Risk stratification for advanced colorectal neoplasia according to fecal hemoglobin concentration in a colorectal cancer screening program

Gastroenterology. 2014 Sep;147(3):628-636.e1. doi: 10.1053/j.gastro.2014.06.008. Epub 2014 Jun 14.


Background & aims: The latest generation of fecal immunochemical tests (FIT) allows for quantitation of hemoglobin in feces, allowing for selection of optimal cut-off concentrations. We investigated whether individuals with positive results from quantitative FITs, in combination with other factors, could be identified as being at greatest risk for advanced colorectal neoplasia.

Methods: In a retrospective study, we analyzed data from a consecutive series of 3109 participants with positive results from FITs (≥20 μg/g of feces) included in the first round of the Barcelona colorectal cancer screening program, from December 2009 through February 2012. All participants underwent colonoscopy and were assigned to groups with any advanced colorectal neoplasia or with nonadvanced colorectal neoplasia (but with another diagnosis or normal examination findings).

Results: Median fecal hemoglobin concentrations were significantly higher in participants with advanced colorectal neoplasia (105 μg/g; interquartile range, 38-288 μg/g) compared with participants with nonadvanced colorectal neoplasia (47 μg/g; interquartile range, 23-119 μg/g) (P < .001). Positive predictive values for advanced colorectal neoplasia, determined using arbitrary fecal hemoglobin concentrations, differed with sex and age. Multivariate logistic regression analysis identified sex (men: odds ratio [OR], 2.07; 95% confidence interval, 1.78-2.41), age (60-69 y: OR, 1.24; 95% confidence interval, 1.07-1.44), and fecal hemoglobin concentration (>177 μg/g: OR, 3.80; 95% confidence interval, 3.07-4.71) as independent predictive factors for advanced colorectal neoplasia. Combining these factors, we identified 16 risk categories associated with different probabilities of identifying advanced colorectal neoplasia. Risk for advanced colorectal neoplasia increased 11.46-fold among individuals in the highest category compared with the lowest category; positive predictive values ranged from 21.3% to 75.6%.

Conclusions: Fecal hemoglobin concentration, in addition to sex and age, in individuals with positive results from FITs can be used to stratify probability for the detection of advanced colorectal neoplasia. These factors should be used to prioritize individuals for colonoscopy examination.

Keywords: Colonoscopy; Colorectal Cancer Screening; Fecal Immunochemical Tests; Risk Stratification.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Biomarkers, Tumor / analysis*
  • Colonoscopy
  • Colorectal Neoplasms / chemistry*
  • Colorectal Neoplasms / pathology
  • Early Detection of Cancer*
  • Feces / chemistry*
  • Female
  • Hemoglobins / analysis*
  • Humans
  • Immunochemistry
  • Logistic Models
  • Male
  • Mass Screening / methods*
  • Middle Aged
  • Multivariate Analysis
  • Occult Blood*
  • Odds Ratio
  • Predictive Value of Tests
  • Prognosis
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Sex Factors
  • Spain


  • Biomarkers, Tumor
  • Hemoglobins