A SYNTHESIS PAPER

ON:
Fecal Immunochemical Test versus
Guaiacs Test in Colorectal Cancer
Screening
In partial requirement of the Requirement for the
Degree of Bachelor of Science in Medical Technology

Presented by:
ARCIAGA, FRANCES GELINE R
.
Presented to:
DEAN CESAR M. MENDOZA, JR.

EMILIO AGUINALDO COLLEGE MANILA

Fecal Immunochemical Test versus Guaiacs Test

in Colorectal Cancer Screening
Colorectal cancer is the third most common cancer worldwide and the
second leading cause of cancer-related deaths. (Ferlay, J., et.al 2008) The
disease is not uniformly fatal, although there are large differences in survival
according to the stage at which the disease is detected. (Morson, BC. 1979)
Several studies have shown that colorectal-cancer screening is effective and
cost-effective in the average-risk population. (Heitman SJ et.al 2010)
Screening aims to reduce Colorectal cancer (CRC) mortality and incidence on
a population basis. The International Agency for Research on Cancer (IARC)
states that screening programs, whether organized or opportunistic, should
provide protection against the harms of screening, over-screening, the
complications of screening, poor follow-up of those who test positive and
poor quality of treatment (Miles, A. et.al 2004).
The

identification

of

well-defined

pre-malignant

lesion,

the

adenomatous polyp, together with the good survival associated with early
disease, make colorectal cancer an ideal target for screening. In the past
quarter of a century, great progress has been made in our ability to screen
patients for colorectal cancer or its precursor state, using advances in
imaging and diagnostic technology. Winawer (2001) noted that Greegor
(1967) had first employed the faecal occult blood guaiac test cards, that the
flexible sigmoidoscope was introduced in the mid-1970s to replace the rigid
sigmoidoscope that had been first introduced in 1870 and that colonscopy
has been available since 1970 (Winawer, SJ. 1997).
According to Levin (2008), recommended strategies for colorectalcancer screening fall into two broad categories: stool tests (occult blood and

exfoliated DNA tests) and structural examinations (flexible sigmoidoscopy,

colonoscopy, and computed tomographic colonography). Stool tests primarily
detect cancer, and structural examinations detect both cancer and
premalignant lesions. Stool tests for occult blood (guaiac testing and fecal
immunochemical testing [FIT]) are predominantly used in Europe and
Australia, whereas colonoscopy is the predominant screening method in the
United States. Colonoscopy is considered the most accurate test for early
detection

and

prevention

of

colorectal

cancer.

Although

data

from

randomized studies evaluating the effect of colonoscopy on the rate of death

from colorectal cancer are lacking, the procedure is recommended as a firstline screening test on the basis of indirect data and observational
studies. (Brenner, H., et.al 2011)
According to Detsky (2001), there are five important reasons why
colonoscopy is not routinely recommended as a screening tool: the standard
of evidence, adherence, risk, economics and availability. The issue of
standard of evidence is one that requires much attention in epidemiology at
the present time.
The effect of gFOBT on mortality is modest. The traditional (i.e.,
unrehydrated) gFOBT (Hemoccult II was the FOBT used) returned an
intention-to-screen reduction in CRC mortality of 15 % (Hewitson, P. 2008).
This effect was limited by screenee acceptance (generally just over one-half
of the population) and sensitivity for neoplasia. Once-only test sensitivity for
cancer may approximate 50 % although other studies indicate it is lower.
(Allison, JE. 1996) For some countries, this limited sensitivity raised concern
among practitioners for legal liability for missed lesions. In consequence,
some jurisdictions have not been enthusiastic about adopting this as the
primary population screening.
A number of studies have compared Guaiac fecal occult blood test
(gFOBT) with (Fecal immunochemical test) FIT, with the same limitations

applying when comparing different FITs. The studies have shown that the
semiquantitative FIT is more accurate than the guaiac test for the detection
of colorectal cancer and advanced adenomas (Dancourt, V. et.al 2008) and
this new test is now recommended as the first-choice fecal occult blood test
in colorectal-cancer screening. Although FIT is less effective for neoplastic
detection than colonoscopy or sigmoidoscopy, evidence suggests that it may
be better accepted (Hol, L. et.al 2010) and higher acceptance may
counteract its lower detection capacity. It has been suggested that FIT may
be more effective and less costly than other screening strategies. (Segnan, S.
2007)
Higher sensitivities are achievable for CRC with FIT than gFOBT. For
example, one test with a positivity threshold of 20 g Hb/g feces as cutoff
has been reported to have a sensitivity for cancer of 87.192.3 % compared
with 30.874.2 % for a traditional gFOBT (Oort FA, et.al 2010) (Park DI, et.al
2010) In addition to offering higher sensitivity, the immunochemical tests
may be more acceptable to patients because they do not require dietary
restriction and the sample collection methods for some of the tests are
designed to be more user-friendly, requiring fewer samples or less direct
handling of stool. (Cole, SR. 2003)
Test positivity rate in a general screening population tends to be higher
with FIT compared with gFOBT. One comparison using a FIT at a positivity
threshold of 20 g Hb/g feces (and collection of 1 sample), the positivity rate
for the FIT was 3.45.5 % compared with 2.43.5 % for the gFOBT. (Fraser
CG, et.al 2012) (Chubak J, et.al 2012) (van Rossum LG, et.al 2008)
FITs are more sensitive for advanced adenomas than gFOBT and so
improve capacity to prevent cancer. Several studies show that FIT has a
sensitivity for advanced adenoma 23 times that of gFOBT although this is
dependent on the chosen cutoff concentration (Brenner, H., et.al 2013) (Oort
FA, et.al 2010) (Park DI, et.al 2010)

Overall, FIT technology is more selective for colorectal bleeding, less

affected by nonpathological factors such as diet and drugs, more suitable for
the modern laboratory and large-scale processing of tests, more acceptable
to individuals and more flexible in terms of choice of screening test
characteristics than is the gFOBT technology. It has been suggested that
gFOBT is now obsolete (Young, GP. 2012)
Despite the existing evidence of efficacy of guaiac testing in reducing
CRC mortality, its inefficiency prevents a wide distribution of CRC screening.
The information now available on immunochemical tests is enough to
encourage the use of immunochemical FOBTs in order to improve screening
performances

and

cost-effectiveness.

In

conclusion,

including

immunochemical tests among currently available screening tools for CRC

would help improve the efficacy, cost-effectiveness and acceptability of the
tests. (Castiglione, G., Zappa, M. 2003)
References:
Oort FA, Terhaar Sive Droste JS, Van Der Hulst RW, et al. Colonoscopycontrolled intra-individual comparisons to screen relevant neoplasia: faecal
immunochemical test vs. guaiac-based faecal occult blood test. Aliment
Pharmacol Ther. 2010;31:432439.
Park DI, Ryu S, Kim YH, et al. Comparison of guaiac-based and quantitative
immunochemical fecal occult blood testing in a population at average risk
undergoing colorectal cancer screening. Am J Gastroenterol. 2010;105:2017
2025. doi: 10.1038/ajg.2010.179.
Parra-Blanco A, Gimeno-Garcia AZ, Quintero E, et al. Diagnostic accuracy of
immunochemical versus guaiac faecal occult blood tests for colorectal cancer
screening. J Gastroenterol 2010;45:703-712

van Rossum LG, van Rijn AF, Laheij RJ, et al. Random comparison of guaiac
and immunochemical fecal occult blood tests for colorectal cancer in a
screening population.Gastroenterology 2008;135:82-90
Marion R. Nadel, Zahava Berkowitz, Carrie N. Klabunde, Robert A. Smith,
Steven S. Coughlin, Mary C. White Fecal Occult Blood Testing Beliefs and
Practices of U.S. Primary Care Physicians: Serious Deviations from EvidenceBased RecommendationsJ Gen Intern Med. 2010 Aug; 25(8): 833839.
Levy BT, Bay C, Xu Y, Daly JM, Bergus G, Dunkelberg J, Moss C. Test
characteristics of faecal immunochemical tests (FIT) compared with optical
colonoscopy. Journal of Medical Screening.2014;21(3):13343.
Allison JE, Tekawa IS, Ransom LJ, et al. A comparison of fecal occult-blood
tests for colorectal-cancer screening. N Engl J Med. 1996;334:155159.
Stephen Ip, AbdulRazaq AH Sokoro, Lisa Kaita, Claudia Ruiz, Elaine McIntyre,
Harminder Singh Use of fecal occult blood testing in hospitalized patients:
Results of an audit Can J Gastroenterol Hepatol. 2014 Oct; 28(9): 489494.
Boyle P. Faecal occult blood testing (FOBT) as screening for colorectal cancer:
the current controversy. Ann Oncol2002; 13: 1618.
Graeme P. Young, Erin L. Symonds, James E. Allison, Stephen R. Cole, Callum
G. Fraser, Stephen P. Halloran, Ernst J. Kuipers, Helen E. Seaman Advances in
Fecal Occult Blood Tests: The FIT Revolution
Dig Dis Sci. 2015; 60(3): 609622.