Falvey James, Frampton Christopher M A, Gearry Richard B, Hudson Ben, Whiteley Lucinda
Gastroenterologist, Department of Gastroenterology, Christchurch Hospital, Te Whatu Ora Waitaha, Christchurch.
Professor of Biostatistics, Department of Medicine, University of Otago, Christchurch Campus, Christchurch.
N Z Med J. 2023 Jul 7;136(1578):55-76. doi: 10.26635/6965.5966.
Incorporating faecal haemoglobin (FHb) measurement using the faecal immunochemical test (FIT) in the investigation pathway for patients with colorectal symptoms may improve access to colonoscopy for those at greatest risk of significant disease.
To derive a colorectal symptom pathway incorporating standard clinical and FIT data to guide referral, triage, and prioritisation of cases in New Zealand.
Diagnostic accuracy of FIT to rule out colorectal cancer (CRC) was determined by meta-analysis. Thereafter, the risk of CRC after FIT was estimated for common clinical presentations by Bayesian methodology, using a specifically collated retrospective cohort of symptomatic cases. A symptom/FIT pathway was developed iteratively following multi-disciplinary engagement.
Eighteen studies were included in meta-analysis. The sensitivity and specificity for CRC were 89.0% (95%CI 87.0-90.9%) and 80.1% (95%CI 77.7-82.4%) respectively, at a FHb threshold of >10mcg haemoglobin per gram stool, and 95.7% (95%CI 93.2-97.7%) and 60.5% (95%CI 53.8-67.0%) respectively, at the limit of detection. The final pathway was 97% sensitive for CRC, compared with 90% for the current direct access criteria, and requires 47% fewer colonoscopies. Estimated prevalence of CRC among those declined investigation was 0.23%.
Incorporating FIT in the new patient symptomatic pathway as presented appears feasible, safe, and allows for resources to be targeted to those at greatest risk of disease. Further work is needed to ensure equity for Māori if this pathway were introduced nationally.
在结直肠症状患者的检查流程中纳入使用粪便免疫化学检测（FIT）测量粪便血红蛋白（FHb），可能会改善那些患重大疾病风险最高的患者接受结肠镜检查的机会。
制定一个结合标准临床和FIT数据的结直肠症状检查流程，以指导新西兰病例的转诊、分诊和优先级排序。
通过荟萃分析确定FIT排除结直肠癌（CRC）的诊断准确性。此后，使用专门整理的有症状病例回顾性队列，通过贝叶斯方法估计常见临床表现患者FIT检测后患CRC的风险。经过多学科参与，迭代制定了症状/FIT检查流程。
荟萃分析纳入了18项研究。当粪便血红蛋白阈值>10微克/克粪便时，CRC的敏感性和特异性分别为89.0%（95%CI 87.0 - 90.9%）和80.1%（95%CI 77.7 - 82.4%）；在检测限处，敏感性和特异性分别为95.7%（95%CI 93.2 - 97.7%）和60.5%（95%CI 53.8 - 67.0%）。最终的检查流程对CRC的敏感性为97%，而当前直接就诊标准的敏感性为90%，所需结肠镜检查减少47%。估计拒绝检查的患者中CRC患病率为0.23%。
将FIT纳入所提出的新的患者症状检查流程似乎是可行、安全的，并且能够将资源用于那些疾病风险最高的患者。如果在全国范围内引入该检查流程，还需要进一步努力确保毛利人的公平性。
