Gastroenterology

Gastroenterology

Volume 152, Issue 4, March 2017, Pages 767-775.e2
Gastroenterology

Original Research
Full Report: Clinical—Alimentary Tract
Real-Time Monitoring of Results During First Year of Dutch Colorectal Cancer Screening Program and Optimization by Altering Fecal Immunochemical Test Cut-Off Levels

https://doi.org/10.1053/j.gastro.2016.11.022Get rights and content

Background & Aims

After careful pilot studies and planning, the national screening program for colorectal cancer (CRC), with biennial fecal immunochemical tests (FITs), was initiated in The Netherlands in 2014. A national information system for real-time monitoring was developed to allow for timely evaluation. Data were collected from the first year of this screening program to determine the importance of planning and monitoring for optimal screening program performance.

Methods

The national information system of the CRC screening program kept track of the number of invitations sent in 2014, FIT kits returned, and colonoscopies performed. Age-adjusted rates of participation, the number of positive test results, and positive predictive values (PPVs) for advanced neoplasia were determined weekly, quarterly, and yearly.

Results

In 2014, there were 741,914 persons invited for FIT; of these, 529,056 (71.3%; 95% CI, 71.2%–71.4%) participated. A few months into the program, real-time monitoring showed that rates of participation and positive test results (10.6%; 95% CI, 10.5%–10.8%) were higher than predicted and the PPV was lower (42.1%; 95% CI, 41.3%–42.9%) than predicted based on pilot studies. To reduce the burden of unnecessary colonoscopies and alleviate colonoscopy capacity, the cut-off level for a positive FIT result was increased from 15 to 47 μg Hb/g feces halfway through 2014. This adjustment decreased the percentage of positive test results to 6.7% (95% CI, 6.6%–6.8%) and increased the PPV to 49.1% (95% CI, 48.3%–49.9%). In total, the first year of the Dutch screening program resulted in the detection of 2483 cancers and 12,030 advanced adenomas.

Conclusions

Close monitoring of the implementation of the Dutch national CRC screening program allowed for instant adjustment of the FIT cut-off levels to optimize program performance.

Section snippets

The Dutch CRC Screening Program

The Dutch CRC screening program was implemented gradually by age group from 2014 onward, with a projected roll-out period of 5 years, allowing for timely increase of the colonoscopy capacity to ultimately accommodate the target population of 2.2 million invitees annually (Appendix 1). The target population for 2014 consisted of all individuals reaching the age of 63, 65, 67, or 75 years in 2014. The oldest age group was included in 2014 because it was their only opportunity to be invited. The

Invitation and Participation

The target population for 2014 consisted of 865,048 persons. By the end of the year, 703,626 (81.3%) of those had been invited for screening. Weekly monitoring showed that in some screening regions the entire target population of 2014 had been invited before the end of the year. In these regions, an additional 38,288 persons aged 60 years were invited for screening, resulting in 741,914 invitees in total. Figure 2 shows the flow of individuals through the screening process. A total of 529,056

Discussion

These data show the additional value of real-time monitoring to successfully implement a national screening program. A few months into the program, real-time monitoring showed a higher positivity rate and a lower PPV than expected. This resulted in a higher number of false-positive test results, leading to unnecessary diagnostic colonoscopies with associated risks. In July 2014 the program was adjusted, resulting in a lower positivity rate and fewer false-positive results, which was more in

Acknowledgments

The authors thank the other members of the Dutch national colorectal cancer screening working group: D. L. Schipper, A. A. M. Masclee, T. J. Wiersma, J. A. Otte, A. van der Beek, F. J. van Kemenade, J. Stoker, G. J. den Heeten, E. J. R. de Graaf, W. M. U. van Grevenstein, Y. C. M. Kluiters, and M. A. Blankenstein for their role (on behalf of their professional association) in the realization and implementation of the current screening program and their critical review of the manuscript. The

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    Conflicts of interest The authors disclose no conflicts.

    Funding This study was funded by the Dutch National Institute for Public Health and the Environment.

    Author names in bold designate shared co-first authorship.

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