Screening for colorectal cancer and advanced colorectal neoplasia in kidney transplant recipients: cross sectional prevalence and diagnostic accuracy study of faecal immunochemical testing for haemoglobin and colonoscopy
Screening for colorectal cancer and advanced colorectal neoplasia in kidney transplant recipients: cross sectional prevalence and diagnostic accuracy study of faecal immunochemical testing for haemoglobin and colonoscopy
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DOI：
10.1136/bmj.e4657
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发表时间：
2012-07-25
影响因子：
105.7
通讯作者：
Coates, P. Toby
中科院分区：
文献类型：
--
作者：
Collins, Michael G.;Teo, Edward;Coates, P. Toby
目的通过对50岁以上肾移植受者的进展期结直肠癌患病率进行测定，并与结肠镜检查进行比较，探讨粪便中血红蛋白免疫化学检测在50岁以上肾移植受者中筛查结直肠癌的合理性。设计以粪便血红蛋白指数检验和结肠镜检查为参考标准的横断面患病率和诊断准确性研究。在南澳大利亚州的大都市和地区医院设立门诊。参与者229名50岁及以上的肾移植受者，移植后至少6个月(平均9.0(SD)8.4年)或其他平均风险为结直肠癌，这项研究于2008年6月至2011年10月完成。介入人类血红蛋白的粪便免疫化学检测(肠道保险)，随后是结肠镜检查，并对回收的样本进行组织学评估。主要结果衡量晚期结直肠肿瘤的患病率，定义为直径至少10 mm的腺瘤、绒毛特征、高度不典型增生或结直肠癌；结果29例(13%，95%可信区间9%~18%)受试者中发现晚期结直肠癌，其中高度不典型增生2%(n=4)，结直肠癌2%(n=5)。粪便血红蛋白检测阳性率为12%(n=28)，对晚期肿瘤的敏感性、特异性、阳性预测值和阴性预测值分别为31.0%(15.3%~50.8%)、90.5%(85.6%~94.2%)、32.1%(15.9%~52.4%)和90.1%(85.1%~93.8%)。结肠镜检查耐受性良好，没有明显的不良后果。为了确诊一例晚期肿瘤，需要8次(6~12次)结肠镜检查。结论50岁以上的肾移植受者中晚期结直肠癌的发病率较高。粪便血红蛋白筛查结直肠肿瘤在移植受者中的表现特征与普通人群研究中报道的相似，灵敏度较低，但特异度合理。监视结肠镜检查在这一人群中可能是一种更合适的方法。
Objective To investigate whether screening kidney transplant recipients aged over 50 years for colorectal cancer with a faecal immunochemical test for haemoglobin might be justified, by determining the prevalence of advanced colorectal neoplasia and evaluating the diagnostic accuracy of faecal haemoglobin testing compared with colonoscopy in a population of kidney transplant recipients at otherwise average risk.Design Cross sectional prevalence and diagnostic accuracy study with index test of faecal haemoglobin and reference standard of colonoscopy.Setting Outpatient clinics in metropolitan and regional hospitals in South Australia.Participants 229 kidney transplant recipients aged 50 years and over, who were at least 6 months (mean 9.0 (SD 8.4) years) post-transplant and otherwise at average risk of colorectal cancer, completed the study between June 2008 and October 2011.Interventions Faecal immunochemical testing (Enterix Insure) for human haemoglobin, followed by colonoscopy with histological evaluation of retrieved samples.Main outcome measures Prevalence of advanced colorectal neoplasia, defined as an adenoma at least 10 mm in diameter, villous features, high grade dysplasia, or colorectal cancer; sensitivity, specificity, and predictive values of faecal haemoglobin testing for advanced neoplasia compared with colonoscopy.Results Advanced colorectal neoplasia was found in 29 (13%, 95% confidence interval 9% to 18%) participants, including 2% (n=4) with high grade dysplasia and 2% (n=5) with colorectal cancer. Faecal testing for haemoglobin was positive in 12% (n=28); sensitivity, specificity, and positive and negative predictive values for advanced neoplasia were 31.0% (15.3% to 50.8%), 90.5% (85.6% to 94.2%), 32.1% (15.9% to 52.4%), and 90.1% (85.1% to 93.8%). Colonoscopy was well tolerated, with no significant adverse outcomes. To identify one case of advanced neoplasia, 8 (6 to 12) colonoscopies were needed.Conclusions Kidney transplant recipients aged over 50 years have a high prevalence of advanced colorectal neoplasia. Faecal haemoglobin screening for colorectal neoplasia has similar performance characteristics in transplant recipients to those reported in general population studies, with poor sensitivity but reasonable specificity. Surveillance colonoscopy might be a more appropriate approach in this population.