Journal of General Internal Medicine

, Volume 25, Issue 11, pp 1211–1221 | Cite as

Effect of Verification Bias on the Sensitivity of Fecal Occult Blood Testing: a Meta-Analysis

  • Alan S. Rosman
  • Mark A. Korsten



There is controversy regarding the sensitivity of fecal occult blood tests (FOBT) for detecting colorectal cancer. Many of the published studies failed to correct for verification bias which may have increased the sensitivity.


A meta-analysis of published studies evaluating the sensitivity and specificity of chemical-based FOBT for colorectal cancer was performed. Studies were included if both cancer and control subjects underwent confirmatory testing. We also included studies that attempted to correct for verification bias by either performing colonoscopy on all subjects regardless of the FOBT result or by using longitudinal follow-up. We then compared the sensitivity, specificity, and other diagnostic characteristics of the studies that attempted to correct for verification (n = 10) vs. those that did not correct for this bias (n = 19).


The pooled sensitivity of guaiac-based FOBT for colorectal cancer of studies without verification bias was significantly lower than those studies with this bias [0.36 (95% CI 0.25-0.47) vs. 0.70 (95% CI 0.60–0.80), p = 0.001]. The pooled specificity of the studies without verification bias was higher [0.96 (95% CI 0.94–0.97) vs. 0.88 (95% CI 0.84–0.91), p < 0.005]. There was no significant difference in the area under the summary receiver operating characteristic curves. More sensitive chemical-based FOBT methods (e.g., Hemoccult® SENSA®) had a higher sensitivity but a lower specificity than standard guaiac methods.


The sensitivity of guaiac-based FOBT for colorectal cancer has been overestimated as a result of verification bias. This test may not be sensitive enough to serve as an effective screening option for colorectal cancer.


fecal occult blood guaiac colorectal cancer summary receiver operating characteristic curve meta-analysis 


Funding Source

Department of Veterans Affairs.

Conflict of interest

None disclosed.

Author participation

Both authors had access to the data and a role in writing the manuscript.


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Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  1. 1.Section of Gastroenterology and Medicine ProgramJames J. Peters Veterans Affairs Medical CenterBronxUSA
  2. 2.Mount Sinai School of Medicine (NYU)New YorkUSA

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