published online before print
August 6, 2010

CA Cancer J Clin 2010; 60:275-276
doi: 10.3322/caac.20084

© 2010 American Cancer Society

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Articles by Dreyfuss, J. H.

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Articles by Dreyfuss, J. H.

News and Views

Fecal Occult Blood Testing Has Great Potential as a Screening Tool for
Colorectal Cancer
John Henry Dreyfuss

In 2005, researchers from the Centers for Disease Control and
Prevention, the National Cancer Institute, and the American
Cancer Society (ACS) reported the disconcerting results of a
national survey conducted between 1999 and 2000 of fecal occult
blood testing (FOBT) by primary care physicians (Annals of
Internal Medicine 2005;142:86-94). Contrary to guidelines, there
was substantial use of single-sample, in-office testing reported
and abnormal FOBT results were frequently followed by a repeat
FOBT or by sigmoidoscopy rather than colonoscopy. A follow-up
publication (Journal of General Internal Medicine 2010 Apr 10
[Epub ahead of print]) from the same organizations reported
encouraging progress during the subsequent 7 years, but substantial
room for improvement in guideline adherence remains.

Despite suboptimal implementation, stool testing remains an
important option for colorectal cancer (CRC) screening, explains
Robert Smith, PhD, director of Cancer Screening for the ACS and
a co-author of both reports. In fact, FOBT "meets all the classic
criteria for a good screening test," says Dr. Smith. "But the tests
themselves are highly vulnerable to quality assurance failures."

"Currently," Dr. Smith says, "the 3 biggest challenges [to successful
implementation of FOBT] are 1) getting primary care physicians
to stop using in-office FOBT; 2) [primary care physicians] starting
to use high-sensitivity, guaiac- or immunochemistry-based tests
as opposed to the lower sensitivity tests; and 3) getting the
public to adhere to annual FOBT testing."

The researchers conducted a cross-sectional, national survey of
1134 primary care physicians who had reported ordering or performing
FOBT in the 2006-2007 National Survey of Primary Care Physicians'
Recommendations and Practices for Cancer Screening. The main measures
in this study were self-reported data regarding details of FOBT
implementation and follow-up of patients with positive results.

Inappropriate Use of In-Office
FOBT

FOBT using 3 separate stool samples collected at home has been
shown to be an effective strategy for reducing CRC incidence
and mortality. Conversely, the authors wrote, "...in-office
FOBT [of a sample collected during a digital rectal examination
(DRE)] misses 95% of cases of advanced neoplasia, giving patients
a false sense of reassurance."

Disappointingly, 32.5% of primary care physicians participating in
the 1999 through 2000 survey reported using only single-sample,
in-office sample collection by DRE for the majority of their
patients, and another 41.2% used both 3 samples collected at
home, as recommended by ACS guidelines, as well as single-sample
collection. Between 2006 and 2007, the corresponding results
were 24.9% and 52.9%, respectively.

Low-Sensitivity Versus High-Sensitivity
FOBT

The ACS guidelines recommend the use of high-sensitivity, guaiac-based
or immunochemical FOBTs (also known as fecal immunochemical
tests [FITs]). Between 2000 and 2001 and 2006 and 2007, the
percentage of physicians using low-sensitivity, guaiac-based
tests decreased from 77.4% to 61.1%, with an increase in the
use of high-sensitivity tests from 13.1% to 22.0%. In the earlier
survey, 6.5% of physicians reported the use of other tests, a
category that included FITs as well as nonrecommended options such as
"throw-in-the-bowl" tests. By 2006 through 2007, 8.9% of physicians
specifically reported the use of FITs.

Improving FOBT Adherence

No matter the technique, "stool testing is only going to be
effective if it's done annually," Dr. Smith says.

One approach that can improve patient adherence to annual testing
is to counsel patients during the visit in which FOBT is prescribed.
Physicians, nurses, and other staff can all help patients understand
the importance of at-home FOBT, and how to complete the test.
"A casual recommendation for stool testing," Dr. Smith explains,
"is not nearly as effective as carefully explaining to the patient
how important it is to undergo these tests and that there's an
expectation that these tests will be returned for processing."

Another strategy for improving adherence is the use of reminder
systems. The researchers noted that, "...patient and provider
reminder systems have been shown to be effective in increasing
adherence, but were reported by only a minority of physicians
in our [2006-2007] survey." Of those who administered at-home
tests, 44.3% of 2006 through 2007 survey respondents and 29.7%
of 2000 through 2001 survey respondents reported that they had
mechanisms in place to remind patients to complete the test.
Mechanisms reported in the 2006 through 2007 survey included
chart reminders or other office system reminders (29.7%), telephone
reminders (13.3%), and mail reminders (7.2%).

Diagnostic Workup After Positive FOBT
Results

ACS guidelines specify the use of colonoscopy for the evaluation
of patients with positive FOBT results. In the 2000 through
2001 and 2006 through 2007 surveys, 29.7% and 17.8% of physicians,
respectively, recommended repeating the FOBT as the initial
test after a positive result. Although adherence to annual testing
provides sufficient program sensitivity, the sensitivity of a
single FOBT is too low for a diagnostic test. If the FOBT is used in
this context, a false-positive follow-up FOBT could prevent
recognition of cancers suggested by an initial true-positive
screening FOBT.

Need for Improvement

The results of these 2 surveys demonstrated some improvement took
place during the intervening 7 years. However, the authors conclude
that, "Although FOBT is an important option for colorectal cancer
screening, our study suggests that its potential to save lives is not
currently being realized because many physicians are continuing to
use inappropriate implementation methods...Intensified efforts to
inform physicians of recommended techniques and promote the use of
tracking systems are needed."

A fecal
occult blood test card is shown.

Credit: Beckman Coulter, Inc.

Comments:

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Complication Influence on Fecal Occult Blood Testing

Yuesheng Xia, et al.

CA Online, 13 Aug 2010 [Full
text]

How to improve colorectal cancer screening?

Ronghuai Zhang, et al.

CA Online, 18 Aug 2010 [Full
text]

This Article

Full
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All Versions of this
Article:
caac.20084v1

60/5/275    most
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