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Screening for colorectal cancer: A critical review

World Journal of Surgery volume 13, pages 38–44 (1989)Cite this article

Abstract

This article discusses the place of symptom detection, endoscopy, and fecal occult blood testing in population screening for colorectal cancer. There is now considerable evidence that screening the population over the age of 50 years for occult blood in the feces will result in an increased yield of tumors localized to the bowel at the time of surgical treatment. These tumors also have other favorable prognostic features and it is likely that the prognosis of this group will be better than the prognosis of patients presenting with symptoms in the usual way. Because of the biases that result from the selection and detection of tumors in screening studies, the mortality results of the control trials now underway must be awaited until it is known whether population screening is of real value.

In chemical fecal occult blood screening tests, a compromise has to be made between sensitivity and specificity. The fecal occult blood test most widely used and the one that has been subjected to the most evaluation in screening studies is the guaiac-based slide test, Hemoccult. The predictive value of a positive test for invasive cancer is 11–17%, and for adenomas, 36–41%. This specificity is achieved at a loss of sensitivity, the interval cancer rate reported in screening studies being over 20%. Newly developed immunological techniques appear to be more sensitive and specific, but require further evaluation in population screening studies.

Résumé

Dans cet article, on traite la place de la détection des symptômes, de l'endoscopie, et de la recherche de sang occulte dans les selles pour le dépistage du cancer colorectal. Il est maintenant prouvé que la recherche de sang occulte dans les selles augmente le pourcentage de tumeurs colorectales découvertes sans extension extradigestive au moment de la chirurgie. Ces tumeurs ont d'autres caractéristiques pronostiques favorables et il est possible que le pronostic des tumeurs détectées de cette manière soit meilleur que pour les patients présentant des symptômes classiques de tumeurs colorectales.

Cependant en raison des biais dus aux modes de sélection et de détection des tumeurs décelées par cette méthode de dépistage, il faut attendre les résultats sur la mortalité des essais contrôlés actuellement en cours pour savoir si ce dépistage est valable. Il existe un compromis entre la sensibilité et la spécificité des tests destinés à détecter le sang occulte dans les selles. Le test le plus utilisé et le plus étudié de nos jours est l'Hémoccult, test basé sur la lecture d'une lame contenant le guaïc. La valeur prédictive positive du cancer invasif est de 11 à 17%, et celle de l'adénome est de 36 à 41%. Cette spécificité est atteinte aux dépens d'une perte de sensibilité, les cancers détectés dans l'intervalle (après un premier test négatif) de deux ans étant de 20%. Des techniques immunologiques nouvelles paraissent être plus sensibles et plus spécifiques mais nécessitent plus d'évaluation pour savoir si elles sont applicables aux études de dépistage de masse.

Resumen

Este artículo revisa el valor de las pruebas de tamizaje para cáncer colorrectal a saber: detección de síntomas intestinales, endoscopia, y examen de sangre oculta en heces. Hoy existe evidencia considerable de que el tamizaje de la población de edad mayor de 50 años mediante el examen de sangre oculta en heces résulta en un aumento en el número de tumores localizados (sin extensión regional) encontrados en el momento de realizar el tratamiento quirúrgico. Los tumores en este estadio exhiben otras características favorables en cuanto a pronóstico, y es posible que el pronóstico en este grupo sea mejor que en los pacientes que se presentan con la sintomatología usual. Sin embargo, debido al sesgo que resulta de la selección y detección de tumores en los estudios de tamizaje, los resultados de mortalidad que emergen de los ensayos controlados actualmente en progreso deben esperar hasta cuando se conozca si el tamizaje poblacional es de real valor.

En la realización de las pruebas de tamizaje de sangre oculta en heces, hay que asumir una transacción entre sensibilidad y especificidad. La prueba de sangre oculta mayormente utilizada y la que ha sido sometida a mayor evaluación en los estudios de tamizaje es la de laminilla con guayaco, Haemocult. El valor predictivo de una prueba positiva para cáncer invasivo es 11–17%, y para adenomas, 36–41%. Este nivel de especificidad se logra a costa de una pérdida de sensibilidad; la tasa de cáncer de intervalo reportada en los estudios de tamizaje superior a 20%. Las técnicas inmunológicas recientemente desarrolladas parecen ser más sensibles y específicas, pero requieren mayor evaluación en los programas de tamizaje poblacional.

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Affiliations

  1. Department of Surgery, University Hospital, NG7 2UH, Nottingham, England, UK

    Jack D. Hardcastle M.A., M.Chir., F.R.C.S., F.R.C.P. & Geoffrey Pye B.Sc, M.Sc, D.M., F.R.C.S.

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  1. Jack D. Hardcastle M.A., M.Chir., F.R.C.S., F.R.C.P.
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  2. Geoffrey Pye B.Sc, M.Sc, D.M., F.R.C.S.
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Mr. G. Pye is supported by Medical Research Council Grant.

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Hardcastle, J.D., Pye, G. Screening for colorectal cancer: A critical review. World J. Surg. 13, 38–44 (1989). https://doi.org/10.1007/BF01671152

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Keywords

  • Adenoma
  • Fecal Occult Blood Test
  • Fecal Occult Blood
  • Population Screening
  • Interval Cancer