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The Findings and Impact of Nonrehydrated Guaiac Examination ORIGINAL INVESTIGATION 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 Edmund J. Bini, MD; Roshini C. Rajapaksa, MD; Elizabeth H. Weinshel, MD Background: Testing stool for occult blood at the time ity fee for endoscopy, and the pathology fee for the of digital rectal examination (DRE) has been discour- biopsy specimens. aged because it is thought to increase the number of false- positive test results. Results: During the 5-year study period, 672 patients were evaluated and a colonic source of occult bleeding was iden- tified in 145 patients (21.6%). The predictive value of a posi- Objective: To compare the diagnostic yield of colonos- tive fecal occult blood test result (22.0% vs 21.3%, P = .85) copy and the cost per cancer detected in asymptomatic andthecostpercancerdetected($7604.80vs$7814.54)were patients with a positive fecal occult blood test result ob- no different in the DRE and SPS groups, with carcinomas tained by DRE with that obtained from spontaneously being detected in 11.7% and 11.3% of patients, respectively. passed stool (SPS) samples. Conclusions: Testing stool for occult blood at the time Methods: We reviewed the medical records of con- of DRE does not increase the number of false-positive test secutive asymptomatic patients at average risk for colo- results or the cost per cancer detected in asymptomatic rectal cancer who were referred for colonoscopy to patients at average risk for colorectal cancer. In this pa- evaluate a positive fecal occult blood test result tient population, all individuals should be evaluated by full obtained by DRE (n = 282) or SPS samples (n = 390). colonoscopy regardless of the method of stool collection. The cost of colonoscopy was estimated by adding the physician fee under Medicaid reimbursement, the facil- Arch Intern Med. 1999;159:2022-2026 CREENING FOR fecal occult In clinical practice, asymptomatic in- blood has been shown to re- dividuals with a positive FOBT result ob- duce mortality from colorec- tained by DRE are often referred for a colo- tal cancer,1-3 the second lead- noscopic evaluation.10 To date, there are ing cause of cancer death in almost no data on the diagnostic yield of Sthe United States.4 Because 70% to 80% of colonoscopy in asymptomatic patients with colorectal cancers are diagnosed in “av- a positive FOBT result obtained by DRE. The erage-risk” patients,5 the American Can- aims of this study were to compare the di- cer Society recommends annual fecal oc- agnostic yield of colonoscopy in patients cult blood testing (FOBT) of stool samples with a positive FOBT result obtained by DRE in all patients aged 50 years or older us- with that obtained by SPS sampling and to ing 3 specimens obtained from spontane- determine the cost of identifying a source ously passed stools (SPS).6 To decrease the of occult gastrointestinal bleeding by colo- number of false-positive FOBT results, pa- noscopy in these 2 groups of patients. tients are placed on dietary restrictions, and nonsteroidal anti-inflammatory drug RESULTS (NSAID) and aspirin use is discontinued 1 week before testing. Despite these rec- During the 5-year study period, 672 ommendations, clinicians often test stool asymptomatic average-risk patients with samples for occult blood at the time of digi- From the Division of 7 Gastroenterology, New York tal rectal examination (DRE). Although University Medical Center, widely practiced, this screening method has been discouraged because it is thought This article is also available on our Bellevue Hospital, and New Web site: www.ama-assn.org/internal. York Veterans Affairs Medical to increase the number of false-positive Center, New York, NY. FOBT results.8,9 ARCH INTERN MED/ VOL 159, SEP 27, 1999 2022 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 PATIENTS AND METHODS ENDOSCOPY All colonoscopic examinations were performed by gastro- PATIENTS enterology fellows with an experienced faculty member in attendance. Informed consent was obtained from each pa- Consecutive asymptomatic patients older than 50 years at tient before every procedure. All endoscopic abnormali- average risk for colorectal cancer with a positive FOBT ties were noted, and multiple biopsy specimens were ob- result obtained by DRE or SPS sampling who were tained from each one. All polyps were removed whenever referred to the gastroenterology service at Bellevue Hospi- possible. No major complications directly related to en- tal Center, New York, NY, between January 1992 and doscopy were noted. Lesions that were considered a source January 1997 were identified. Patients were excluded of occult gastrointestinal blood loss included: adenoma- from this study if they had any abdominal signs or symp- tous polyps greater than or equal to 1 cm in diameter, car- toms. Average-risk individuals were defined as patients cinoma, active colitis or inflammatory bowel disease, co- who did not have a history of colon polyps or colorectal lonic ulcers greater than or equal to 1 cm in diameter, and cancer, a family history of colorectal cancer, or inflamma- multiple vascular ectasias. Hemorrhoids and diverticula were tory bowel disease. not considered a source of occult gastrointestinal blood loss. DATA COLLECTION COST OF ENDOSCOPY Data on each patient, which were collected by means of a The cost of endoscopy was estimated by adding the phy- review of endoscopy records, patient charts, and pathol- sician fee under Medicaid reimbursement, the facility fee ogy reports, included age, sex, race, location at the time for endoscopy, and the pathology fee for the biopsy speci- of endoscopy (inpatient vs outpatient), presence of mens. Medicaid reimbursement values were used in the cost comorbid illness, history of peptic ulcer disease, history analysis because this payment method is most applicable of upper or lower gastrointestinal hemorrhage, presence to the Bellevue Hospital Center patient population. The to- of anemia, and use of alcohol, aspirin, NSAIDs, antico- tal estimated cost, including the physician fee, facility fee, agulants, or tobacco. Comorbid illness was defined as and pathology fee, was $739.64 for colonoscopy and $999.64 the presence of any of the following: cardiovascular dis- for colonoscopy with biopsy and/or polypectomy. ease (congestive heart failure, recurrent angina, or endo- carditis), pulmonary disease (pneumonia, pulmonary STATISTICAL ANALYSIS embolus, or chronic obstructive pulmonary disease), liver disease (acute hepatitis, chronic hepatitis, or cir- The diagnostic yield of colonoscopy in patients with a posi- rhosis), renal disease (creatinine level .177 µmol/L [.2 tive FOBT result obtained by DRE was compared with that mg/dL]), neurologic disease (meningitis or central ner- in patients who were found to have occult blood in SPS vous system disease with loss of independence), meta- samples. The cost of identifying a source of occult bleeding, static cancer, or the presence of a systemic bacterial or cost per neoplasm, cost per adenoma, cost per adenoma greater fungal infection. Anemia was defined as a hemoglobin than or equal to 1 cm in diameter, and cost per cancer de- level of less than 140 g/L in men or less than 120 g/L in tected by these 2 methods of screening were calculated. Con- women. Fecal occult blood testing was performed by tinuous variables were compared using a t test or a nonpara- testing 2 samples from each of 3 SPS or 1 specimen metric test, as appropriate. Categorical variables were obtained during DRE using commercially available test compared using the Fisher exact test. A 2-tailed P value of kits (Hemoccult II; SmithKline Diagnostics Inc, San Jose, less than .05 was considered statistically significant. All data Calif) without rehydration. The presence of occult blood are expressed as mean ± SD. Statistical analysis was per- was identified when a positive test result was noted on at formed using a commercially available software package (SPSS least 1 slide. version 7.5 for Windows; SPSS Inc, Chicago, Ill). a positive FOBT result were evaluated by colonoscopy. in diameter, and adenocarcinoma were similar in The patient characteristics are shown in Table 1. Pa- both groups of patients. Also, 7 patients had vascular tients referred for a positive FOBT result obtained by SPS ectasias, 3 had ulcerative colitis, and 1 had Crohn dis- sampling were more likely to be outpatients than those ease. Five of the 7 patients with vascular ectasias had who were tested during DRE. The remaining demo- multiple lesions located in the cecum and ascending graphic and clinical characteristics were similar in both colon; the remaining 2 patients had isolated lesions in groups of patients. the sigmoid colon. Of the 3 patients with ulcerative coli- A colonic source of occult gastrointestinal bleed- tis, 1 had pancolitis, 1 had proctosigmoiditis, and 1 had ing was identified in 145 patients (21.6%). The predic- disease limited to the rectum. The patient with Crohn tive value of a positive FOBT result was no different disease had involvement of the ileum and proximal between those who were tested by DRE and those who colon. Lesions that were thought not to be a cause of had occult bleeding detected by SPS sampling (22.0% occult bleeding included hemorrhoids (125 patients vs 21.3%, P = .85). The lesions detected by colonos- [18.6%]), diverticulosis (49 patients [7.3%]), and both copy are shown in Table 2. The number of patients hemorrhoids and diverticulosis (37 patients [5.5%]). with neoplastic lesions (adenoma or adenocarcinoma), The findings of colonoscopic examination were normal adenomas, adenomas greater than or equal to 1 cm in 249 patients (37.1%). ARCH INTERN MED/ VOL 159, SEP 27, 1999 2023 ©1999 American Medical Association. All rights reserved.
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