Review Article
A Clinician's Guide to Fecal Occult Blood Testing for Colorectal Cancer
Abstract
Colorectal cancer (CRC) is a significant healthcare issue, with substantial morbidity and mortality. Screening for CRC is essential in the prevention and treatment of this disease. The two most common CRC screening modalities are colonoscopy and the stoolbased occult blood test, with two types of stool-based occult blood tests: the guaiac-based fecal occult blood test (FOBT) and the immunochemical FOBT. Despite many similarities, these two stool tests are different and often are confused in clinical practice. In an effort to improve awareness of these testing modalities, this review provides extensive information on both of these FOBTs, as well as discusses comparisons in the literature between these stool-based blood tests and other screening modalities such as stool DNA and colonoscopy.This content is limited to qualifying members.
Existing members, please login first
If you have an existing account please login now to access this article or view purchase options.
Purchase only this article ($25)
Create a free account, then purchase this article to download or access it online for 24 hours.
Purchase an SMJ online subscription ($75)
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
Purchase a membership plan (fees vary)
Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.
References
1. Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014. CA Cancer J Clin 2014;64:104-117.
2. American Cancer Society. Colorectal cancer facts & figures, 2014-2016. http://www.cancer.org/acs/groups/content/documents/document/acspc-042280.pdf. Accessed February 22, 2016.
3. Edwards BK, Noone AM, Mariotto AB, et al. Annual report to the nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer. Cancer 2014;120:1290-1314.
4. Rim SH, Seeff L, Ahmed F, et al. Colorectal cancer incidence in the United States, 1999-2004 : an updated analysis of data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program. Cancer 2009;115:1967-1976.
5. Fearon ER, Vogelstein B. A genetic model for colorectal tumorigenesis. Cell 1990;61:759-767.
6. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009. Am J Gastroenterol 2009;104:739-750.
7. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008;134:1570-1595.
8. US Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-637.
9. Seeff LC, Nadel MR, Klabunde CN, et al. Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 2004; 100:2093-2103.
10. Sirovich BE, Schwartz LM, Woloshin S. Screening men for prostate and colorectal cancer in the United States: does practice reflect the evidence? JAMA 2003;289:1414-1420.
11. Centers for Disease Control and Prevention. United States cancer statistics. 1999-2010 incidence and mortality data. http://www.cdc.gov/uscs. Accessed February 1, 2016.
12. Calderwood AH, Roy HK. Increasing colorectal cancer screening adherence: comment on ‘‘A randomized comparison of print and web communication on colorectal cancer screening.’’. JAMA Intern Med 2013;173:129-131.
13. Centers for Disease Control and Prevention. National Health Interview Survey public use data file 2010. http://www.cdc.gov/nchs/nhis.htm. Accessed February 1, 2016.
14. Behavioral Risk Factor Surveillance System Public Use Data Tapes 2012, National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. http://www.cdc.gov/brfss/brfssprevalence/index.html.
15. Centers for Disease Control and Prevention. Vital signs: colorectal cancer screening test use--United States, 2012. MMWR Morb Mortal Wkly Rep 2013;62:881-888.
16. Wilkinson RH, Penfold WA. The guaiacum test for occult blood in faeces. Lancet 1969;2:847-848.
17. Greegor DH. Occult blood testing for detection of asymptomatic colon cancer. Cancer 1971;28:131-134.
18. Rabeneck L, Rumble RB, Thompson F, et al. Fecal immunochemical tests compared with guaiac fecal occult blood tests for populationbased colorectal cancer screening. Can J Gastroenterol 2012;26:131-147.
19. Ahlquist DA, Shuber AP. Stool screening for colorectal cancer: evolution from occult blood to molecular markers. Clin Chim Acta 2002;315:157-168.
20. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993;328:1365-1371.
21. American College of Physicians. Suggested technique for fecal occult blood testing and interpretation in colorectal cancer screening. Ann Intern Med 1997;126:808-810.
22. Whitlock EP, Lin JS, Liles E, et al. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149:638-658.
23. Allison JE, Sakoda LC, Levin TR, et al. Screening for colorectal neoplasms with new fecal occult blood tests: update on performance characteristics. J Natl Cancer Inst 2007;99:1462-1470.
24. Allison JE, Tekawa IS, Ransom LJ, et al. A comparison of fecal occult blood tests for colorectal-cancer screening. N Engl J Med 1996;334:155-159.
25. Cheng TI, Wong JM, Hong CF, et al. Colorectal cancer screening in asymptomaic adults: comparison of colonoscopy, sigmoidoscopy and fecal occult blood tests. J Formos Med Assoc 2002;101:685-690.
26. Itoh M, Takahashi K, Nishida H, et al. Estimation of the optimal cut off point in a new immunological faecal occult blood test in a corporate colorectal cancer screening programme. J Med Screen 1996;3:66-7.
27. Launoy GD, Bertrand HJ, Berchi C, et al. Evaluation of an immunochemical fecal occult blood test with automated reading in screening for colorectal cancer in a general average-risk population. Int J Cancer 2005;115:493-496.
28. Levi Z, Rozen P, Hazazi R, et al. A quantitative immunochemical fecal occult blood test for colorectal neoplasia. Ann Intern Med 2007;146:244-255.
29. Morikawa T, Kato J, Yamaji Y, et al. A comparison of the immunochemical fecal occult blood test and total colonoscopy in the asymptomatic population. Gastroenterology 2005;129:422-428.
30. Nakama H, Yamamoto M, Kamijo N, et al. Colonoscopic evaluation of immunochemical fecal occult blood test for detection of colorectal neoplasia. Hepatogastroenterology 1999;46:228-231.
31. Nakama H, Kamijo N, Abdul Fattah AS, et al. Validity of immunological faecal occult blood screening for colorectal cancer: a follow up study. J Med Screen 1996;3:63-65.
32. Parra-Blanco A, Gimeno-Garcıa 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.
33. Brenner H, Tao S. Superior diagnostic performance of faecal immunochemical tests for haemoglobin in a head-to-head comparison with guaiac based faecal occult blood test among 2235 participants of screening colonoscopy. Eur J Cancer 2013;49:3049-3054.
34. van Dam L, Kuipers EJ, van Leerdam ME. Performance improvements of stool-based screening tests. Best Pract Res Clin Gastroenterol 2010;24:479-492.
35. Burch JA, Soares-Weiser K, St John DJ, et al. Diagnostic accuracy of faecal occult blood tests used in screening for colorectal cancer: a systematic review. J Med Screen 2007;14:132-137.
36. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996;348:1472-1477.
37. Kronborg O, Fenger C, Olsen J, et al. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996;348:1467-1471.
38. Sohn DK, Jeong SY, Choi HS, et al. Single immunochemical fecal occult blood test for detection of colorectal neoplasia. Cancer Res Treat 2005;37:20-23.
39. Levi Z, Birkenfeld S, Vilkin A, et al. A higher detection rate for colorectal cancer and advanced adenomatous polyp for screening with immunochemical fecal occult blood test than guaiac fecal occult blood test, despite lower compliance rate. A prospective, controlled, feasibility study. Int J Cancer 2011;128:2415-2424.
40. Nakazato M, Yamano HO, Matsushita HO, et al. Immunologic fecal occult blood test for colorectal cancer screening. Japan Med Assoc 2006;49:203-207.
41. 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.
42. de Wijkerslooth TR, Stoop EM, Bossuyt PM, et al. Immunochemical fecal occult blood testing is equally sensitive for proximal and distal advanced neoplasia. Am J Gastroenterol 2012;107:1570-1578.
43. Chiu HM, Lee YC, Tu CH, et al. Association between early stage colon neoplasms and false-negative results from the fecal immunochemical test. Clin Gastroenterol Hepatol 2013;11:832-8.e1-2.
44. Chiang TH, Lee YC, Tu CH, et al. Performance of the immunochemical fecal occult blood test in predicting lesions in the lower gastrointestinal tract. CMAJ 2011;183:1474-1481.
45. Lee JK, Liles EG, Bent S, et al. Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis. Ann Intern Med 2014;160:171.
46. Federici A, Giorgi Rossi P, et al. The immunochemical faecal occult blood test leads to higher compliance than the guaiac for colorectal cancer screening programmes: a cluster randomized controlled trial. J Med Screen 2005;12:83-88.
47. Hol L, Wilschut JA, van Ballegooijen M, et al. Screening for colorectal cancer: random comparison of guaiac and immunochemical faecal occult blood testing at different cut-off levels. Br J Cancer 2009;100:1103-1110.
48. Hughes K, Leggett B, Del Mar C, et al. Guaiac versus immunochemical tests: faecal occult blood test screening for colorectal cancer in a rural community. Aust N Z J Public Health 2005;29:358-364.
49. Ko CW, Dominitz JA, Nguyen TD. Fecal occult blood testing in a general medical clinic: comparison between guaiac-based and immunochemical-based tests. Am J Med 2003;115:111-114.
50. 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.
51. Zhu MM, Xu XT, Nie F, et al. Comparison of immunochemical and guaiac-based fecal occult blood test in screening and surveillance for advanced colorectal neoplasms: a meta-analysis. J Dig Dis 2010;11:148-160.
52. Hoffman RM, Steel S, Yee EF, et al. Colorectal cancer screening adherence is higher with fecal immunochemical tests than guaiac-based fecal occult blood tests: a randomized, controlled trial. Prev Med 2010;50:297-299.
53. Young GP, Cole S. New stool screening tests for colorectal cancer. Digestion 2007;76:26-33.
54. Young GP. Fecal immunochemical tests (FIT) vs. office-based guaiac fecal occult blood test (FOBT). Practical Gastroenterol 2004;28:46-56.
55. Fletcher RH. Diet for fecal occult blood test screening: help or harm? Eff Clin Pract 2001;4:180-182.
56. Hoogewerf PE, Hislop TG, Morrison BJ, et al. Patient compliance with screening for fecal occult blood in family practice. CMAJ 1987;137:195-198. .
57. Joseph A. Compliance with fecal occult blood testing: the role of restrictive diets. Am J Public Health 1988;78:839-841.
58. Verne J, Kettner J, Mant D, et al. Self-administered faecal occult blood tests do not increase compliance with screening for colorectal cancer: results of a randomized controlled trial. Eur J Cancer Prev 1993;2:301-305.
59. Robinson MH, Pye G, Thomas WM, et al. Haemoccult screening for colorectal cancer: the effect of dietary restriction on compliance. Eur J Surg Oncol 1994;20:545-548.
60. Pignone M, Campbell MK, Carr C, et al. Meta-analysis of dietary restriction during fecal occult blood testing. Eff Clin Pract 2001;4:150-156.
61. Fries JF, Britton MC. Fenoprofen calcium in rheumatoid arthritis. A controlled double-blind crossover evaluation. Arthritis Rheum 1973;16:629-634.
62. Greenberg PD, Cello JP, Rockey DC. Relationship of low-dose aspirin to GI injury and occult bleeding: a pilot study. Gastrointest Endosc 1999;50:618-622.
63. Jaffin BW, Bliss CM, LaMont JT. Significance of occult gastrointestinal bleeding during anticoagulation therapy. Am J Med 1987;83:269-272.
64. Kershenbaum A, Lavi I, Rennert G, et al. Fecal occult blood test performance indicators in warfarin-treated patients. Dis Colon Rectum 2010;53:224-229.
65. Greenberg PD, Cello JP, Rockey DC. Asymptomatic chronic gastrointestinal blood loss in patients taking aspirin or warfarin for cardiovascular disease. Am J Med 1996;100:598-604.
66. Hurlen M, Eikvar L, Seljeflot I, et al. Occult bleeding in three different antithrombotic regimes after myocardial infarction. A WARIS-II subgroup analysis. Thromb Res 2006;118:433-438.
67. Anderson GD, Yuellig TR, Krone RE Jr. An investigation into the effects of oral iron supplementation on in vivo Hemoccult stool testing. Am J Gastroenterol 1990;85:558-561.
68. Jaffe RM, Zierdt W. A new occult blood test not subject to false-negative results from reducing substances. J Lab Clin Med 1979;93:879-886.
69. Zierdt WS, Zierdt CH. Occult blood testing using tetramethylbenzidine in an extraction procedure for patients on unrestricted diets. Am J Clin Pathol 1985;83:486-488.
70. Konrad G, Katz A. Are medication restrictions before FOBT necessary? Practical advice based on a systematic review of the literature. Can Fam Physician 2012;58:939-948.
71. Bini EJ, Rajapaksa RC, Weinshel EH. Positive predictive value of fecal occult blood testing in persons taking warfarin. Am J Gastroenterol 2005;100:1586-1592.
72. Clarke P, Jack F, Carey FA, et al. Medications with anticoagulant properties increase the likelihood of a negative colonoscopy in faecal occult blood test population screening. Colorectal Dis 2006;8:389-392.
73. Sawhney MS, McDougall H, Nelson DB, et al. Fecal occult blood test in patients on low-dose aspirin, warfarin, clopidogrel, or non-steroidal anti-inflammatory drugs. Dig Dis Sci 2010;55:1637-1642.
74. Iles-Shih L, Collins JF, Holub JL, et al. Prevalence of significant neoplasia in FOBT-positive patients on warfarin compared with those not on warfarin. Am J Gastroenterol 2010;105:2030-2035.
75. Levi Z, Hazazi R, Rozen P, et al. A quantitative immunochemical faecal occult blood test is more efficient for detecting significant colorectal neoplasia than a sensitive guaiac test. Aliment Pharmacol Ther 2006;23:1359-1364.
76. Mandelli G, Radaelli F, Paggi S, et al. Anticoagulant or aspirin treatment does not affect the positive predictive value of an immunological fecal occult blood test in patients undergoing colorectal cancer screening: results from a nested in a cohort case-control study. Eur J Gastroenterol Hepatol 2011;23:323-326.
77. Pye G, Ballantyne KC, Armitage NC, et al. Influence of non-steroidal anti-inflammatory drugs on the outcome of faecal occult blood tests in screening for colorectal cancer. Br Med J (Clin Res Ed) 1987;294:1510-1511.
78. Ashraf I, Paracha S, Paracha S, et al. Antithrombotics during fecal occult blood testing: a meta-analysis. Internet J Gastroenterol 2013;13:1-11.
79. Ashraf I, Paracha S, Paracha SR, et al. Warfarin use during fecal occult blood testing: a meta-analysis. Gastroenterol Res 2012;5:45-51.
80. Bujanda L, Sarasqueta C, Lanas A´ , et al. Effect of oral anticoagulants on the outcome of faecal immunochemical test. Br J Cancer 2014;110:1334-1337.
81. Bujanda L, Lanas A, Quintero E, et al. Effect of aspirin and antiplatelet drugs on the outcome of the fecal immunochemical test. Mayo Clin Proc 2013;88:683-689.
82. Nadel MR, Shapiro JA, Klabunde CN, et al. A national survey of primary care physicians’ methods for screening for fecal occult blood. Ann Intern Med 2005;142:86-94.
83. Eisner MS, Lewis JH. Diagnostic yield of a positive fecal occult blood test found on digital rectal examination. Does the finger count? Arch Intern Med 1991;151:2180-2184.
84. Bini EJ, Rajapaksa RC, Weinshel EH. The findings and impact of nonrehydrated guaiac examination of the rectum (FINGER) study: a comparison of 2 methods of screening for colorectal cancer in asymptomatic average-risk patients. Arch Intern Med 1999;159:2022-2026.
85. Burke CA, Tadikonda L, Machicao V. Fecal occult blood testing for colorectal cancer screening: use the finger. Am J Gastroenterol 2001; 96:3175-3177.
86. Collins JF, Lieberman DA, Durbin TE, et al. 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;142:81-85.
87. Nakama H, Fattah AS, Zhang B, et al. Digital rectal examination sampling of stool is less predictive of significant colorectal pathology than stool passed spontaneously. Eur J Gastroenterol Hepatol 2000;12:1235-1238.
88. Nakama H, Zhang B, Abdul Fattah AS, et al. Does stool collection method affect outcomes in immunochemical fecal occult blood testing? Dis Colon Rectum 2001;44:871-875.
89. Rockey DC, Koch J, Cello JP, et al. Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult-blood tests. N Engl J Med 1998;339:153-159.
90. Ahlquist DA. Occult blood screening Obstacles to effectiveness. Cancer 1992;70(5 Suppl):1259-1265.
91. Ashraf I, Paracha SR, Arif M, et al. Digital rectal examination versus spontaneous passage of stool for fecal occult blood testing. South Med J 2012;105:357-361.
92. Fraser CG, Mathew CM, Mowat NA, et al. Evaluation of a card collection-based faecal immunochemical test in screening for colorectal cancer using a two-tier reflex approach. Gut 2007;56:1415-1418.
93. Colon Cancer Alliance. Guaiac fecal occult blood test (FOBT). http://www.ccalliance.org/test/guaiac-fecal-occult-blood-test-fobt. Accessed February 22, 2016.
94. Colon Cancer Alliance. Fecal immunochemical test (FIT). http://www.ccalliance.org/test/fecal-immunochemical-test-fit. Accessed February 22, 2016.
95. Canadian Agency for Drugs and Technologies in Health. Primary screening programs for colorectal cancer in Canada using non-invasive home tests. https://www.cadth.ca/health-technology-update-issue-9-primary-screening-programs-colorectal-cancer-canada-using-non. Published March 25, 2009. Accessed February 22, 2016.
96. Lin JS, Webber EM, Beil TL, et al. Fecal DNA Testing in Screening for Colorectal Cancer in Average-Risk Adults. AHRQ Comparative Effectiveness Reviews. Rep No. 12-EHC022-EF. Agency for Healthcare Research and Quality: Rockville, MD, 2012.
97. Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med 2004;351:2704-2714.
98. Ahlquist DA, Sargent DJ, Loprinzi CL, et al. Stool DNA and occult blood testing for screen detection of colorectal neoplasia. Ann Intern Med 2008;149:441-450, W81.
99. Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med 2014;370:1287-1297.
100. Robertson DJ, Imperiale TF. Stool testing for colorectal cancer screening. Gastroenterology 2015;149:1286-1293.
101. Guy GP Jr, Richardson LC, Pignone MP, et al. Costs and benefits of an organized fecal immunochemical test-based colorectal cancer screening program in the United States. Cancer 2014;120:2308-2315.
102. Quintero E, Castells A, Bujanda L, et al. Colonoscopy versus fecal immunochemical testing in colorectal-cancer screening. N Engl J Med 2012;366:697-706.
103. Cubiella J, Castro I, Hernandez V, et al. Characteristics of adenomas detected by fecal immunochemical test in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2014;23:1884-1892.
104. Levy BT, Bay C, Xu Y, et al. Test characteristics of faecal immunochemical tests (FIT) compared with optical colonoscopy. J Med Screen 2014;21:133-143.
105. Khalid-de Bakker CA, Jonkers DM, Sanduleanu S, et al. Test performance of immunologic fecal occult blood testing and sigmoidoscopy compared with primary colonoscopy screening for colorectal advanced adenomas. Cancer Prev Res (Phila) 2011;4:1563-1571.
106. Castells A, Quintero E, Alvarez C, et al. Rate of detection of advanced neoplasms in proximal colon by simulated sigmoidoscopy vs fecal immunochemical tests. Clin Gastroenterol Hepatol 2014;12:1708-1716.e4.
107. Castells A, Bessa X, Quintero E, et al. Risk of advanced proximal neoplasms according to distal colorectal findings: comparison of sigmoidoscopy-based strategies. J Natl Cancer Inst 2013;105:878-886.
108. Hernandez V, Cubiella J, Gonzalez-Mao MC, et al. Fecal immunochemical test accuracy in average-risk colorectal cancer screening. World J Gastroenterol 2014;20:1038-1047.
109. Terhaar sive Droste JS, van Turenhout ST, Oort FA, et al. Faecal immunochemical test accuracy in patients referred for surveillance colonoscopy: a multi-centre cohort study. BMC Gastroenterol 2012;12:94.
