Vicente Sotto Memorial Medical Center (VSMMC)

Department of Family and Community Medicine

Post Graduate Interns Program
2018-2019

EVIDENCE-BASED MEDICINE
A Critical Appraisal on Therapeutics

Submitted by:
Vina Faye Alvizo
Karl Gamolo
Marione Mellijor
Ivy Salig
Stacy Yin Ting
Jassalya Villafranca

Residents in Charge:
TITLE OF ARTICLE: The effectiveness of FOBT vs. FIT: A meta-analysis on colorectal
cancer screening test

CLINICAL SCENARIO
Among patients undergoing routine screening for Colorectal Cancer, what is the
accuracy of Guiac Fecal Occult Blood Test compared to Fecal Immunochemical Test in
screening for Colorectal cancer?

SEARCH :
Pubmed Homepage Search
Keywords
 Guiac Fecal Occult Blood Test
 Fecal Immunochemical Test
 Screening for Colorectal CA

Summary of Search
Step 1: Clicked free full text and published in the last 5 years and Human under species.
Step 2: Search Guiac Fecal Occult Blood Test  25 results
Step3: Search Fecal Immunochemical Test  120 results
Step 4: Search Screening for Colorectal CA  5742 results
Step 5: Click Advanced Search Builder
Step 6: From the History, click ADD Guiac Occult blood test, ADD Fecal Immunochemical
Test, and ADD Screening for Colorectal CA then click Search
RELEVANCE

1. Is the objective of the article comparing therapeutic intervention similar to your

clinical dilemma? Yes

Clinical Dilemma: Among patients undergoing routine screening for Colorectal Cancer,
what is the accuracy of Guiac Fecal Occult Blood Test compared to Fecal
Immunochemical Test in screening for Colorectal cancer?

Objective of the Study: This study aimed to assess the effectiveness of colorectal
diagnostic tests (FOBT versus FIT) in terms of technical performance and to examine the
ethical, organizational, social and legal aspects of this technology in those Iranians at
moderate-risk of colorectal cancer.

CRITICAL APPRAISAL:

Clinical Decision Tree

Testing Zone

75%
25 %
50% Patient Upper Testing
Lower Testing
Threshold
Threshold

 Upper testing threshold – the probability of disease in a patient that you will stop
testing and start treatment
 Lower testing threshold – the probability of disease in a patient that you will stop
testing and rule out the disease
 Testing zone – is the probability of the disease that fall between the lower and upper
testing threshold
VALIDITY

1. Was there an independent and blind comparison with a reference standard?

Yes

Fecal Occult Blood test, preferably using FIT, Flexible sigmoidoscopy, and colonoscopy
are recommended screening examinations for CRC. and colonoscopy was done to
confirm the diagnosis of the patients which is the reference for Colorectal cancer.

2. Did the patient sample include an appropriate spectrum of patients to whom the
test will be used? Yes

3. Was the reference standard done regardless of the result of the diagnostic test
being evaluated? Yes

4. Were the methods for performing the test described in sufficient detail to permit
replication? Yes
 5. What were the likelihood ratios for the different possible test results?

Likelihood ratio of a positive test:

LR (+) = Sn/1-Sp
LR (-) = 1-Sn/Sp

RESULTS:
Guiac Fecal Occult Blood:
Sensitivity (Sn) – 65.00%
Specificity (Sp) – 77.87%

Fecal Immunochemical Test

Sensitivity (Sn) – 80.00%
Specificity (Sp) – 90.12%

Guiac Fecal Occult Blood

LR (+) = Sn/1-Sp
= 0.65 / 1 - 0.78
= 2.9
= 2.9 (generate small (but sometimes important) changes in probability)

LR (-) = 1-Sn/Sp
= 1 – 0.65 / 0.78
= 0.44
= 0.44(generate small (but sometimes important) changes in probability)

Fecal Immunochemical Test

LR (+) = Sn/1-Sp
= 0.80 / 1 - 0.90
= 0.39 / 0.13
= 8 (generate moderate shifts in pre- to post-test probability)

LR (-) = 1-Sn/Sp
= 1 – 0.80 / 0.90
= 0.22/ 0.87
= 0.22 (generate small (but sometimes important) changes in probability)

Converting pre-test probability to post-test odds (p/1-p)

Pretest odds= 0.50/1-0.50 = 1
Multiply pre-test odds by the likelihood ratio to get the Post test odds

a.) If gFOBT result is (-)

= 1 x 0.44 = 0.44

b.) If gFOBT result is (+)

= 1 x 2.9 = 2.9

Converting pre-test probability to post-test odds (p/1-p)

Pretest odds= 0.50/1-0.50 = 1

Multiply pre-test odds by the likelihood ratio to get the Post test odds

a.) If FIT result is (-)

= 1 x 0.22 = 0.22

b.) If FIT result is (+)

=1x8=8

Convert the post-test odds to Post-test probability (o/o+1)

a.) If gFOBT result is (-)

(o/o+1)
0.44/ 0.44 + 1
0.44 / 1.44
0.30 or 30%

b.) If gFOBT result is (+)

(o/o+1)
2.9 / 2.9 +1
2.9/ 3.9
0.74 or 74%
Convert the post-test odds to Post-test probability (o/o+1)

a.) If FIT result is (-)

(o/o+1)
0.22/ 0.22 + 1
0.22 / 1.22
0.18 or 18%

b.) If FIT result is (+)

(o/o+1)
8 / 8 +1
8/ 9
0.88 or 88%

Clinical Decision Tree: gFOBT

Testing Zone
30% 74%

25 %
Lower Testing 75 %
Threshold 50% Patient Lower Testing
Threshold

Clinical Decision Tree: gFOBT

Testing Zone
18% 88%

25 %
75 %
Lower Testing 50% Patient Lower Testing
Threshold
Threshold
 6. Will the reproducibility of the test result and its interpretation be satisfactory in
my settings?
Yes

7. Are the results applicable to my patient?

Yes

8. Will the results change my management?

NO

Conclusion:

Thus, if the gFOBT test is negative, the probability that the patient has Colorectal
Cancer is 30%, so there is still need to do more tests so that we can rule out the disease.
If the gFOBT test is positive, the probability that the patient has Colorectal Cancer is 74%,
so therefore there is still a need to do more tests.
However, if the FIT is negative, the probability that the patient has Colorectal
Cancer is 18%, so there is no need to do more tests and we can rule out the disease. If
the FIT is positive, the probability that the patient has Colorectal Cancer is 88%, so
therefore there is no need to do more tests and we can start treatment immediately.