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Which factors increase the risk of an infant becoming an overweight child?
Variables that increase the risk of overweight in childhood include formula feeding, high birth weight, high rate of weight gain in the first 4 months of life, low socioeconomic status, and maternal obesity (strength of recommendation [SOR]: A, systematic reviews and consistent cohort studies). No single risk factor predicts overweight, and not all infants with risk factors become overweight children.
Evidence summary
The Centers for Disease Control and Prevention defines overweight in children as weight-for-length greater than the 95th percentile for sex in children younger than 24 months and body mass index (BMI) greater than the 95th percentile for age and sex in children >24 months.
Breastfeeding is protective
Breastfed infants are less likely to be over-weight later in life than infants fed formula. A meta-analysis of 9 studies found that 7 showed a significantly lower risk of overweight among children who were breastfed (odds ratio [OR]=0.78; 95% confidence interval [CI], 0.71-0.85).1
Four of the studies demonstrated that longer duration of breastfeeding offered greater protection than shorter duration. Two of the 4 studies defined longer duration as more than 6 months, 1 defined it as more than 3 months, and 1 examined breastfeeding for periods of less than 1 week, 1 week to 1 month, 2 to 3 months, 4 to 6 months, 7 to 9 months, and longer than 9 months, showing a duration-dependent decrease in risk. The other studies in the meta-analysis evaluated never-breastfed vs ever-breastfed infants.1
Higher birth weight increases risk
Several meta-analyses report that birth weight is an early risk factor for later overweight. One found a positive association between birth weight and over-weight in childhood in 9 of 11 studies.2 Another meta-analysis found a positive association in 25 of 28 studies that examined birth weight and BMI in childhood.3 These descriptive meta-analyses didn’t calculate pooled odds ratios (ORs) because of heterogeneity of the ages included and methods used to measure obesity.
A high rate of weight gain in infancy is also a risk factor for later overweight. One descriptive meta-analysis reported that 13 of 15 studies found a positive association between weight gain in the first year of life and overweight later in childhood, although overall OR and relative risk weren’t reported.4 A large cohort study found that each 100 g per month increase in weight gain above the mean (820 g per month) during the first 4 months of life increased the odds of overweight at 7 years of age by 38% (OR=1.38; 95% CI, 1.32-1.44).5
Socioeconomic status is a factor
Low socioeconomic status in infancy or early childhood increases the risk of childhood overweight, perhaps because of less breastfeeding and more smoking, among other factors.6,7 Socioeconomic status was determined using the International Standard Classification of Occupations; children whose parents worked at unskilled manual labor jobs or were unemployed were considered in the lowest socioeconomic group.6,7
A Brazilian study found that children born in the lowest socioeconomic group had BMI measurements at 18 years of age that were an average of 1.21 kg/m2 higher than children in the highest socioeconomic group (P<.05). The study controlled for birth weight, maternal smoking, gestational age, and level of schooling eventually achieved by the child.8
Maternal overweight or obesity during the child’s infancy also increases the risk of childhood overweight.9,10 Infants of obese parents were more likely to be overweight at 7 years, compared with children whose mothers were normal weight (OR=10.44; 95% CI, 5.11-21.23).9
Recommendations
The American Academy of Pediatrics (AAP) cites prevention of overweight as a potential benefit of breastfeeding.11 The American Academy of Family Physicians notes that obese mothers should be especially encouraged to breastfeed.12 The American Medical Association-AAP Expert Panel recommends breastfeeding; safe, free movement; and no television for infants to decrease the risk of later over-weight.13
1. Arenz S, Ruckerl R, Koletzko B, et al. Breast-feeding and childhood obesity—a systematic review. Int J Obes Relat Metab Disord. 2004;28:1247-1256.
2. Parsons TJ, Power C, Logan S, et al. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord. 1999;23(suppl 8):S1-S107.
3. Rogers I. EURO-BLCS Study Group. The influence of birthweight and intrauterine environment on adiposity and fat distribution in later life. Int J Obes Relat Metab Disord. 2003;27:755-777.
4. Monteiro PO, Victora CG. Rapid growth in infancy and childhood and obesity in later life—a systematic review. Obes Rev. 2005;6:143-154.
5. Stettler N, Zemel BS, Kumanyika S, et al. Infant weight gain and childhood overweight status in a multicenter, cohort study. Pediatrics. 2002;109:194-199.
6. Bergmann KE, Bergmann RL, Von Kries R, et al. Early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding. Int J Obes Relat Metab Disord. 2003;27:162-172.
7. Dubois L, Girard M. Early determinants of over-weight at 4.5 years in a population-based longitudinal study. Int J Obes. 2006;30:610-617.
8. Goldani MZ, Haeffner LS, Agranonik M, et al. Do early life factors influence body mass index in adolescents? Braz J Med Biol Res. 2007;40:1231-1236.
9. Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ. 2005;330-1357.
10. Whitaker RC. Predicting preschooler obesity at birth: the role of maternal obesity in early pregnancy. Pediatrics. 2004;114:e29-e36.
11. Gartner LM, Morton J, Lawrence RA, et al. for the American Academy of Pediatrics Section on Breastfeeding Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.
12. American Academy of Family Physicians. Breast-feeding, family physicians supporting (position paper). Available at: www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html. Accessed February 12, 2008.
13. Barlow SE. The Expert Committee. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S192.
Variables that increase the risk of overweight in childhood include formula feeding, high birth weight, high rate of weight gain in the first 4 months of life, low socioeconomic status, and maternal obesity (strength of recommendation [SOR]: A, systematic reviews and consistent cohort studies). No single risk factor predicts overweight, and not all infants with risk factors become overweight children.
Evidence summary
The Centers for Disease Control and Prevention defines overweight in children as weight-for-length greater than the 95th percentile for sex in children younger than 24 months and body mass index (BMI) greater than the 95th percentile for age and sex in children >24 months.
Breastfeeding is protective
Breastfed infants are less likely to be over-weight later in life than infants fed formula. A meta-analysis of 9 studies found that 7 showed a significantly lower risk of overweight among children who were breastfed (odds ratio [OR]=0.78; 95% confidence interval [CI], 0.71-0.85).1
Four of the studies demonstrated that longer duration of breastfeeding offered greater protection than shorter duration. Two of the 4 studies defined longer duration as more than 6 months, 1 defined it as more than 3 months, and 1 examined breastfeeding for periods of less than 1 week, 1 week to 1 month, 2 to 3 months, 4 to 6 months, 7 to 9 months, and longer than 9 months, showing a duration-dependent decrease in risk. The other studies in the meta-analysis evaluated never-breastfed vs ever-breastfed infants.1
Higher birth weight increases risk
Several meta-analyses report that birth weight is an early risk factor for later overweight. One found a positive association between birth weight and over-weight in childhood in 9 of 11 studies.2 Another meta-analysis found a positive association in 25 of 28 studies that examined birth weight and BMI in childhood.3 These descriptive meta-analyses didn’t calculate pooled odds ratios (ORs) because of heterogeneity of the ages included and methods used to measure obesity.
A high rate of weight gain in infancy is also a risk factor for later overweight. One descriptive meta-analysis reported that 13 of 15 studies found a positive association between weight gain in the first year of life and overweight later in childhood, although overall OR and relative risk weren’t reported.4 A large cohort study found that each 100 g per month increase in weight gain above the mean (820 g per month) during the first 4 months of life increased the odds of overweight at 7 years of age by 38% (OR=1.38; 95% CI, 1.32-1.44).5
Socioeconomic status is a factor
Low socioeconomic status in infancy or early childhood increases the risk of childhood overweight, perhaps because of less breastfeeding and more smoking, among other factors.6,7 Socioeconomic status was determined using the International Standard Classification of Occupations; children whose parents worked at unskilled manual labor jobs or were unemployed were considered in the lowest socioeconomic group.6,7
A Brazilian study found that children born in the lowest socioeconomic group had BMI measurements at 18 years of age that were an average of 1.21 kg/m2 higher than children in the highest socioeconomic group (P<.05). The study controlled for birth weight, maternal smoking, gestational age, and level of schooling eventually achieved by the child.8
Maternal overweight or obesity during the child’s infancy also increases the risk of childhood overweight.9,10 Infants of obese parents were more likely to be overweight at 7 years, compared with children whose mothers were normal weight (OR=10.44; 95% CI, 5.11-21.23).9
Recommendations
The American Academy of Pediatrics (AAP) cites prevention of overweight as a potential benefit of breastfeeding.11 The American Academy of Family Physicians notes that obese mothers should be especially encouraged to breastfeed.12 The American Medical Association-AAP Expert Panel recommends breastfeeding; safe, free movement; and no television for infants to decrease the risk of later over-weight.13
Variables that increase the risk of overweight in childhood include formula feeding, high birth weight, high rate of weight gain in the first 4 months of life, low socioeconomic status, and maternal obesity (strength of recommendation [SOR]: A, systematic reviews and consistent cohort studies). No single risk factor predicts overweight, and not all infants with risk factors become overweight children.
Evidence summary
The Centers for Disease Control and Prevention defines overweight in children as weight-for-length greater than the 95th percentile for sex in children younger than 24 months and body mass index (BMI) greater than the 95th percentile for age and sex in children >24 months.
Breastfeeding is protective
Breastfed infants are less likely to be over-weight later in life than infants fed formula. A meta-analysis of 9 studies found that 7 showed a significantly lower risk of overweight among children who were breastfed (odds ratio [OR]=0.78; 95% confidence interval [CI], 0.71-0.85).1
Four of the studies demonstrated that longer duration of breastfeeding offered greater protection than shorter duration. Two of the 4 studies defined longer duration as more than 6 months, 1 defined it as more than 3 months, and 1 examined breastfeeding for periods of less than 1 week, 1 week to 1 month, 2 to 3 months, 4 to 6 months, 7 to 9 months, and longer than 9 months, showing a duration-dependent decrease in risk. The other studies in the meta-analysis evaluated never-breastfed vs ever-breastfed infants.1
Higher birth weight increases risk
Several meta-analyses report that birth weight is an early risk factor for later overweight. One found a positive association between birth weight and over-weight in childhood in 9 of 11 studies.2 Another meta-analysis found a positive association in 25 of 28 studies that examined birth weight and BMI in childhood.3 These descriptive meta-analyses didn’t calculate pooled odds ratios (ORs) because of heterogeneity of the ages included and methods used to measure obesity.
A high rate of weight gain in infancy is also a risk factor for later overweight. One descriptive meta-analysis reported that 13 of 15 studies found a positive association between weight gain in the first year of life and overweight later in childhood, although overall OR and relative risk weren’t reported.4 A large cohort study found that each 100 g per month increase in weight gain above the mean (820 g per month) during the first 4 months of life increased the odds of overweight at 7 years of age by 38% (OR=1.38; 95% CI, 1.32-1.44).5
Socioeconomic status is a factor
Low socioeconomic status in infancy or early childhood increases the risk of childhood overweight, perhaps because of less breastfeeding and more smoking, among other factors.6,7 Socioeconomic status was determined using the International Standard Classification of Occupations; children whose parents worked at unskilled manual labor jobs or were unemployed were considered in the lowest socioeconomic group.6,7
A Brazilian study found that children born in the lowest socioeconomic group had BMI measurements at 18 years of age that were an average of 1.21 kg/m2 higher than children in the highest socioeconomic group (P<.05). The study controlled for birth weight, maternal smoking, gestational age, and level of schooling eventually achieved by the child.8
Maternal overweight or obesity during the child’s infancy also increases the risk of childhood overweight.9,10 Infants of obese parents were more likely to be overweight at 7 years, compared with children whose mothers were normal weight (OR=10.44; 95% CI, 5.11-21.23).9
Recommendations
The American Academy of Pediatrics (AAP) cites prevention of overweight as a potential benefit of breastfeeding.11 The American Academy of Family Physicians notes that obese mothers should be especially encouraged to breastfeed.12 The American Medical Association-AAP Expert Panel recommends breastfeeding; safe, free movement; and no television for infants to decrease the risk of later over-weight.13
1. Arenz S, Ruckerl R, Koletzko B, et al. Breast-feeding and childhood obesity—a systematic review. Int J Obes Relat Metab Disord. 2004;28:1247-1256.
2. Parsons TJ, Power C, Logan S, et al. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord. 1999;23(suppl 8):S1-S107.
3. Rogers I. EURO-BLCS Study Group. The influence of birthweight and intrauterine environment on adiposity and fat distribution in later life. Int J Obes Relat Metab Disord. 2003;27:755-777.
4. Monteiro PO, Victora CG. Rapid growth in infancy and childhood and obesity in later life—a systematic review. Obes Rev. 2005;6:143-154.
5. Stettler N, Zemel BS, Kumanyika S, et al. Infant weight gain and childhood overweight status in a multicenter, cohort study. Pediatrics. 2002;109:194-199.
6. Bergmann KE, Bergmann RL, Von Kries R, et al. Early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding. Int J Obes Relat Metab Disord. 2003;27:162-172.
7. Dubois L, Girard M. Early determinants of over-weight at 4.5 years in a population-based longitudinal study. Int J Obes. 2006;30:610-617.
8. Goldani MZ, Haeffner LS, Agranonik M, et al. Do early life factors influence body mass index in adolescents? Braz J Med Biol Res. 2007;40:1231-1236.
9. Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ. 2005;330-1357.
10. Whitaker RC. Predicting preschooler obesity at birth: the role of maternal obesity in early pregnancy. Pediatrics. 2004;114:e29-e36.
11. Gartner LM, Morton J, Lawrence RA, et al. for the American Academy of Pediatrics Section on Breastfeeding Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.
12. American Academy of Family Physicians. Breast-feeding, family physicians supporting (position paper). Available at: www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html. Accessed February 12, 2008.
13. Barlow SE. The Expert Committee. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S192.
1. Arenz S, Ruckerl R, Koletzko B, et al. Breast-feeding and childhood obesity—a systematic review. Int J Obes Relat Metab Disord. 2004;28:1247-1256.
2. Parsons TJ, Power C, Logan S, et al. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord. 1999;23(suppl 8):S1-S107.
3. Rogers I. EURO-BLCS Study Group. The influence of birthweight and intrauterine environment on adiposity and fat distribution in later life. Int J Obes Relat Metab Disord. 2003;27:755-777.
4. Monteiro PO, Victora CG. Rapid growth in infancy and childhood and obesity in later life—a systematic review. Obes Rev. 2005;6:143-154.
5. Stettler N, Zemel BS, Kumanyika S, et al. Infant weight gain and childhood overweight status in a multicenter, cohort study. Pediatrics. 2002;109:194-199.
6. Bergmann KE, Bergmann RL, Von Kries R, et al. Early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding. Int J Obes Relat Metab Disord. 2003;27:162-172.
7. Dubois L, Girard M. Early determinants of over-weight at 4.5 years in a population-based longitudinal study. Int J Obes. 2006;30:610-617.
8. Goldani MZ, Haeffner LS, Agranonik M, et al. Do early life factors influence body mass index in adolescents? Braz J Med Biol Res. 2007;40:1231-1236.
9. Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ. 2005;330-1357.
10. Whitaker RC. Predicting preschooler obesity at birth: the role of maternal obesity in early pregnancy. Pediatrics. 2004;114:e29-e36.
11. Gartner LM, Morton J, Lawrence RA, et al. for the American Academy of Pediatrics Section on Breastfeeding Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.
12. American Academy of Family Physicians. Breast-feeding, family physicians supporting (position paper). Available at: www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html. Accessed February 12, 2008.
13. Barlow SE. The Expert Committee. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S192.
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