Result card

  • SOC7: Which social areas does the use of FIT and gFOBT influence?
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Which social areas does the use of FIT and gFOBT influence?

Authors: Pseudo275 Pseudo275, Pseudo108 Pseudo108

Internal reviewers: Pernilla Östlund, Claudia Santos

We used the SOC domain literature search and selected records according to explicit criteria (see domain methodology section). Systematic review by Vart et al. provided answers to SOC7 domain question. Vart included 7 studies: Cole et al., 2003; Federici et al., 2005; Hoffman et al., 2010; Hol et al. 2009,  Hughes et al., 2005; Levi et al., 2011 van Rossum et al 2008. We had selected 4 more primary studies Birkenfeld et al. (2011), Hawley et al. (2008), Hol L, De Jonge et al (2010) and Hol L, De Jonge et al (2010) (which are not the same study by Hol included by Vart et al, as this is Hol, Wilschut J.A et al. 2009) and 1 further systematic review (Hassan et al., 2012). Among the studies Vart et al. included, there is just Hoffman which we decided to exclude as being not being on our target population as it involved  just veterans (male and with potential specific health history related to being in the army).

In reporting results we start from the Vart systematic review and add the primary studies we selected that were not included in Vart review and  answered to this specific SOC7 question.

Having the two tests implies a change in one’s own daily activities and routine which can affect the patient’s willingness to participate to the whole program or/and his/her compliance with test. The tests differ in the procedure of sampling and keeping stools. A procedure that breaks daily routines and social areas – such as lunch time - can be less acceptable and affect compliance with tests and overall participation to the screening.

Systematic review by Vart et al. (2012) beside a meta-analysis of participation rates, gives an exploratory synthesis of tests characteristics and a qualitative analysis of all authors claims about possible effects that certain tests characteristics have on enhancing or diminishing compliance with tests and thus with screening participation. Vart et al. highlights that the procedure for the tests has 4 main steps:

1)dietary and drugs assumption restrictions before the test;

2)collecting faecal samples;

3)test kit return;

4)sample storage.

The first of them can be seen as a social activity (food-dietary restriction), while the others are less “social” and more related to the individual psychology.

Vart et al. explain that just 5 studies (Cole et al., 2003; Federici et al., 2005; Hoffman et al., 2010; Hughes et al., 2005; Levi et al., 2011)  cited the possible determinants for higher participation in the FIT or g-FOBT groups. A description of the explanations given in the above 5 studies is provided below. All explanation and claims are reported by Vart as they can be seen as authoritative hypothesis, but ad hoc studies should be performed to prove that they are sound.

Four studies claimed that FIT was more acceptable because it did not require dietary or medicinal restrictions (Cole et al., 2003; Federici et al., 2005; Hoffman et al., 2010; Hughes et al., 2005). One of these studies reported that participation increased by 28% when these restrictions were removed (Cole et al., 2003). However, about “medical restriction”, Federici et al. (2005) asked the FIT group to abstain from anticoagulant use, thus enforcing medical restriction also in this group, and this was not reported to impact on the higher participation rate for that group. Two studies (Cole et al., 2003; Federici et al., 2005) claimed participation was higher in the FIT group because this test required fewer samples than the g-FOBT. This characteristics makes the FIT test more convenient since lessens the aversion to handle faecal samples, which can be a psychological barriers to the use of the test. Four studies stated that FIT was more readily used because the sampling was simpler (Cole et al., 2003; Federici et al., 2005; Hoffman et al., 2010; Hughes et al., 2005). Cole et al. stated that the FIT, using brush sampling, combated inconvenience and aversion to the manipulation of faecal samples: in Cole’s study participation significantly increased by 30% if the sampling procedure was simplified, i.e. by allowing a sample to be taken from the toilet water, in addition to taking fewer samples. Participation further improved to 66% if these factors were combined with the removal of dietary or medical restrictions.  Hughes et al. (2005) concluded that participants must have preferred the FIT because it is more ‘user-friendly’, convenient, and less messy. Federici et al. (2005) stated participation was higher in the FIT group because they did not have to handle their faeces with a paper sampler, as in the g-FOBt group. Hoffman et al. (2010) claimed that the FIT was easier to perform as a reason for a higher compliance and participation to the FIT and added that their findings suggest that less faecal manipulation makes the test more acceptable. Vart et al.  highlights that FIT did not have a better rate of participation just in one of the selected studies, the one by Levi et al. (2011). Vart et al reports Levi et al’s explanation for that, who claim that this could be due to the fact that participants were requested to keep the FIT refrigerated and return the samples to the clinic in a cooling bag due to Israel hot climate. Moreover, according to Levi et al.’s, participants in their study were required to take the same amount of samples for the FIT as the g-FOBt, and the authors state that this could be a added possible explanation as to why the FIT was not as favorable in this study.

Vart et al highlights that the method of test kit return and storage was not cited as a predictor of response rate in any of the other studies. Authors state that although three studies (Cole et al., 2003; Federici et al., 2005; Hughes et al., 2005) discussed the reasons for a higher participation in the FIT group claims that it was because FIT is easier to complete, they did not ask participants directly why they preferred a particular test, and they interpreted possible reasons for higher participation in the FIT group from previous literature. Other studies either did not discuss reasons for different participation rates (Hol et al., 2009), or claimed that the reasons were not apparent (van Rossum et al., 2008). Therefore, absolute conclusions as to why the FIT participation rate was mostly found to be significantly higher than g-FOBt cannot be drawn.

Three studies that were not included in Vart‘systematic review  where useful to answer the question of this Result card: Birkenfeld et al (2011), Hol L, De Jonge et al (2010) and L Hol, Van Leerdam M.E. ,(2010), while study by Hawely et al. (2008) and Hassan systematic review (2012) did not provide data and information for this results card.

The Birkenfeld et al. study (2011) was conducted in Israel on the same population as Levi’s et al (2011). In this study,  a higher participation rate for the FIT than G-FOBT is not demonstrated (as already happened with Levi et al.’s) . Authors state that they believe reasons for this difference  with international results that usually favor Fit vs GFOBT are the familiarity of the population with G-FOBT and the procedure needed for keeping the FIT in the refrigerator and bring the samples to the clinic in a cooling bag. The overall participation rate with the FIT was 3.2% lower that with G-FOBT. Once the kit was dispensed, the compliance was 15.8% higher in the FIT arm. However data on “overall compliance” in table 4 p. 139 of Birkenfeld 2011 show that FIT was performed by 23,1% and gFOBT by 24.6% (p=0.036). There were some inconsistencies between text and tables in these two studies including the same population for different aspects.

The study by Hol L, De Jonge et al (2010).involved a representative sample of the Dutch population (aged 50–74 years) who was randomized be invited for gFOBT, FIT and FS screening. A random sample of participants of each group was asked to complete a questionnaire about test burden and willingness to return for CRC screening. Screeners rated overall embarrassment during gFOBT and FIT equally (0.07 versus 0.06; p = 0.30) . A larger proportion of gFOBT than FIT screenees described the test as uncomfortable (0.15 versus 0.11; p = 0.02), mainly due to more discomfort while collecting faeces and performing the test. FIT was perceived as slightly less burdensome than gFOBT  due to less reported discomfort during faecal collection and test performance. The number of faecal samples required may explain the difference in discomfort during faecal collection, as the gFOBT had to be performed on three consecutive bowel movements and FIT was a one-sample test.

Hol L., Van Leerdam ME (2010) shows that gFOBT screening performed without dietary restrictions remains associated with a lower uptake than FIT screening. A more demanding sampling procedure and the number of consecutive bowel movements that had to be collected (three for gFOBT vs one for FIT) seem likely explanations for the difference in participation rate.

Pseudo275 P, Pseudo108 P Result Card SOC7 In: Pseudo275 P, Pseudo108 P Social aspects In: Jefferson T, Cerbo M, Vicari N [eds.]. Fecal Immunochemical Test (FIT ) versus guaiac-based fecal occult blood test (FOBT) for colorectal cancer screening [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali; 2014. [cited 3 December 2022]. Available from: