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Which tool is most useful in diagnosing bipolar disorder in children?
No single, well-validated screening instrument for clinical diagnosis of bipolar disorder in children exists. That said, the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS), a semi-structured interview, along with clinical evaluation by a childhood mental health specialist, is used most frequently in major research studies (strength of recommendation [SOR]: C).
As a screening tool in the primary care setting, family history of bipolar disorder in either biologic parent increases the odds of diagnosis (SOR: A). High or low scores on parent-reported screening tests (Parent Young Mania Rating Scale [P-YMRS], Parent General Behavior Inventory [P-GBI], and Child Behavior Checklist [CBCL]) also significantly increase or decrease the likelihood of diagnosis (SOR: B).
Make sure it’s not ADHD
Adam J. Zolotor, MD, MPH
University of North Carolina at Chapel Hill
When evaluating a child for mental health, behavioral, or academic concerns, I always begin with an assessment targeting potential attention deficit hyperactivity disorder (ADHD). Distinguishing mania from hyperactivity and impulsivity is difficult. The most useful clue is family history. Suspicion of bipolar disorder (based on mood cycling or family history) would prompt me to refer to a child mental health specialist. Also, when I’m treating a child with ADHD, I consider alternate or comorbid conditions when he or she fails to achieve behavioral goals.
Of the rating scales reviewed above, I consider the P-GBI and the P-YMRS useful in risk stratification. However, screening instruments are less useful when a disease is rare (as with childhood bipolar disorder). Children with hyperactivity and impulsivity may have a range of conditions from hyperthyroidism to anxiety disorders, but we must listen to the history, observe the patient, and proceed with an evaluation based on the likelihood of disease.
Evidence summary
Retrospective analysis of 2 large cohort studies of adults with bipolar disorder indicated that at least 50% of these patients had an onset of illness before age 19, establishing support for the presence of bipolar disorder among children and adolescents.1 The criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) cannot be easily applied to most children and adolescents with bipolar disorder because most do not meet the criteria for Bipolar I or II, but fall into the less well-defined category Bipolar NOS (not otherwise specified).2,3
Compared with adults, children and adolescents are more difficult to diagnose because they are less likely to have discrete episodes of mania, and instead present with severe irritability, rapid cycling, or mixed mania.2,4 In laddition, symptoms progress and evolve as children and adolescents grow.1 Comorbid disorders such as ADHD, oppositional defiant disorder, conduct disorder, and learning disorders are common in this population, further complicating diagnosis.2
Screening instruments are imperfect
Different versions of the KSADS have been used in most research studies on this disorder.2 Despite this, concerns about the validity of the instrument still exist because of lack of sufficient testing, vagueness of the diagnostic criteria, and the subjective nature of the test.5,6 Because specialized training is required to administer the test and testing can last a full day, its use in most office settings is impractical. It is also not meant as a stand-alone test, but to be used in conjunction with a clinical evaluation by a trained mental health professional.7
In a general clinical setting, family history and selected screening instruments may help to increase or decrease clinical suspicion for the disorder and guide referral for more specialized evaluation by a child mental health provider. In addition, a meta-analysis found that children or adolescents who have a biologic parent with bipolar disorder have 2 to 10 times the odds of being diagnosed with bipolar disorder.7
Three screening tests (CBCL, P-GBI, and P-YMRS) available for the office setting use parent-reported scores, and perform best when compared with KSADS as the standard.3 These instruments were associated with likelihood ratios that significantly improved the odds of diagnosis and could allow clinicians to stratify patients as high or low risk (TABLE).3
TABLE
Likelihood ratios for 3 screening tools you can use in the office
| For ages 5–10* | For ages 11–17† | |||||||
| IF THE SCORE IS… | IF THE SCORE IS… | |||||||
| LOW | MOD. LOW | HIGH | VERY HIGH | LOW | MOD. LOW | HIGH | VERY HIGH | |
| THEN THE LR FOR THE INSTRUMENT IS… | THEN THE LR FOR THE INSTRUMENT IS… | |||||||
| P-YMRS | 0.08 | 0.48 | 6.94 | 8.92 | 0.20 | 0 .32 | 4.07 | 7.41 |
| P-GBI | 0.10 | 0.48 | 4.90 | 6.29 | 0.06 | 0.25 | 4.82 | 9.21 |
| CBCL | 0.07 | 0.47 | 3.15 | 3.52 | 0.04 | 0.53 | 2.65 | 4.29 |
| * Population studied had a 50.3% prevalence of bipolar disorder. | † Population studied had a 40.7% prevalence of bipolar disorder. | |||||||
Recommendations from others
Two consensus conferences, a Canadian guideline, and a National Institute of Mental Health round-table all concluded that there is currently no ideal test for the diagnosis of child and adolescent bipolar disorder, but that such an instrument needed to be developed.2,5,6,8 One consensus conference further concluded that the diagnosis is best made by childhood mental health specialists based on multiple informants, such as the child and parents, with symptoms present in at least 2 settings or by direct observation.6
A Canadian consensus conference proposed screening patients with depressive symptoms for a history of hypomanic or manic symptoms, and consider an underlying mood disorder in those with vague or nonspecific somatic symptoms or reverse vegetative symptoms (eg, hypersomnia and hyperphagia). Their recommendations also emphasized screening for family history of bipolar disorder when there were clinical concerns.8
1. Post R, Kowatch R. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry 2006;67:115-125.
2. National Institute of Mental Health research round-table on prepubertal bipolar disorder J Am Acad Chld Adolesc Psychiatry 2001;40:871-878.
3. Youngstrom E, Findling R, Calabrese J, et al. Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psychiatry 2004;43:847-858.
4. Weckerly J. Pediatric bipolar mood disorder. J Dev Behav Pediatr 2002;23:42-56.
5. Coyle J, Pine D, Charney D, et al. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003;42:1494-1503.
6. Carlson G, Jensen P, Findling R, et al. Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder: Report of a Consensus Conference. J Child Adolesc Psychopharamcol 2003;13:13-27.
7. Youngstrom E, Findling R, Youngstrom J, Calabrese J. Toward an evidence-based assessment of pediatric bipolar disorder. J Clin Child Adolesc Psychol 2005;34:433-448.
8. Yatham L, Kennedy S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CAN-MAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.
No single, well-validated screening instrument for clinical diagnosis of bipolar disorder in children exists. That said, the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS), a semi-structured interview, along with clinical evaluation by a childhood mental health specialist, is used most frequently in major research studies (strength of recommendation [SOR]: C).
As a screening tool in the primary care setting, family history of bipolar disorder in either biologic parent increases the odds of diagnosis (SOR: A). High or low scores on parent-reported screening tests (Parent Young Mania Rating Scale [P-YMRS], Parent General Behavior Inventory [P-GBI], and Child Behavior Checklist [CBCL]) also significantly increase or decrease the likelihood of diagnosis (SOR: B).
Make sure it’s not ADHD
Adam J. Zolotor, MD, MPH
University of North Carolina at Chapel Hill
When evaluating a child for mental health, behavioral, or academic concerns, I always begin with an assessment targeting potential attention deficit hyperactivity disorder (ADHD). Distinguishing mania from hyperactivity and impulsivity is difficult. The most useful clue is family history. Suspicion of bipolar disorder (based on mood cycling or family history) would prompt me to refer to a child mental health specialist. Also, when I’m treating a child with ADHD, I consider alternate or comorbid conditions when he or she fails to achieve behavioral goals.
Of the rating scales reviewed above, I consider the P-GBI and the P-YMRS useful in risk stratification. However, screening instruments are less useful when a disease is rare (as with childhood bipolar disorder). Children with hyperactivity and impulsivity may have a range of conditions from hyperthyroidism to anxiety disorders, but we must listen to the history, observe the patient, and proceed with an evaluation based on the likelihood of disease.
Evidence summary
Retrospective analysis of 2 large cohort studies of adults with bipolar disorder indicated that at least 50% of these patients had an onset of illness before age 19, establishing support for the presence of bipolar disorder among children and adolescents.1 The criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) cannot be easily applied to most children and adolescents with bipolar disorder because most do not meet the criteria for Bipolar I or II, but fall into the less well-defined category Bipolar NOS (not otherwise specified).2,3
Compared with adults, children and adolescents are more difficult to diagnose because they are less likely to have discrete episodes of mania, and instead present with severe irritability, rapid cycling, or mixed mania.2,4 In laddition, symptoms progress and evolve as children and adolescents grow.1 Comorbid disorders such as ADHD, oppositional defiant disorder, conduct disorder, and learning disorders are common in this population, further complicating diagnosis.2
Screening instruments are imperfect
Different versions of the KSADS have been used in most research studies on this disorder.2 Despite this, concerns about the validity of the instrument still exist because of lack of sufficient testing, vagueness of the diagnostic criteria, and the subjective nature of the test.5,6 Because specialized training is required to administer the test and testing can last a full day, its use in most office settings is impractical. It is also not meant as a stand-alone test, but to be used in conjunction with a clinical evaluation by a trained mental health professional.7
In a general clinical setting, family history and selected screening instruments may help to increase or decrease clinical suspicion for the disorder and guide referral for more specialized evaluation by a child mental health provider. In addition, a meta-analysis found that children or adolescents who have a biologic parent with bipolar disorder have 2 to 10 times the odds of being diagnosed with bipolar disorder.7
Three screening tests (CBCL, P-GBI, and P-YMRS) available for the office setting use parent-reported scores, and perform best when compared with KSADS as the standard.3 These instruments were associated with likelihood ratios that significantly improved the odds of diagnosis and could allow clinicians to stratify patients as high or low risk (TABLE).3
TABLE
Likelihood ratios for 3 screening tools you can use in the office
| For ages 5–10* | For ages 11–17† | |||||||
| IF THE SCORE IS… | IF THE SCORE IS… | |||||||
| LOW | MOD. LOW | HIGH | VERY HIGH | LOW | MOD. LOW | HIGH | VERY HIGH | |
| THEN THE LR FOR THE INSTRUMENT IS… | THEN THE LR FOR THE INSTRUMENT IS… | |||||||
| P-YMRS | 0.08 | 0.48 | 6.94 | 8.92 | 0.20 | 0 .32 | 4.07 | 7.41 |
| P-GBI | 0.10 | 0.48 | 4.90 | 6.29 | 0.06 | 0.25 | 4.82 | 9.21 |
| CBCL | 0.07 | 0.47 | 3.15 | 3.52 | 0.04 | 0.53 | 2.65 | 4.29 |
| * Population studied had a 50.3% prevalence of bipolar disorder. | † Population studied had a 40.7% prevalence of bipolar disorder. | |||||||
Recommendations from others
Two consensus conferences, a Canadian guideline, and a National Institute of Mental Health round-table all concluded that there is currently no ideal test for the diagnosis of child and adolescent bipolar disorder, but that such an instrument needed to be developed.2,5,6,8 One consensus conference further concluded that the diagnosis is best made by childhood mental health specialists based on multiple informants, such as the child and parents, with symptoms present in at least 2 settings or by direct observation.6
A Canadian consensus conference proposed screening patients with depressive symptoms for a history of hypomanic or manic symptoms, and consider an underlying mood disorder in those with vague or nonspecific somatic symptoms or reverse vegetative symptoms (eg, hypersomnia and hyperphagia). Their recommendations also emphasized screening for family history of bipolar disorder when there were clinical concerns.8
No single, well-validated screening instrument for clinical diagnosis of bipolar disorder in children exists. That said, the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS), a semi-structured interview, along with clinical evaluation by a childhood mental health specialist, is used most frequently in major research studies (strength of recommendation [SOR]: C).
As a screening tool in the primary care setting, family history of bipolar disorder in either biologic parent increases the odds of diagnosis (SOR: A). High or low scores on parent-reported screening tests (Parent Young Mania Rating Scale [P-YMRS], Parent General Behavior Inventory [P-GBI], and Child Behavior Checklist [CBCL]) also significantly increase or decrease the likelihood of diagnosis (SOR: B).
Make sure it’s not ADHD
Adam J. Zolotor, MD, MPH
University of North Carolina at Chapel Hill
When evaluating a child for mental health, behavioral, or academic concerns, I always begin with an assessment targeting potential attention deficit hyperactivity disorder (ADHD). Distinguishing mania from hyperactivity and impulsivity is difficult. The most useful clue is family history. Suspicion of bipolar disorder (based on mood cycling or family history) would prompt me to refer to a child mental health specialist. Also, when I’m treating a child with ADHD, I consider alternate or comorbid conditions when he or she fails to achieve behavioral goals.
Of the rating scales reviewed above, I consider the P-GBI and the P-YMRS useful in risk stratification. However, screening instruments are less useful when a disease is rare (as with childhood bipolar disorder). Children with hyperactivity and impulsivity may have a range of conditions from hyperthyroidism to anxiety disorders, but we must listen to the history, observe the patient, and proceed with an evaluation based on the likelihood of disease.
Evidence summary
Retrospective analysis of 2 large cohort studies of adults with bipolar disorder indicated that at least 50% of these patients had an onset of illness before age 19, establishing support for the presence of bipolar disorder among children and adolescents.1 The criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) cannot be easily applied to most children and adolescents with bipolar disorder because most do not meet the criteria for Bipolar I or II, but fall into the less well-defined category Bipolar NOS (not otherwise specified).2,3
Compared with adults, children and adolescents are more difficult to diagnose because they are less likely to have discrete episodes of mania, and instead present with severe irritability, rapid cycling, or mixed mania.2,4 In laddition, symptoms progress and evolve as children and adolescents grow.1 Comorbid disorders such as ADHD, oppositional defiant disorder, conduct disorder, and learning disorders are common in this population, further complicating diagnosis.2
Screening instruments are imperfect
Different versions of the KSADS have been used in most research studies on this disorder.2 Despite this, concerns about the validity of the instrument still exist because of lack of sufficient testing, vagueness of the diagnostic criteria, and the subjective nature of the test.5,6 Because specialized training is required to administer the test and testing can last a full day, its use in most office settings is impractical. It is also not meant as a stand-alone test, but to be used in conjunction with a clinical evaluation by a trained mental health professional.7
In a general clinical setting, family history and selected screening instruments may help to increase or decrease clinical suspicion for the disorder and guide referral for more specialized evaluation by a child mental health provider. In addition, a meta-analysis found that children or adolescents who have a biologic parent with bipolar disorder have 2 to 10 times the odds of being diagnosed with bipolar disorder.7
Three screening tests (CBCL, P-GBI, and P-YMRS) available for the office setting use parent-reported scores, and perform best when compared with KSADS as the standard.3 These instruments were associated with likelihood ratios that significantly improved the odds of diagnosis and could allow clinicians to stratify patients as high or low risk (TABLE).3
TABLE
Likelihood ratios for 3 screening tools you can use in the office
| For ages 5–10* | For ages 11–17† | |||||||
| IF THE SCORE IS… | IF THE SCORE IS… | |||||||
| LOW | MOD. LOW | HIGH | VERY HIGH | LOW | MOD. LOW | HIGH | VERY HIGH | |
| THEN THE LR FOR THE INSTRUMENT IS… | THEN THE LR FOR THE INSTRUMENT IS… | |||||||
| P-YMRS | 0.08 | 0.48 | 6.94 | 8.92 | 0.20 | 0 .32 | 4.07 | 7.41 |
| P-GBI | 0.10 | 0.48 | 4.90 | 6.29 | 0.06 | 0.25 | 4.82 | 9.21 |
| CBCL | 0.07 | 0.47 | 3.15 | 3.52 | 0.04 | 0.53 | 2.65 | 4.29 |
| * Population studied had a 50.3% prevalence of bipolar disorder. | † Population studied had a 40.7% prevalence of bipolar disorder. | |||||||
Recommendations from others
Two consensus conferences, a Canadian guideline, and a National Institute of Mental Health round-table all concluded that there is currently no ideal test for the diagnosis of child and adolescent bipolar disorder, but that such an instrument needed to be developed.2,5,6,8 One consensus conference further concluded that the diagnosis is best made by childhood mental health specialists based on multiple informants, such as the child and parents, with symptoms present in at least 2 settings or by direct observation.6
A Canadian consensus conference proposed screening patients with depressive symptoms for a history of hypomanic or manic symptoms, and consider an underlying mood disorder in those with vague or nonspecific somatic symptoms or reverse vegetative symptoms (eg, hypersomnia and hyperphagia). Their recommendations also emphasized screening for family history of bipolar disorder when there were clinical concerns.8
1. Post R, Kowatch R. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry 2006;67:115-125.
2. National Institute of Mental Health research round-table on prepubertal bipolar disorder J Am Acad Chld Adolesc Psychiatry 2001;40:871-878.
3. Youngstrom E, Findling R, Calabrese J, et al. Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psychiatry 2004;43:847-858.
4. Weckerly J. Pediatric bipolar mood disorder. J Dev Behav Pediatr 2002;23:42-56.
5. Coyle J, Pine D, Charney D, et al. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003;42:1494-1503.
6. Carlson G, Jensen P, Findling R, et al. Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder: Report of a Consensus Conference. J Child Adolesc Psychopharamcol 2003;13:13-27.
7. Youngstrom E, Findling R, Youngstrom J, Calabrese J. Toward an evidence-based assessment of pediatric bipolar disorder. J Clin Child Adolesc Psychol 2005;34:433-448.
8. Yatham L, Kennedy S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CAN-MAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.
1. Post R, Kowatch R. The health care crisis of childhood-onset bipolar illness: some recommendations for its amelioration. J Clin Psychiatry 2006;67:115-125.
2. National Institute of Mental Health research round-table on prepubertal bipolar disorder J Am Acad Chld Adolesc Psychiatry 2001;40:871-878.
3. Youngstrom E, Findling R, Calabrese J, et al. Comparing the diagnostic accuracy of six potential screening instruments for bipolar disorder in youths aged 5 to 17 years. J Am Acad Child Adolesc Psychiatry 2004;43:847-858.
4. Weckerly J. Pediatric bipolar mood disorder. J Dev Behav Pediatr 2002;23:42-56.
5. Coyle J, Pine D, Charney D, et al. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. J Am Acad Child Adolesc Psychiatry 2003;42:1494-1503.
6. Carlson G, Jensen P, Findling R, et al. Methodological Issues and Controversies in Clinical Trials with Child and Adolescent Patients with Bipolar Disorder: Report of a Consensus Conference. J Child Adolesc Psychopharamcol 2003;13:13-27.
7. Youngstrom E, Findling R, Youngstrom J, Calabrese J. Toward an evidence-based assessment of pediatric bipolar disorder. J Clin Child Adolesc Psychol 2005;34:433-448.
8. Yatham L, Kennedy S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CAN-MAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.
Evidence-based answers from the Family Physicians Inquiries Network
How does colonoscopy compare with fecal occult blood testing as a screening tool for colon cancer?
No studies have directly compared colonoscopy with fecal occult blood testing (FOBT). Multiple screening trials have demonstrated that a primary strategy of 3-card home FOBT with follow-up colonoscopy for positive results is associated with significant reduction in mortality from colorectal cancer (strength of recommendation [SOR]: A, based on systematic reviews of randomized and nonrandomized controlled trials). A single negative office-based digital FOBT does not decrease the likelihood of advanced neoplasia (SOR: B, based on a single prospective cohort study).
There are no publications of screening trials with colonoscopy, but the odds of dying from colorectal cancer are lower for patients undergoing colonoscopy compared with patients not having a colonoscopy (SOR: B, based on extrapolation from a case-control study). Both strategies are cost-effective (SOR: A, based on a systematic review of high-quality cost-effective analyses).
For those at average risk, consider patient preference, likelihood of adherence to follow-up, community resources
While a clear answer does not emerge for a preferred strategy for colorectal cancer screening between FOBT and colonoscopy, colorectal cancer causes a significant burden of suffering including death. Clinicians must find a systematic way to address colorectal cancer screening with their own patient populations, and find an effective way to determine whether their patients are at average or increased risk for colorectal cancer. For those at average risk, consider patient preference, likelihood of patient adherence to follow-up screening, and community resources as you and your patient try to find common ground. When discussing three-card home FOBT with patients, make them aware that positive test results will lead to colonoscopy.
Evidence summary
A Cochrane review conducted a meta-analysis looking only at FOBT for colorectal cancer screening. This review, based on published and unpublished data from 5 controlled trials, demonstrated that 3-card home FOBT conferred a reduction in colorectal cancer mortality of 16% (relative risk [RR]=0.84; 95% confidence interval [CI], 0.77–0.92) and a number needed to screen of 1173 (95% CI, 741–2807) to prevent 1 death from colon cancer over a 10-year period.1 If adjusted for adherence to screening, the reduction in mortality increased to 23% (RR=0.77; 95% CI, 0.57–0.89).
In addition, long-term follow up of one of the RCTs in the review showed a continued reduction in colorectal cancer mortality of 34% (RR=0.66; 95% CI, 0.54–0.81) in subjects adhering to the FOBT screening protocol over a 13-year interval.2 Overall mortality did not differ between the screened and unscreened groups.
A systematic review performed for the US Preventive Services Task Force (USPSTF) incorporated more recent data on colorectal cancer screening including colonoscopy.3 This review reached similar conclusions as above. This review also looked at office FOBT performed after digital rectal exam. It is important to note that a single office FOBT has a lower sensitivity than 3-card home FOBT and its effectiveness for reducing colorectal cancer mortality was unknown at the time of the systematic review. A subsequent 2005 Veterans Affairs prospective cohort study found that the sensitivity for detecting advanced neoplasia was only 4.9% for digital FOBT, and negative results did not decrease the likelihood of advanced neoplasia.4
The USPSTF review did not find any screening trials of colonoscopy but analyzed data from the National Polyp Study and a case-control study to draw its conclusions.3 The review reported an odds ratio for colorectal cancer mortality for patients who had colonoscopy to be 0.43 (95% CI, 0.30–63).
The USPSTF review also looked at the sensitivity and adverse effects of FOBT compared to colonoscopy. One-time 3-card home FOBT had a sensitivity of 30% to 40% for detecting cancer. The sensitivity of one-time colonoscopy was difficult to determine since it was the criterion standard examination, but it was estimated to be greater than 90%, with a risk of perforation of 1/2000.
The USPSTF review found both screening strategies cost-effective (<$30,000 per additional life-year gained) compared to no screening. FOBT had a cost per life-year saved of $5691 to $17,805 compared with $9038 to $22,012 for colonoscopy performed every 10 years.5
Recommendations from others
The USPSTF found strong evidence to recommend screening in this age group beginning at age 50 but found insufficient evidence to determine a preferred strategy. The evidence reviewed here does not apply to patients at higher risk for colorectal cancer based on personal history, family history or symptoms.
The TABLE details the American Cancer Society and the US Multisociety Task Force on Colorectal Cancer’s 2003 updates recommending options for screening average-risk individuals for colorectal cancer beginning at age 50.6,7
TABLE
Recommended options for screening average-risk individuals for colorectal cancer
| TEST OR PROCEDURE | FREQUENCY* |
|---|---|
| 3-card fecal occult blood test | Annually |
| Flexible sigmoidoscopy | Every 5 years |
| Double-contrast barium enema | Every 5 years |
| Colonoscopy | Every 10 years |
| *Beginning at age 50 for men and women. | |
1. Towler BP, Irwig L, Glasziou P, Weller D, Kewenter J. Screening for colorectal cancer using the faecal occult blood test, hemoccult. Cochrane Database Syst Rev 2000;(2):CD001216.-
2. Jorgensen OD, Kronborg O, Fenger C. A randomised study of screening for colorectal cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds. Gut 2002;50:29-32.
3. Pignone M, Rich M, Teutsch S, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:132-141.
4. Pignone M, Saha S, Hoerger T, Mandelblatt J. Costeffectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:96-104.
5. Collins JF, Lieberman DA, Durbin TE, Weiss DG. Veterans Affairs Cooperative Study #380 Group. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. Ann Intern Med 2005;142:81-85.
6. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003;124:544-560.Available at: www.guideline.gov. Accessed October 3, 2005.
7. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin 2003;53:27-43.Available at: www.guideline.gov. Accessed October 3, 2005.
No studies have directly compared colonoscopy with fecal occult blood testing (FOBT). Multiple screening trials have demonstrated that a primary strategy of 3-card home FOBT with follow-up colonoscopy for positive results is associated with significant reduction in mortality from colorectal cancer (strength of recommendation [SOR]: A, based on systematic reviews of randomized and nonrandomized controlled trials). A single negative office-based digital FOBT does not decrease the likelihood of advanced neoplasia (SOR: B, based on a single prospective cohort study).
There are no publications of screening trials with colonoscopy, but the odds of dying from colorectal cancer are lower for patients undergoing colonoscopy compared with patients not having a colonoscopy (SOR: B, based on extrapolation from a case-control study). Both strategies are cost-effective (SOR: A, based on a systematic review of high-quality cost-effective analyses).
For those at average risk, consider patient preference, likelihood of adherence to follow-up, community resources
While a clear answer does not emerge for a preferred strategy for colorectal cancer screening between FOBT and colonoscopy, colorectal cancer causes a significant burden of suffering including death. Clinicians must find a systematic way to address colorectal cancer screening with their own patient populations, and find an effective way to determine whether their patients are at average or increased risk for colorectal cancer. For those at average risk, consider patient preference, likelihood of patient adherence to follow-up screening, and community resources as you and your patient try to find common ground. When discussing three-card home FOBT with patients, make them aware that positive test results will lead to colonoscopy.
Evidence summary
A Cochrane review conducted a meta-analysis looking only at FOBT for colorectal cancer screening. This review, based on published and unpublished data from 5 controlled trials, demonstrated that 3-card home FOBT conferred a reduction in colorectal cancer mortality of 16% (relative risk [RR]=0.84; 95% confidence interval [CI], 0.77–0.92) and a number needed to screen of 1173 (95% CI, 741–2807) to prevent 1 death from colon cancer over a 10-year period.1 If adjusted for adherence to screening, the reduction in mortality increased to 23% (RR=0.77; 95% CI, 0.57–0.89).
In addition, long-term follow up of one of the RCTs in the review showed a continued reduction in colorectal cancer mortality of 34% (RR=0.66; 95% CI, 0.54–0.81) in subjects adhering to the FOBT screening protocol over a 13-year interval.2 Overall mortality did not differ between the screened and unscreened groups.
A systematic review performed for the US Preventive Services Task Force (USPSTF) incorporated more recent data on colorectal cancer screening including colonoscopy.3 This review reached similar conclusions as above. This review also looked at office FOBT performed after digital rectal exam. It is important to note that a single office FOBT has a lower sensitivity than 3-card home FOBT and its effectiveness for reducing colorectal cancer mortality was unknown at the time of the systematic review. A subsequent 2005 Veterans Affairs prospective cohort study found that the sensitivity for detecting advanced neoplasia was only 4.9% for digital FOBT, and negative results did not decrease the likelihood of advanced neoplasia.4
The USPSTF review did not find any screening trials of colonoscopy but analyzed data from the National Polyp Study and a case-control study to draw its conclusions.3 The review reported an odds ratio for colorectal cancer mortality for patients who had colonoscopy to be 0.43 (95% CI, 0.30–63).
The USPSTF review also looked at the sensitivity and adverse effects of FOBT compared to colonoscopy. One-time 3-card home FOBT had a sensitivity of 30% to 40% for detecting cancer. The sensitivity of one-time colonoscopy was difficult to determine since it was the criterion standard examination, but it was estimated to be greater than 90%, with a risk of perforation of 1/2000.
The USPSTF review found both screening strategies cost-effective (<$30,000 per additional life-year gained) compared to no screening. FOBT had a cost per life-year saved of $5691 to $17,805 compared with $9038 to $22,012 for colonoscopy performed every 10 years.5
Recommendations from others
The USPSTF found strong evidence to recommend screening in this age group beginning at age 50 but found insufficient evidence to determine a preferred strategy. The evidence reviewed here does not apply to patients at higher risk for colorectal cancer based on personal history, family history or symptoms.
The TABLE details the American Cancer Society and the US Multisociety Task Force on Colorectal Cancer’s 2003 updates recommending options for screening average-risk individuals for colorectal cancer beginning at age 50.6,7
TABLE
Recommended options for screening average-risk individuals for colorectal cancer
| TEST OR PROCEDURE | FREQUENCY* |
|---|---|
| 3-card fecal occult blood test | Annually |
| Flexible sigmoidoscopy | Every 5 years |
| Double-contrast barium enema | Every 5 years |
| Colonoscopy | Every 10 years |
| *Beginning at age 50 for men and women. | |
No studies have directly compared colonoscopy with fecal occult blood testing (FOBT). Multiple screening trials have demonstrated that a primary strategy of 3-card home FOBT with follow-up colonoscopy for positive results is associated with significant reduction in mortality from colorectal cancer (strength of recommendation [SOR]: A, based on systematic reviews of randomized and nonrandomized controlled trials). A single negative office-based digital FOBT does not decrease the likelihood of advanced neoplasia (SOR: B, based on a single prospective cohort study).
There are no publications of screening trials with colonoscopy, but the odds of dying from colorectal cancer are lower for patients undergoing colonoscopy compared with patients not having a colonoscopy (SOR: B, based on extrapolation from a case-control study). Both strategies are cost-effective (SOR: A, based on a systematic review of high-quality cost-effective analyses).
For those at average risk, consider patient preference, likelihood of adherence to follow-up, community resources
While a clear answer does not emerge for a preferred strategy for colorectal cancer screening between FOBT and colonoscopy, colorectal cancer causes a significant burden of suffering including death. Clinicians must find a systematic way to address colorectal cancer screening with their own patient populations, and find an effective way to determine whether their patients are at average or increased risk for colorectal cancer. For those at average risk, consider patient preference, likelihood of patient adherence to follow-up screening, and community resources as you and your patient try to find common ground. When discussing three-card home FOBT with patients, make them aware that positive test results will lead to colonoscopy.
Evidence summary
A Cochrane review conducted a meta-analysis looking only at FOBT for colorectal cancer screening. This review, based on published and unpublished data from 5 controlled trials, demonstrated that 3-card home FOBT conferred a reduction in colorectal cancer mortality of 16% (relative risk [RR]=0.84; 95% confidence interval [CI], 0.77–0.92) and a number needed to screen of 1173 (95% CI, 741–2807) to prevent 1 death from colon cancer over a 10-year period.1 If adjusted for adherence to screening, the reduction in mortality increased to 23% (RR=0.77; 95% CI, 0.57–0.89).
In addition, long-term follow up of one of the RCTs in the review showed a continued reduction in colorectal cancer mortality of 34% (RR=0.66; 95% CI, 0.54–0.81) in subjects adhering to the FOBT screening protocol over a 13-year interval.2 Overall mortality did not differ between the screened and unscreened groups.
A systematic review performed for the US Preventive Services Task Force (USPSTF) incorporated more recent data on colorectal cancer screening including colonoscopy.3 This review reached similar conclusions as above. This review also looked at office FOBT performed after digital rectal exam. It is important to note that a single office FOBT has a lower sensitivity than 3-card home FOBT and its effectiveness for reducing colorectal cancer mortality was unknown at the time of the systematic review. A subsequent 2005 Veterans Affairs prospective cohort study found that the sensitivity for detecting advanced neoplasia was only 4.9% for digital FOBT, and negative results did not decrease the likelihood of advanced neoplasia.4
The USPSTF review did not find any screening trials of colonoscopy but analyzed data from the National Polyp Study and a case-control study to draw its conclusions.3 The review reported an odds ratio for colorectal cancer mortality for patients who had colonoscopy to be 0.43 (95% CI, 0.30–63).
The USPSTF review also looked at the sensitivity and adverse effects of FOBT compared to colonoscopy. One-time 3-card home FOBT had a sensitivity of 30% to 40% for detecting cancer. The sensitivity of one-time colonoscopy was difficult to determine since it was the criterion standard examination, but it was estimated to be greater than 90%, with a risk of perforation of 1/2000.
The USPSTF review found both screening strategies cost-effective (<$30,000 per additional life-year gained) compared to no screening. FOBT had a cost per life-year saved of $5691 to $17,805 compared with $9038 to $22,012 for colonoscopy performed every 10 years.5
Recommendations from others
The USPSTF found strong evidence to recommend screening in this age group beginning at age 50 but found insufficient evidence to determine a preferred strategy. The evidence reviewed here does not apply to patients at higher risk for colorectal cancer based on personal history, family history or symptoms.
The TABLE details the American Cancer Society and the US Multisociety Task Force on Colorectal Cancer’s 2003 updates recommending options for screening average-risk individuals for colorectal cancer beginning at age 50.6,7
TABLE
Recommended options for screening average-risk individuals for colorectal cancer
| TEST OR PROCEDURE | FREQUENCY* |
|---|---|
| 3-card fecal occult blood test | Annually |
| Flexible sigmoidoscopy | Every 5 years |
| Double-contrast barium enema | Every 5 years |
| Colonoscopy | Every 10 years |
| *Beginning at age 50 for men and women. | |
1. Towler BP, Irwig L, Glasziou P, Weller D, Kewenter J. Screening for colorectal cancer using the faecal occult blood test, hemoccult. Cochrane Database Syst Rev 2000;(2):CD001216.-
2. Jorgensen OD, Kronborg O, Fenger C. A randomised study of screening for colorectal cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds. Gut 2002;50:29-32.
3. Pignone M, Rich M, Teutsch S, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:132-141.
4. Pignone M, Saha S, Hoerger T, Mandelblatt J. Costeffectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:96-104.
5. Collins JF, Lieberman DA, Durbin TE, Weiss DG. Veterans Affairs Cooperative Study #380 Group. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. Ann Intern Med 2005;142:81-85.
6. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003;124:544-560.Available at: www.guideline.gov. Accessed October 3, 2005.
7. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin 2003;53:27-43.Available at: www.guideline.gov. Accessed October 3, 2005.
1. Towler BP, Irwig L, Glasziou P, Weller D, Kewenter J. Screening for colorectal cancer using the faecal occult blood test, hemoccult. Cochrane Database Syst Rev 2000;(2):CD001216.-
2. Jorgensen OD, Kronborg O, Fenger C. A randomised study of screening for colorectal cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds. Gut 2002;50:29-32.
3. Pignone M, Rich M, Teutsch S, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:132-141.
4. Pignone M, Saha S, Hoerger T, Mandelblatt J. Costeffectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:96-104.
5. Collins JF, Lieberman DA, Durbin TE, Weiss DG. Veterans Affairs Cooperative Study #380 Group. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. Ann Intern Med 2005;142:81-85.
6. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003;124:544-560.Available at: www.guideline.gov. Accessed October 3, 2005.
7. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin 2003;53:27-43.Available at: www.guideline.gov. Accessed October 3, 2005.
Evidence-based answers from the Family Physicians Inquiries Network