POPH90243 EPIDEMIOLOGY 3 2016

TUTE: SCREENING

Faecal occult blood testing for colorectal cancer

The presence of blood in faeces may indicate the presence of abnormalities of the bowel,
including pre-cancerous conditions or bowel cancer (colorectal cancer). The blood may
be in microscopic amounts often referred to as occult blood. Faecal occult blood tests
(FOBTs) are designed to detect the presence of blood in faeces. Where an FOBT is
positive, that is, it shows the presence of blood, this indicates further diagnostic follow-up
tests are necessary, usually a colonoscopy to visually examine the entire bowel. Evidence
from clinical trials has shown that regular screening using faecal occult blood testing can
reduce mortality from bowel cancer by 15-33% (Towler B, et al. BMJ. 1998;317:559-65).
The test used in these trials has been superseded by an improved immunochemical test
for faecal occult blood called the iFOBT.
The Australian Government began the National Bowel Cancer Screening Program in
2006. According to the most recent data:
Overall participation completion and return of the iFOBT is 33%
There was some pressure on colonoscopy services in public hospitals with months
long waiting lists to follow-up positive iFOBT results.
Tasks: Is iFOBT an appropriate screen for colorectal cancer
1. The most recent data from Analysis of bowel cancer outcomes for the National
Bowel Cancer Screening Program is of 322,340 men and women who completed
and returned an iFOBT test from 2006 to 2008. For these people, there were 887
positive results that turned out to be colorectal cancer. There were an additional 176
cases of colorectal cancer diagnosed within two years in individuals who previously
tested negative. What is the sensitivity in this study? Is this acceptable?

2. The same study also reported that 24,786 (approximately 7.7%) of all iFOBT tests
were positive. What is the estimated positive predictive value and negative predictive
value? Are these acceptable?
3. Only about one third of Australians invited to participate in the screening program
participated. Is this acceptable for a screening program?

Home Testing for HIV

In July, 2014, the Australian Federal Minister for Health announced that he was lifting
restrictions on the sale of home-testing kits for HIV in a bid to increase the early
diagnosis of the disease.
The user applies oral fluid to test stick and a positive result (band) indicates presence of
HIV antibodies (HIV-1 and HIV-2). A positive result is preliminary and needs to be
validated using a gold-standard test. Although some warn of the perils of the loss of faceto-face counselling that this home test provides, others argue that the home tests provided
increase access and much-needed anonymity and privacy.
The manufactures claim the test is very accuratedetected 91.7% of people who were
infected with HIV, and 99.9% of people who were not infected with HIV (FAQ on
OralQuick website).
Tasks:
1. What is the sensitivity and specificity of the test?
2. Given the sensitivity and specificity, what is the expected positive predictive
value in a person at low risk of HIV infection? Assume low risk means 1 in
10,000 (for example a heterosexual, non-drug user male).
3. Given the sensitivity and specificity, what is the positive predictive value in
someone at high risk of HIV infection? Assume high risk means 1 in 50 (e.g. men
who have sex with men and/or injecting drug user).
4. Do you think home testing is appropriate as a screening test for HIV? If so, in
whom?