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CNC

Cochrane Review

Deborah K. Mayer, PhD, RN, AOCN®, FAAN—Editor

Flexible Sigmoidoscopy Versus Fecal Occult Blood Testing for Colorectal Cancer Screening in Asymptomatic Individuals Cindy Stern, BHSc (Hons), PhD

Objective To assess the effectiveness of colorectal cancer screening using flexible sigmoidoscopy compared to fecal occult blood testing.

Type of Review A systematic review of randomized, controlled trials (RCTs). Meta-analysis was undertaken where possible.

Relevance for Nursing Colorectal cancer is considered a global health problem, particularly in industrialized countries. Early diagnosis is associated with a good prognosis. Screening is commonly undertaken using flexible sigmoidoscopy, colonoscopy, or fecal occult blood testing. Colonoscopy is considered the gold standard in colorectal screening, but it has not been tested in RCTs. Flexible sigmoidoscopy and fecal occult blood testing have benefits and limitations; therefore, determining which is the most effective screening method is important. Nurses need to be aware of the best available evidence regarding screening methods for colorectal cancer because nurses are often involved in the process.

Characteristics of the Evidence Nine RCTs containing a total of 744,386 participants were included in the review. Participants in colorectal screening trials were asymptomatic, aged 18 years or older, and included men and women. Interventions were flexible sigmoidoscopy or fecal occult blood testing, and

they could be compared to each other or to no screening. The only requirements outlined were that fecal occult blood testing had to be repeated annually or biannually, and they could be guaiac-based (rehydrated or not) or immunologic tests. Trials containing rigid endoscopes were not considered eligible for inclusion. The primary outcome of interest was mortality from colorectal cancer. Secondary outcomes included incidence of colorectal cancer, all-cause mortality, attendance rates, adverse effects, colorectal cancer staging, and use of endoscopy workup. The risk of bias across studies was considered low. One RCT had a high risk of bias because of inadequate randomization. Blinding was not possible, and all studies reported intention-to-treat analyses. The reporting of adverse effects was described as incomplete. Length of follow-up varied significantly between studies, ranging from a median of 6 years to 19.5 years.

Summary of Key Evidence Five trials examined flexible sigmoidoscopy versus no screening. Colorectal cancer mortality was significantly lower in those receiving the intervention compared to no screening (risk ratio [RR] = 0.72; 95% confidence interval [CI] [0.65, 0.79]; random effects model). Colorectal cancer incidence was significantly reduced in intervention groups (RR =

0.82; 95% CI [0.73, 0.9]; random effects model); however, substantial heterogeneity was present. No difference was found in all-cause mortality between groups. Four trials observed fecal occult blood testing versus no screening. Colorectal cancer mortality was significantly lower in those receiving the intervention compared to no screening (RR = 0.86; 95% CI [0.8, 0.92]; random effects model). No difference was found in colorectal cancer incidence or all-cause mortality between groups. The reviewers also undertook an indirect comparison of the two interventions using a Bayesian approach, which demonstrated a RR of 0.72 (95% credibile interval [0.72, 1.01]) for flexible sigmoidoscopy compared to fecal occult blood testing. In terms of adverse effects, a major complication was reported in 0.08% of participants receiving flexible sigmoidoscopy, and 0.03% of participants receiving fecal occult testing suffered a major complication after follow-up. Caution was advised when interpreting these results.

Best Practice Recommendations Screening using flexible sigmoidoscopy or fecal occult blood testing was shown to reduce colorectal mortality. Caution is advised when interpreting these results. Four of the included studies could be considered at a high risk of bias,

Cindy Stern, BHSc (Hons), PhD, is a field coordinator for the Cochrane Nursing Care Field in the School of Translational Health Science at the University of Adelaide in Australia. Stern can be reached at cncn@ adelaide.edu.au. Key words: colorectal cancer screening; flexible sigmoidoscopy; fecal occult blood testing Digital Object Identifier: 10.1188/14.CJON.471-472

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which may have resulted in an overestimate of the effect of sigmoidoscopy.

Research Recommendations Additional research on measuring complications associated with screen-

ing methods should be undertaken. Researchers should also focus on adherence to screening, available resources, and cost.

Reference Holme, Ø., Bretthauer, M., Fretheim, A., Odgaard-Jensen, J., & Hoff, G. (2013). Flex-

ible sigmoidoscopy versus faecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Cochrane Database of Systematic Reviews, 9, CD009259. doi:10.1002/14651858 .CD009259.pub2

For more about the Cochrane Library of systematic reviews, visit www.thecochranelibrary.com.

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August 2014 • Volume 18, Number 4 • Clinical Journal of Oncology Nursing

Flexible sigmoidoscopy versus fecal occult blood testing for colorectal cancer screening in asymptomatic individuals.

To assess the effectiveness of colorectal cancer screening using flexible sigmoidoscopy compared to fecal occult blood testing...
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