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REPLY
Office-Based Testing for Fecal Occult Blood
Harold C. Sox, MD, Editor
2 August 2005 | Volume 143 Issue 3 | Page 236
IN RESPONSE:
In response to Dr. Wolff and Dr. Hoffer, I can but elaborate on my editorial. One concern is using office guaiac in lieu of other, better tests, which is common practice, according to Nadel and colleagues' survey (1). A second concern is placing too much weight on a negative result on a test that misses 95% of colonic neoplasia. The third concern is inefficient use of invasive follow-up tests. The office guaiac has a positive likelihood ratio of 1.68 (2), which means that the probability of high-risk neoplasia rises from 7.0% to 12% after a positive test result, which means doing 8.5 negative follow-up colonoscopies for every positive colonoscopy. When the 6-sample home test is used, the probability would rise from 7.0% to 35%, which would require fewer than 3 colonoscopies to detect an important lesion. Ultimately, physicians must develop better office systems to support home testing and identify nonadherent patients.
I only partially agree with Drs. Jackson and Craig. Fecal occult blood testing using 6 samples obtained at home is an important test because, coupled with colonoscopy when results are positive, it reduces mortality from colorectal cancer from 8.83 deaths per 1000 over 13 years to 5.88 deaths per 1000 (3). It's not a perfect test. Its sensitivity of 23.5% is very poor, so that it generates many negative colonoscopies. But it does reduce colorectal cancer death rates, which is more than you can say for sure about any other colorectal cancer screening test, least of all the office guaiac. We should advocate home testing, and we should develop office systems to help us raise adherence rates to a test that reduces colorectal cancer rates substantially.
Is a bad screening test better than none at all? Now there's a good subject for debate!
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Author and Article Information
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Potential Financial Conflicts of Interest: None disclosed.
1. Nadel MR, Shapiro JA, Klabunde CN, Seeff LC, Uhler R, Smith RA, et al. A national survey of primary care physicians' methods for screening for fecal occult blood. Ann Intern Med. 2005;142:86-94. [PMID: 15657156].
2. Collins JF, Lieberman DA, Durbin TE, Weiss DG. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. Ann Intern Med. 2005;142:81-5. [PMID: 15657155].
3. Mandel JS, Bond JH, Church TR, Snover DC, Bradley GM, Schuman LM, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. 1993;328:1365-71. [PMID: 8474513].
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Office-Based Testing for Fecal Occult Blood: Do Only in Case of Emergency
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- Annals 2005 142: 146-148.
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