Optimizing colorectal cancer screening intervals using fecal hemoglobin concentration: a personalized approach

Dear Editor, Colorectal carcinoma (CRC) is a major cancer burden and efforts are being made to reduce its devastating effects globally. These efforts have focused on developing screening programs to identify precancerous lesions, such as adenomas and polyps, before they become neoplastic. One of the tools developed to improve colorectal cancer screening is fecal immunologic testing (FIT), a test based on fecal hemoglobin (f-Hb) concentration1. A direct relationship between f-Hb concentration and CRC has already been established in previous studies. Recently, this gradient relationship between f-Hb concentration and CRC has become a major topic of research for developing a screening program that is more personalized and based on individual risk levels2–4. A recent study showed strong evidence that screening intervals could be adjusted based on fecal Hb levels5. The data for this retrospective cohort study were obtained from a Taiwanese cancer screening program that used FIT and colonoscopy biennially. More than three million people with a mean age of 57.8 years participated in this screening program. This study aimed to develop guidelines for optimal screening intervals based on f-Hb levels. An increase in baseline f-Hb levels related to colorectal neoplasia and mortality was observed. The CRC incidence rate (per 1000 person-years) increased with f-Hb from 0.94 for undetected f-Hb to 10.25 for f-Hb ≥150 μg Hb/g5. Another finding was an increase in the incidence of advanced colorectal cancer with an increase in f-Hb. Through careful analysis of these data, participants were stratified into different groups based on f-Hb levels, and various screening intervals were developed. A reduction of 49 and 28% in FIT tests and colonoscopies, respectively, was attributed to the use of personalized f-Hb-based screening intervals compared with biennial screening. This study suggests that adjustment of screening intervals can be performed using f-Hb metrics. The findings of this study have a meaningful impact on clinical practice. First, a decrease in the number of colonoscopies among patients stratified as low-risk using f-Hb concentration can save them from unwanted adverse events such as bleeding and perforations. Additionally, it reduces psychological stress related to repeated testing, according to established screening recommendations. Second, by personalizing the screening interval by f-Hb levels at the individual level, the optimal allocation of healthcare resources can be achieved. Third, the principle of decreasing tests using a personalized screening method is also supported by the minimization of costs, which also diminishes the risk of over-detection among low-risk populations. The development of a precision screening interval based on f-Hb can also guide the judicious use of other more specific tests, such as colonoscopy. The study’s findings and large sample size provide compelling evidence of its credibility; however, some limitations must be considered. Although this method of precision screening intervals can be used in other populations, adjustments for f-Hb levels are required because of the differences in incidence and mortality rates among specific populations. This analysis did not include various individual characteristics such as BMI, family history, and smoking, which are also risk factors for CRC. The inclusion of these risk factors, along with f-Hb levels, can increase the precision of risk detection. Integration of these findings into clinical practice can be advantageous; however, research is required to determine ways to implement such methods in practice. Regulatory bodies should consider adding this method of precision individualized screening to reduce the testing burden among low-risk populations and accurately identify pathology before it reaches an advanced stage. The incorporation of such screening methods can improve the cost-effectiveness of CRC surveillance. In conclusion, this study demonstrated a relationship between f-Hb levels and CRC incidence and mortality. It also showed how f-Hb concentrations can be used to develop a precise screening interval program for different risk groups, thereby reducing the number of FIT tests and colonoscopies. Ethical approval Not applicable. Consent Not applicable. Sources of funding None. Author contribution H.S.: conceptualization, writing – original draft, and writing – review and editing; A.V.: validation, writing – original draft, and writing – review and editing; M.N.K., Q.S.Z., A.M.G., R.K.S., S.R., M.P.S., and A.M.T.: writing – original draft and writing – review and editing. All authors are accountable for all the aspects of this work. Conflicts of interest disclosure The authors declares no conflicts of interest. Research registration unique identifying number (UIN) Not applicable. Guarantor Hamza Sajjad. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Provenance and peer review Not commissioned, externally peer-reviewed.

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