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Objective How faecal haemoglobin concentrations (f-Hb) vary from one round to the next in a colorectal cancer (CRC) screening programme, and relate to colonoscopy findings, are unknown. Our aim was to use data from the first two rounds of the faecal immunochemical test (FIT) based Scottish Bowel Screening Programme (SBoSP) to explore these issues. Methods Faecal haemoglobin concentration (f-Hb) percentiles in the second round were compared with those in the first when the first round yielded a negative FIT result (Results The profiles of f-Hb in the first and second rounds differed in (a) those who had had a negative FIT result in the first round and (b) those in whom neoplastic pathology had been found. In contrast, the pattern of difference between profiles in those who had had a negative colonoscopy was very similar to that in those in whom an adenoma had been found. In addition, the risk of CRC being diagnosed in the second round after a negative colonoscopy in the first was 3.0%, not very different to that after a negative test result (4.9%). Conclusions Adenomas may be rarely the cause of a positive FIT result. An alternative explanation as to why these are detected using FIT is required. In addition, a negative colonoscopy for a positive FIT result does not rule out the finding of significant neoplastic pathology in the next round.

Objective Guidelines on colorectal cancer (CRC) screening with guaiac faecal occult blood tests (gFOBTs) and faecal immunochemical tests (FITs) include the need for a pilot before a programme is introduced. Interval cancers (ICs), cancers arising after a negative screening test result but before the next scheduled invite, are important indicators of programme quality. Our aim was to compare IC in the gFOBT-based Scottish Bowel Screening Programme (SBoSP), a FIT-based pilot, and the FIT-based SBoSP, to assess if the pilot provided data that was reflected in the subsequent programme. Design The IC proportions (ICPs) data ([IC/(IC + screen detected CRC)] x 100) from the penultimate year of the gFOBT-based SBoSP, the 6-month pilot and the first year of the FIT-based SBoSP were compared. To ensure appropriate comparison, these data were only from the two pilot NHS Boards. Results For all participants, and females and males, the ICPs were very similar in the gFOBT-based SBoSP and the pilot. The faecal haemoglobin concentration (f-Hb) threshold for the pilot was set at ≥80 μg Hb/g faeces. However, in marked contrast, in the FIT-based SBoSP, at the same threshold, the ICPs were lower. In all three groups, the ICPs were higher in females than in males. Conclusions Data on variables in pilots, including ICP, can be informative, but only if variables such as FIT system are held consistent between pilot and programme. Lowering the f-Hb threshold for females to give the same ICP as males might be a strategy to minimise sex inequality.

Objectives This study aimed to develop a risk-scoring model in the Scottish Bowel Screening Programme incorporating faecal haemoglobin concentration with other risk factors for colorectal cancer. Methods Data were collected for all individuals invited to participate in the Scottish Bowel Screening Programme between November 2017 and March 2018 including faecal haemoglobin concentration, age, sex, National Health Service Board, socioeconomic status, and screening history. Linkage with The Scottish Cancer Registry identified all screening participants diagnosed with colorectal cancer. Logistic regression was performed to identify which factors demonstrated significant association with colorectal cancer and could be used in the development of a risk-scoring model. Results Of 232,076 screening participants, 427 had colorectal cancer: 286 diagnosed following a screening colonoscopy and 141 arising after a negative screening test result giving an interval cancer proportion of 33.0%. Only faecal haemoglobin concentration and age showed a statistically significant association with colorectal cancer. Interval cancer proportion increased with age and was higher in women (38.1%) than men (27.5%). If positivity in women were mirrored in men at each age quintile interval cancer proportion would still have remained higher in women (33.2%). Moreover, an additional 1201 colonoscopies would be required to detect 11 colorectal cancers. Conclusions Development of a risk scoring model using early data from the Scottish Bowel Screening Programme was not feasible due to most variables showing insignificant association with colorectal cancer. Tailoring the faecal haemoglobin concentration threshold according to age could help to diminish some of the disparity in interval cancer proportion between women and men. Strategies to achieve sex equality using faecal haemoglobin concentration thresholds depend considerably on which variable is selected for equivalency and this requires further exploration.

Background Polypectomy may be performed at colonoscopy and then subsequent surveillance undertaken. It is thought that faecal haemoglobin concentration (f-Hb), estimated by quantitative faecal immunochemical tests (FIT), might be a useful tumour marker. Methods Consecutive patients enrolled in colonoscopy surveillance were approached at two hospitals. A specimen for FIT was provided before colonoscopy and, ideally after 3 weeks, a second FIT sample from those who had polypectomy. A single FIT system (OC-Sensor io, Eiken Chemical Co., Ltd) was used to generate f-Hb. Results 1103 Patients were invited; 643 returned a FIT device (uptake: 58.3%). Four patients had known inflammatory bowel disease (IBD) and were excluded, leaving 639 (57.9%) with an age range of 25–90 years (median 64 years), 54.6% male. Of 593 patients who had a f-Hb result and completed colonoscopy, advanced neoplasia was found in 41 (6.9%); four colorectal cancer (CRC): 0.7% and 37 advanced adenoma (AA): 6.3%, and a further 127 (21.4%) had non-advanced adenoma (NAA). The median f-Hb was significantly greater in AA as compared to NAA; 6.0 versus 1.0 μg Hb/g faeces, p < 0.0001.134/164 (81.7%) of invited patients returned a second FIT device: 28 were patients with AA in whom median pre-polypectomy f-Hb was 19.2, falling to 3.5 μg Hb/g faeces post-polypectomy, p = 0.01, and 106 with NAA had median pre-polypectomy f-Hb 0.8 compared to 1.0 μg Hb/g faeces post-polypectomy, p = 0.96. Conclusions Quantitative FIT could provide a good tumour marker in post-polypectomy surveillance, reduce colonoscopy requirements and minimise potential risk to patients.

ObjectiveColorectal cancer (CRC) leads to significant morbidity/mortality worldwide. Defining critical research gaps (RG), their prioritisation and resolution, could improve patient outcomes.DesignRG analysis was conducted by a multidisciplinary panel of patients, clinicians and researchers (n=71). Eight working groups (WG) were constituted: discovery science; risk; prevention; early diagnosis and screening; pathology; curative treatment; stage IV disease; and living with and beyond CRC. A series of discussions led to development of draft papers by each WG, which were evaluated by a 20-strong patient panel. A final list of RGs and research recommendations (RR) was endorsed by all participants.ResultsFifteen critical RGs are summarised below:RG1: Lack of realistic models that recapitulate tumour/tumour micro/macroenvironment;RG2: Insufficient evidence on precise contributions of genetic/environmental/lifestyle factors to CRC risk;RG3: Pressing need for prevention trials;RG4: Lack of integration of different prevention approaches;RG5: Lack of optimal strategies for CRC screening;RG6: Lack of effective triage systems for invasive investigations;RG7: Imprecise pathological assessment of CRC;RG8: Lack of qualified personnel in genomics, data sciences and digital pathology;RG9: Inadequate assessment/communication of risk, benefit and uncertainty of treatment choices;RG10: Need for novel technologies/interventions to improve curative outcomes;RG11: Lack of approaches that recognise molecular interplay between metastasising tumours and their microenvironment;RG12: Lack of reliable biomarkers to guide stage IV treatment;RG13: Need to increase understanding of health related quality of life (HRQOL) and promote residual symptom resolution;RG14: Lack of coordination of CRC research/funding;RG15: Lack of effective communication between relevant stakeholders.ConclusionPrioritising research activity and funding could have a significant impact on reducing CRC disease burden over the next 5 years.

IARC View on Colorectal Screening The International Agency for Research on Cancer concluded that screening for colorectal cancer with stool-based tests and with lower endoscopy (either colonoscopy or sigmoidoscopy) saves lives. Comparative effectiveness data were inconclusive.

It is estimated that 47% of colorectal cancers (CRC) could be prevented by appropriate lifestyles. This study aimed to identify awareness of the causes of CRC in patients who had been diagnosed with a colorectal adenoma through the Scottish Bowel Screening Programme and subsequently enrolled in an intervention trial (using diet and physical activity education and behavioural change techniques) (BeWEL). At baseline and 12-month follow-up, participants answered an open-ended question on factors influencing CRC development. Of the 329 participants at baseline, 40 (12%) reported that they did not know any risk factors and 36 (11%) failed to identify specific factors related to diet and activity. From a potential knowledge score of 1 to 6, the mean score was 1.5 (SD 1.1, range 0 to 5) with no difference between intervention and control groups. At follow-up, the intervention group had a significantly greater knowledge score and better weight loss, diet, and physical activity measures than the control group. Awareness of relevant lifestyle factors for CRC remains low in people at increased risk of the disease. Opportunities within routine NHS screening to aid the capability (including knowledge of risk factors) of individuals to make behavioural changes to reduce CRC risk deserve exploration.

Total and individual bile acid concentrations in the oesophageal aspirates from 30 patients with Barrett's oesophagus were compared with those from 15 patients with oesophagitis and 15 normal subjects. The highest total bile acid concentrations were found in the Barrett's patients and this was statistically significant when compared with controls but not oesophagitis patients. However, when the 95th percentile value of bile acid concentration in the normal subjects was taken as the 'cut-off' level, a significantly higher number of Barrett's patients (15/30) were bile refluxers than were the oesophagitis patients (3/15). Glycocholic and taurocholic acids were the predominant bile acids detected, but taurochenodeoxycholic acid was also present in significant amounts in the patients with oesophagitis. It is possible that bile reflux contributes to the development of Barrett's oesophagus.

To assess the feasibility of introducing into the UK's NHS a national screening programme for colorectal cancer based on faecal occult blood testing.Demonstration pilot.Two English health authorities and three Scottish health boards.People aged 50-69 years.478,250 residents of the pilot areas were invited to take part in the screening programme. Uptake (the proportion in whom a final faecal occult blood test result was available) was 56.8% (n = 271,646). The overall rate of a positive test result was 1.9% and the rate for detecting cancer was 1.62 per 1000 people screened. Both these values were higher in Scotland than in England, higher in men than in women, and increased with age. The positive predictive value was 10.9% for cancer and 35.0% for adenoma. 552 cancers were detected by screening; 92 (16.6%) were polyp cancers. 48% of all screen detected cancers were Dukes's stage A, and 1% had metastasised at the time of diagnosis.Screening for colorectal cancer by testing for faecal occult blood is feasible within the context of the United Kingdom's NHS. Screening should lead to a reduction in deaths from colorectal cancer in the population offered screening.