Inadequate follow-up of positive fecal occult blood test results: Survey of physician-reported reasons

350

METHODSEndoscopistsperforming FS classified all polyps removed from above distal 5 cm of rectum as HP, AP, CRC,unsure. Expertpathologistsclassifiedthe polyps without knowledge of the endoscopicdiagnosis. RESULTSOf 19,305 polyps, 29.9% were classified by endoscopists as HP, 33.6% as AP, 0.6% as CRC and 35.9% as unsure. Overall, endoscopists were correct in their diagnosis of HPs in 78.3% (4524/5777)see Table. Accuracy did not vary by size but was lower in polyps proximal to the sigmoid colon. Of 5,777 polyps classified as HP, 402 (7%) were found to be AP and 18 (0.3%) had high-risk features. There ware no cancers. CONCLUSIONSEndoscopistajudged 30% of polyps to be hyperplastic and were correct 78% of the time. In only 0.3% would pathologicaldiagnosishavechangedmanagement. Not examiningthese polyps would save 30% of screeningworkload. Polyps above the distal rectum require removal since 7% were found to be adenomatous.

Tota/ Size: Site: ...............

1 - 3 mm 4 - 6 mm 7-1t mm Rectum Sigmoid Descending

Clinical Dx HP

No.Correct

% Cowect

5777 4475 1213 33 3622 2025 130

4524 3523 920 26 2966 1483 75

78.3 78.7 75.9 788 81.9 73.2 57.7

Inadequate Fellow-Up of Positive Fecal Occult Blood Test Results: Survey of Pl~ician-Reported Reasons. Nadeem A. Baig, David S. Weinberg, Run Myers, Jefferson Medical Coil, Philadelphia,PA; Barbara Turner, Univ of Pennsylvania,Philadelphia,PA; Terry Hyslop, Jefferson Medical Coil, Philadelphia,PA Background:Population-basedscreeningemployingFecalOccultBloodTesting (FOBT)reduces cotorectal cancer incidence and mortality. However, in clinical practice many patients with a FOBT positive (FOBT(+)) result do not undergo a complete diagnostic evaluation, (CDE either a colonoscopy or combined flexible sigmoidoscopy and barium enema). The aim of this study is to identify physician-reported reasonsthat limit CDE performance. Methods: In a centralized FOBT-based colorectal cancer screening program, any screening FDBT (+) result triggered a chart audit form to be mailed to the patient's primary care practice. The form requested information regarding the patient's CDE status, in the event that CDE was not performed, PCPs were asked to provide an explanation. Frequency distributions were computed for CDE status and reasons for CDE non-performance. Results: During the study period, 544 consecutive FOBT(+) patients were identified. A total of 266 patients(49%) did not undergo CDE.PCPsprovided explanation(s)for why CDEwas not performed in 141 cases (53%) and provided none for the other 125 cases (47%). In only 10% of cases (26/268), did the patient refuse CDE. Despite referral to a specialist, 18% (44/266) of patients did not have CDE performed. In 39=/0of cases (104/266), the physician decided not to proceed with CDE. The predominent reasons included: the patient had normal result(s) on testing that did not include CDE (26%); attribution of the FOBT(+) result to concomitant medication use (3%), PCP belief ~ the patient's medical history contributed 1o the FOBT(+) result (3%), PCP concern about recommending CDE to patients with co-morbid illnesses (2%), and the PCP's belief that failure to comply with the prescribed dietary regimen was the causefor the FOBT( + ) result (1%). Conclusion:Nearly50% of patientswith a positive FOBTdid not undergo CDE. Physician-baseddecision making frequently accounted for CDE non-performance. In manycases,the reasonscited by physiciansdid not conform to standardexpert recommendations. Patient refusal to submit to CDE is relatively uncommon. Physicianeducation regarding CDE appears warranted.

348 Variability In Yield Of Neoplasis In Average Risk Individuals UnderooinORoxible Sigmoidosoopy(FS) Screening Wendy S. Atkin, Claire F. Cook, Rekha Patel, Imperial Cancer Research Fund, Harrow United Kingdom; Robert Edwards, Imperial Cancer Research Fund, London United Kingdom BACKGROUNDIn the UK FS screeningtrial, 40,332 averagerisk individuals aged 55-64 years have undergonea single FS screen. 14 centres participated,with mostly a single endoscopist performing around 3,000 examinations,using the same equipment.AIMS To examinefactors associatedwith variability in adenomayield. METHODSThe associationbetweenthe variation in prevalenceof adenomas in each centre and a number of possible causative factors was explored by means of a test for trend. RESULTS Detection rates of adenomas in different centres varied between 9% and 15% (p < O.OOt). In this relatively homogeneous group, none of the following factors explainedvariability: sex ratio of participants,underlyingincidence rates of colorectalcancer in the populationssampled,histopathologicalclassification of polyps by different endoscopists, prevalenceof smokers (although smokers had a higher prevalence in all centres). Aspects of FS operator performanceinvestigatedincluded reportedcompletion rates (to the sigmoid/descendingcolon junction), repeat examination rates, reported depth of insertion of the scope, time taken and pain reported. Pain was independentlyassessedby patient questionnaire completed by 98.4% on the following morning. Only time taken to withdraw the scope explainedthe variability, with shorter times associatedwith lower detection rates. Reported completion rates were unrelated to detection rates, and are an unreliable measure of performance. CONCLUSIONSThe detection rate of adenornes at FS screening varies significantly and depends on operator performance. The importance of the variability in detection rates of adenomaswill depend on whether these differences are associatedwith variability in interval cancer rates in the different centres.

351 Comeddd Disorders and Symptoms in Irritable Bowel Syndrome (IBS) Compared to Ofkw 6 a ~ raUenta Kenneth R. Jones, Oiafur S. Palsson, Univ of North Carolina, Chapel Hill, NC; Rona L. Levy, Univ of Washington, SastUe,WA; Andrew D. Feld, Group Health Cooperative,Seattle, WA; George F. Longstreth, Kaiser Permanente, San Diego, CA; Barbara H. Bradshaw, Douglas A. Drossman, William E. Whitehead, Univ of North Carolina, Chapel Hill, NC Chronic fatigue syndrome (CFS),fibromyalgia, or temporomandibulardisorder (TMJ) patients have high rates of IBS (ArchlntMed 2000;160:221-7). Aims: (1) Determinewhich comorbid disorders and non-GI symptomsare reported more often by IBS patients compared to nonIBS patients in gastroenterologyclinic care. (2) Determine whether self-reported anxiety and depression account for increased numbers of comorbid disorders. Methods: Consecutive patients at health maintenanceorganization GI clinics in two states (CA & WA) were asked to complete a questionnaire. IBS status was defined by response to items assessing Rome II IBS criteria; patients meeting IBS criteria but also reporting inflammatory bowel disease (n=11) were excluded from analyses. Results: (1) 3912 patients (57% female) completed questionnaires w~ 1210 subjects completing a longer questionnaire including symptoms. (2) 270 (7%) patientSmet Rome II criteria (71% female). (3) Six of 34 disorderswere reported more often by IBS patients (p<.05): headache(IBS=51% vs non-IBS=35%), chronic back pain (38 vs 27%), premenstrual syndrome (18 vs 8%), TMJ (16 vs 8%), CFS (14 vs 7%), and dysmenorrhea (tO vs 5%) (listed in order of magnitude of differences). (4) More IBS patients (p<.05) reportedsymptomsof fatigue, headaches,back pain, palpitations/flush/dizzy, muscle aches, frequent urination, loss of appetite, sensitivity to heat/cold, trouble urinating, and fever (listed by magnitude of differences). IBS patients averaged 84% more of these symptoms than non-IBS patients. (5) More IBS patients also reported anxiety and depression (p<.O01). When the variance due to self-reported anxiety and depression was removed by covarianceanalysis,group differences remainedsignificant for both disorders and symptoms. Conclusions: (1) Datafrom this large questionnairesamplefrom GI clinics indicatean overlap of IBS with common pain disorders (head, back, TMJ, gynecologic) and CFS. (2) The most commonly reportednon-GI symptoms for IBS patientscluster well with the reporteddisorders. These cluster in three areas:fatigue, pain, and a possible neuro-vascularcluster (palpitations/ flush/dizzy & headache). (3) A higher number of IBS patients reported specific comorbid disorders and symptoms independentof anxiety and depression,which appearedto magnify these differences. (4) Future researchshould focus on the etiological factors in these common comorbid disorders. [Supported by R01 DK31369 & R01 HD36069.]

349 Rightside Colorectal Cancers Are Likely To Give False Negative Test Of Fecal Occult Blood On The Basis Of Screening Total Colonoscopy Yutaka Yamaji, Makoto Okamoto, Haruhiko Yoshida, Takao Kawabe,Yasushi Shiratori, Univ of Tokyo, Tokyo Japan; Keiji Saito, Keiji Yokouchi, Toru Mitsushima, KamedaGen Hosp, Chiba Japan; Masao Omata, Univ of Tokyo, Tokyo Japan [Background] The efficacy of screening colorectal cancer by fecal occult blood test (FOBT) has beenshown by largescale randomizedcontrolled trials. However,the reduction of mortality was rather limited, for which one of the most important reasons may he false negative test of FOBT. [Methods] To elucidatethe difference between colorectal cancers with positive and negativeresults of FOBT,we conducted59,579 sets of FOBTand total colonoscopyon 19,482 Japaneseduring 1983-1999. The subjects consisted of 45,163 male and 14,416 female aged 20-88 years. Fecal occult blood was judged by reversed passive hemagglutination (RPHA) method, an immunological FOBT,conducted once just before colonoscopy on the same day. Colonoscopewas performed irrespective of the result of FOBT. [Results] FOBTwas positive in 2,830 cases (4.7%) among the total examinations.A total of 212 colorectal cancer cases were found, of which 39 cases were invasive beyond submucose, 34 were invasive within submucosa, and 139 were carcinoma in situ. Sensitivity of FOBTwas 40% in total cancers (FOBT positive: nagative = 85: 127), 74% in invasive cancers beyond submucosa (29: 10), 44% in invasive cancers within submucosa (15: 19), and 29% in carcinoma in situ (41: 98). According to multivariate analysis which evaluatedthe parametersof the subject's gender or age, the cancer's location, shape, size or depth of invasion, and accompanying adenoma's quantitiy or size, the location (leftside vs rightside, OR [95% CI] = 2.7 [12-6.0], p = 0.02) and the size (by lOmm increasing, OR [95% CI] = 2.2 [1.6-3.1], p30mm, respectively. Small cancers on rightside were most likely to give false negativetest, and they, in many cases, presentedflat appearance.[Conclusion] S a n s ~ of FOBT for colorectal cancer was 60% for invasive colorectal cancers, and only 40% when including carcinoma in-situ, according to screening total colonoscopy on 19,482 Japanese. Small cancers on rightside colon tended to give false negative result of FOBT by multivaritate analysis.

352 Concordance of IB$ among Monozygoticand Dizygotic Twins Tony Lembo, Mohammed S. Zaman, Norma F. Chavez, Beth israel DeaconessMedical Ctr, Boston, IdA; Robert Kruegar, Univ of Minnesota, Minneapolis, MN; Michael P. Jones, Nicholas J. Talley, Nepean Hosp, Sydney Australia introduction: IBS tends to cluster in families, however the influence of heritable versus environment factors in the development of IBS is not known. The purpose of this study is to investigate the concordance of IBS symptoms among monozygotic (MZ) and dizygotic (DZ) twins. Methods:3,000 twin pairs, ages41 to 64, were mailedthe following questionnaires: modified Mayo Clinic Bowel DiseaseQuestionnaire (BDQ), health-relatedquality of life (SF12), SCL-90-R and Eysenck Personality Inventory. 1,015 twin pairs were identified out of 2,980 completed questionnaires. Results: Among twin pairs, 496 met the criteria for IBS (Rome II). 100 were excluded due to alternative causes for their symptoms. Therefore, 396 (17%; F 295, M 101) subjects were included for further analysis. No differences in the concordancewas presentbetweenMZ, DZ same sex and DZ opposite sex (seetable). Likewise,

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