Original Article

Digital Rectal Examination Versus Spontaneous Passage of Stool for Fecal Occult Blood Testing

Authors: Imran Ashraf, MD, Shafaq R. Paracha, MD, Murtaza Arif, MD, Abhishek Choudhary, MD, Michelle L. Matteson, PhD, Robert E. Clark, MD, Jonathan D. Godfrey, MD, Hazem T. Hammad, MD, Matthew L. Bechtold, MD

Abstract

Background: The diagnostic value of a positive fecal occult blood test (FOBT) at the time of digital rectal examination (DRE) is disputed despite being used commonly by a significant number of physicians. A meta-analysis was conducted to evaluate FOBT by DRE for detecting neoplasia versus FOBT on stool passed spontaneously (SPS) in asymptomatic patients undergoing colorectal cancer screening.


Methods: MEDLINE, the Cochrane Central Register of Controlled Trials and the Cochrane database of systematic reviews, CINAHL, PubMed, and recent abstracts from major conferences were searched in August 2011. We included all of the studies that compared stool sampling techniques for FOBT. Separate analyses were performed for each main outcome (normal, nonadvanced adenoma, advanced adenoma, and colon cancer).


Results: Seven studies (N = 1835) met the inclusion criteria. The use of DRE for FOBT demonstrated statistically significant fewer advanced adenomas than SPS for FOBT. No statistically significant differences were noted for normal findings, neoplasia, nonadvanced adenoma, or colon cancer with DRE compared with SPS for FOBT.


Conclusions: DRE for FOBT appears to be less effective at detecting advanced adenomas as compared with SPS despite cancer detection being similar. FOBT by SPS appears to be statistically superior to FOBT by DRE.

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References

1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin 2009; 59: 225–249.
 
2. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy: the National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977–1981.
 
3. Citarda F, Tomaselli G, Capocaccia R, et al. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut 2001; 48: 812–815.
 
4. Thiis-Evensen E, Hoff GS, Sauar J, et al. Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I. Scand J Gastroenterol 1999; 34: 414–420.
 
5. 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.
 
6. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348: 1472–1477.
 
7. 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.
 
8. Jørgensen OD, Kronborg O, Fenger C. A randomised study of screening for colorectal cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds. Gut 2002; 50: 29–32.
 
9. Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 2000; 343: 1603–1607.
 
10. Faivre J, Dancourt V, Lejeune C, et al. Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study. Gastroenterology 2004; 126: 1674–1680.
 
11. Marks RD, Hall G, Vcerapalli R, et al. Fecal occult blood testing: does the stool collection method affect outcome? Gastroenterology 1997; 112 (suppl): A29.
 
12. Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001; 51: 38–75.
 
13. 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.
 
14. 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.
 
15. 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.
 
16. Burke CA, Tadikonda L, Machicao V. Fecal occult blood testing for colorectal cancer screening: use the finger. Am J Gastroenterol 2001; 96: 3175–3177.
 
17. 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.
 
18. Nakama H, Abdul Fattah ASM, 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.
 
19. Nakama H, Zhang B, Abdul Fattah ASM, et al. Does stool collection method affect outcomes in immunochemical fecal occult blood testing? Dis Colon Rectum 2001; 44: 871–875.
 
20. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–2012.
 
21. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Published 2011. Accessed April 23, 2012.
 
22. 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.
 
23. Burt RW. Colon cancer screening. Gastroenterology 2000; 119: 837–853.
 
24. Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007. CA Cancer J Clin 2007; 57: 90–104.
 
25. Mandel JS, Church TR, Ederer F, et al. Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst 1999; 91: 434–437.
 
26. Ahlquist DA. Occult blood screening. Obstacles to effectiveness. Cancer 1992; 70: 1259–1265.
 
27. Stryker SJ, Wolff BG, Culp CE, et al. Natural history of untreated colonic polyps. Gastroenterology 1987; 93: 1009–1013.
 
28. Morson BC. The evolution of colorectal carcinoma. Clin Radiol 1984; 35: 425–431.