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      High test positivity and low positive predictive value for colorectal cancer of continued faecal occult blood test screening after negative colonoscopy

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          Abstract

          Objectives

          The English Bowel Cancer Screening Programme offers biennial guaiac faecal occult blood test (gFOBT) screening to 60–74-year-olds. Participants with positive results are referred for follow-up, but many do not have significant findings. If they remain age eligible, these individuals are reinvited for gFOBT screening. We evaluated the performance of repeat screening in this group.

          Methods

          We analysed data on programme participants reinvited to gFOBT screening after either previous negative gFOBT ( n = 327,542), or positive gFOBT followed by a diagnostic investigation negative for colorectal cancer (CRC) or adenomas requiring surveillance ( n = 42,280). Outcomes calculated were uptake, test positivity, yield of CRC, and positive predictive value (PPV) of gFOBT for CRC.

          Results

          For participants with a previous negative gFOBT, uptake in the subsequent screening round was 87.5%, positivity was 1.3%, yield of CRC was 0.112% of those adequately screened, and the PPV of gFOBT for CRC was 9.1%. After a positive gFOBT and a negative diagnostic investigation, uptake in the repeat screening round was 82.6%, positivity was 11.3%, CRC yield was 0.172% of participants adequately screened, and the PPV of gFOBT for CRC was 1.7%.

          Conclusion

          With high positivity and low PPV for CRC, the suitability of routine repeat gFOBT screening in two years among individuals with a previous positive test and a negative diagnostic examination needs to be carefully considered.

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          Most cited references18

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          Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies.

          The miss rate of colonoscopy for neoplasms is poorly understood. The aim of this study was to determine the miss rate of colonoscopy by same day back-to-back colonoscopy. Two consecutive same day colonoscopies were performed in 183 patients. The patients were randomized to undergo the second colonoscopy by the same or a different endoscopist and in the same or different position. The overall miss rate for adenomas was 24%, 27% for adenomas or = 1 cm. Patients with two or more adenomas at the first examination were more likely than patients with no or one adenoma detected at the first examination to have one or more adenomas at the second examination (odds ratio, 3.3; 95% confidence interval, 1.69-6.46). Right colon adenomas were missed more often (27%) than left colon adenomas (21%), but the difference was not significant. There was evidence of variation in sensitivity between endoscopists, but significant miss rates for small adenomas were found among essentially all endoscopists. Using current colonoscopic technology, there are significant miss rates for adenomas or = 1 cm. The results suggest the need for improvements in colonoscopic technology.
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            Interval cancers after negative colonoscopy: population-based case-control study.

            The risk of colorectal cancer after a previous negative colonoscopy is very low. Nevertheless, interval cancers occur. We aimed to assess the characteristics and predictors of interval cancers after negative colonoscopy. A population-based case-control study was conducted in Southern Germany in 2003-7. Sociodemographic and tumour characteristics were compared among 78 patients with interval cancers occurring 1-10 years after a negative colonoscopy and 433 colorectal cancers detected at screening. In addition, the indication for the preceding negative colonoscopy and its completeness were compared between patients with interval cancers and 515 controls with a preceding negative colonoscopy. 56.4% of interval cancers occurred among women compared with 33.7% of cases detected by screening (p=0.0001). After adjustment for covariates, female sex (OR 2.28, 95% CI 1.35 to 3.83) and location in the caecum or ascending colon (OR 1.98, 95% CI 1.17 to 3.35) were independently associated with occurrence of interval cancers. The preceding negative colonoscopy was more commonly conducted because of a positive faecal occult blood test (26.0% vs 12.9%, p=0.009) and was more often incomplete (caecum not reached: 18.1% vs 6.7%, p=0.001) among interval cancer cases than among controls. Characteristics of the preceding negative colonoscopy strongly and independently associated with occurrence of interval cancers were follow-up of a positive faecal occult blood test among men (OR 5.49, 95% CI 2.10 to 14.35) and incompleteness among women (OR 4.38, 95% CI 1.69 to 11.30). The observed patterns suggest that a substantial proportion of interval cancers are due to neoplasms missed at colonoscopy and are potentially preventable by enhanced performance of colonoscopy.
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              Interval Colorectal Cancer After Colonoscopy: Exploring Explanations and Solutions.

              There is good evidence that colorectal cancer (CRC) screening has been successful at reducing both CRC incidence and death. Colonoscopy, utilized as either a primary screening tool or a follow-up exam when other screening tests are positive, has significantly contributed to these encouraging trends. However, it is well recognized that colonoscopy is not perfectly sensitive for the detection of neoplasia and that CRC can be diagnosed within a short interval following a colonoscopy that did not detect one. The literature surrounding these cases has rapidly expanded over the last decade. Specifically, studies aimed at understanding the frequency of these events and the likely explanations for their occurrence have been performed. This review will highlight current knowledge around the epidemiology of interval post colonoscopy CRC (PCCRC). The common explanations for these cancers including missed lesions, new lesions, and incompletely resected lesions will be reviewed and their contribution to interval PCCRC estimated. Finally, the relationship of these putative explanations to potential opportunities to prevent interval PCCRC will be explored. Current approaches to prevention largely center on consistent adherence to quality colonoscopy standards. Future approaches include advances in technology to better visualize the colon and adequately resect detected neoplasia. Finally, improvement in training as well as development of a culture of continuous quality improvement will be essential to maximize the benefits of colonoscopy in daily clinical practice.
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                Author and article information

                Journal
                J Med Screen
                J Med Screen
                MSC
                spmsc
                Journal of Medical Screening
                SAGE Publications (Sage UK: London, England )
                0969-1413
                1475-5793
                03 May 2017
                June 2018
                : 25
                : 2
                : 70-75
                Affiliations
                [1 ]Cancer Screening and Prevention Research Group, Department of Surgery and Cancer, Imperial College London, London, UK
                [2 ]NHS Cancer Screening Programmes, Fulwood House, Sheffield, UK
                Author notes
                [*]Wendy S Atkin, Department of Surgery and Cancer, Medical School Building, Norfolk Place, St Mary’s Campus, Imperial College London, London W2 1PG, UK. Email: w.atkin@ 123456imperial.ac.uk
                Article
                10.1177_0969141317698501
                10.1177/0969141317698501
                5956562
                28467146
                a09adafc-fc06-4a4e-9c74-d85fc3a7631c
                © The Author(s) 2017

                This article is distributed under the terms of the Creative Commons Attribution 3.0 License ( http://www.creativecommons.org/licenses/by/3.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 24 August 2016
                : 16 February 2017
                Funding
                Funded by: Cancer Research UK, FundRef http://doi.org/10.13039/501100000289;
                Award ID: A16894
                Categories
                Original Articles

                Medicine
                colorectal cancer,gfobt,colonoscopy,screening programme,faecal occult blood test
                Medicine
                colorectal cancer, gfobt, colonoscopy, screening programme, faecal occult blood test

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