Clinical Biochemistry 38 (2005) 395 – 399

A prospective study of a new immunochemical fecal occult blood test in

Korean patients referred for colonoscopy
Hee Yeon Wooa, Rak Sun Mokb, Young Nam Parkb, Dong Il Parkc,
In Kyung Sungc, Chong Il Sohnc, Hyosoon Parka,T
a
Department of Laboratory Medicine, Kangbuk Samsung Hospital and Sungkyunkwan University School of Medicine,
#108 Pyeong-dong, Jongno-gu, Seoul, South Korea
b
R&D Center, YD Diagnostics, Corp.,Yongin Kyunggi-Do, South Korea
c
Department of Internal Medicine, Kangbuk Samsung Hospital and Sungkyunkwan University School of Medicine, Seoul, South Korea

Received 30 April 2004; received in revised form 4 August 2004; accepted 11 January 2005

Abstract

Objectives: The exquisite performance characteristics of an immunochemical fecal occult blood test (IFOBT) are well understood. We
evaluated the diagnostic validity of a new IFOBT for colorectal neoplasia in patients undergoing colonoscopy and compared its results with
two other commercially available IFOBTs.
Design and methods: Eighty-five consecutive patients referred for colonoscopy were studied. We performed three different IFOBTs,
namely, HM-JackR, Instant-ViewR, and a newly developed OcculTechR on each fecal specimen.
Results: OcculTech was easy to perform and had a sensitivity, specificity, and positive predictive value of 58.3%, 76.3%, and 27.9%,
respectively, for the detection of colorectal cancers and z1 cm adenomas. OcculTech showed higher sensitivity than the automatic analyzer,
HM-Jack. No improvement was obtained by combining tests.
Conclusions: The OcculTech test had performance characteristics comparable to the two other IFOBTs. This study confirms the
usefulness of the OcculTech test for colorectal neoplasia screening.
D 2005 The Canadian Society of Clinical Chemists. All rights reserved.

Keywords: Colorectal cancers; Adenomas; Immunochemical fecal occult blood test; Diagnostic validity

Introduction which detect either the globin protein of human hemoglobin

Colorectal cancer is a major cause of cancer deaths in
many countries [1]. In South Korea, mortality from color-
ectal cancer has doubled during the past decade, from 4.6 to
10.6 per 100,000. Therefore, the importance of screening for
the early detection of colorectal cancer is evident. Fecal
occult blood screening is proving to be an effective tool for
detecting premalignant adenomas and colon cancer since the
guaiac-based test was introduced in the late 1960s [2–4].
There are three types of commercially available fecal occult
blood tests: guaiac-based tests which detect the pseudoper-
oxidase activity of heme, immunochemical-based tests
T Corresponding author. Fax: +82 2 2001 2364.
E-mail address: hspcp@naver.com (H. Park).
0009-9120/$ - see front matter D 2005 The Canadian Society of Clinical Chemists. All rights reserved.
doi:10.1016/j.clinbiochem.2005.01.003
(Hb) or other blood products, and heme-porphyrin tests
which detect heme and heme-derived porphyrin by fluoro-
metric assays. The guaiac-based tests have been the most
studied and remain the most commonly used fecal occult
blood tests for screening colorectal neoplasm. However,
several immunochemical fecal occult blood tests (IFOBTs)
have become commercially available and the majority of
these have demonstrated equal or superior sensitivities and
specificities than the guaiac-based tests [5–7]. Moreover,
IFOBTs remove the difficulties caused by diet and drug
restrictions and are more amenable to standardization and
quality control. Therefore, IFOBTs are replacing guaiac-
based tests despite their higher costs.
In this study, we evaluated the diagnostic validity of a
new IFOBT for the screening of colorectal neoplasia in
396 H.Y. Woo et al. / Clinical Biochemistry 38 (2005) 395–399

patients undergoing colonoscopy. We also compared this
new IFOBT with two other commercially available
IFOBTs—a manual IFOBT cleared by the Food and Drug
Administration (FDA) and an automated immunochemical
fecal occult blood analyzer.
Materials and methods
Subjects
Japan), and two manual tests which produce rapid visual
results, the newly developed OcculTechR test (YD Diag-
nostics, Corp., Yong-in, South Korea) and the Instant-
ViewR test (Alfa Scientific Designs Inc., Poway, CA). All
tests provided similar sample collection devices. The
examinations were performed on fresh stools within 24 h
of collection by a trained technician who was unaware of
any sample information. Two examiners interpreted test
results in concert.

Eighty-five consecutive patients who were referred to the OcculTechR (YD Diagnostics, Corp., Yong-in, Korea)
Endoscopy Center at Kangbuk Samsung Hospital in Seoul,
South Korea, for colonoscopy during February 2004 were The OcculTechR test is a card type rapid immunochro-
studied. Patients who showed non-cooperation (defined as matographic assay and was designed for the qualitative
refusal to participate in this study or no submission of fecal detection of fecal occult blood using mouse anti-human Hb.
samples) or poor bowel preparation were excluded. Indica- The test kit contains test cards and collection tubes filled
tions for colonoscopy are shown in Table 1. All patients with extraction buffer. Specimens were sampled and mixed
were asked to place fecal samples in a sterile plastic box with extraction buffer in collection tubes and were
using a sterile spatula before bowel preparation commenced. dispensed into the sample hole on the test cards. Hemoglo-
No dietary restriction was required. Fecal specimens were bin in the specimen formed an antigen–antibody complex
immediately delivered to the laboratory and stored at 48C with mouse monoclonal anti-Hb IgG gold colloid conjugate
until examined. The institutional ethics committee of in a conjugate pad. When the complex reached the region
Kangbuk Samsung Hospital approved this study. corresponding to immobilized monoclonal anti-Hb IgG, a
red coloration appeared in the test line. A second control
Immunochemical fecal occult blood tests (IFOBTs) line indicated normal test performance. The cut-off stated by
the manufacturer was 10 Ag human Hb/g feces. We
Three different IFOBTs were used for each specimen: an confirmed this cut-off by testing serially diluted solutions
automated system, HM-JackR (Kyowa Medex Co., Tokyo, containing human Hb prepared using a hematology refe-
rence control, EquinoxR8 (Hematronix, Inc., Benica, CA).
Table 1 This test kit obtained the Conformite Europenne (CE) mark
Demographic and clinical data and is currently under examination by the FDA.
Characteristics No (%)
Male 40 (47.1)
Female 45 (52.9) Instant-ViewR (Alfa Scientific Designs Inc., Poway, CA)
Age, year
b40 14 (16.5)
40–49 15 (17.6)
This test was cleared by the FDA for use in fecal occult
50–59 21 (24.7) blood screening. Its operating principle, design, and the
60–69 24 (28.3) procedure used are similar to those of OcculTech. The
z70 11 (12.9) differences between the two tests are the target antigens, the
Indication for colonoscopy type of conjugates, and the composition of the extraction
History of colon cancer 17 (20.0)
Diarrhea 15 (17.6)
buffer used. Instant-View also uses mouse anti-human Hb.
Abdominal pain 13 (15.3) Its cut-off is also 10 Ag human Hb/g feces.
Screening 12 (14.1)
Dyspepsia 9 (10.6)
Hematochezia 5 (5.9) HM-JackR immunoassay (Kyowa Medex Co., Ltd.,
Melena 4 (4.7)
Anemia 4 (4.7)
Tokyo, Japan)
Positive IFOBT 4 (4.7)
Change in bowel habit 1 (1.2) The HM-JackR system is based on an automatic analyzer
History of colon polyp 1 (1.2) that measures fecal occult blood quantitatively using the
Findings at colonoscopy latex agglutination method. It uses sheep anti-human Hb,
Normal 32 (37.6)
Adenoma 22 (25.9)
which is attached to latex particles. The absorbance of the
Colitis 9 (10.6) agglutinated Hb/latex complex is determined by measuring
Cancer 6 (7.1) turbidity. The quantity of feces required for this test is 1/20
Others 16 (18.8) of that required for the other two tests. The test cut-off stated
IFOBT, immunochemical fecal occult blood test. by the manufacturer is 33 Ag human Hb/g feces.
 H.Y. Woo et al. / Clinical Biochemistry 38 (2005) 395–399 397

Evaluation of cross-reactivity and interference with animal USA). The Chi-square analysis and Fisher’s Exact Test
Hbs were used to compare differences in proportions among
the tests and a P value of less than 0.05 was defined as
We examined whether the anti-human Hb antibody statistically significant. The 95% confidence intervals (CI)
showed cross-reactivity with animal Hbs. The animal Hbs were calculated using methods for proportions.
tested were: beef Hb, pig Hb, and chicken Hb. Each original
animal Hb solution was diluted to two concentrations
(52,000 Ag animal Hb/g feces and 26,000 Ag animal Hb/g Results
feces) with extraction buffer. We then tested each aliquot
twice using OcculTech and Instant-View. We also evaluated The demographic and clinical data of the 85 patients
whether the animal Hbs interfered with the human Hb were tabulated (Table 1). The median patient age was 56
reaction. We mixed human Hb and animal Hbs at two years (range: 12–81 years) and the male-to-female ratio was
concentrations to a final concentration of 10 Ag human Hb/g 0.89. All tests were negative in 58 (68.2%) of the 85
feces and tested the mixture using the two tests. patients. The two manual tests, OcculTech and Instant-View,
showed an agreement in 81 (95.3%) patients. OcculTech
Evaluation of interference due to antigen excess alone and Instant-View alone were positive in two persons
apiece.
The human Hb solution, EquinoxR8, was diluted to nine The positive rates of tests by lesion are summarized in
concentrations (10, 12.5, 400, 1000, 2000, 10,000, 20,000, Table 2. No significant difference in positivity by lesion was
100,000, and 200,000 Ag human Hb/g feces) with extraction found between the individual tests or between tests
buffer. We then tested each aliquot twice using OcculTech. performed singly or in combination. The patients with
cancer showed significantly higher positivity than those
Evaluation of stability with normal colonoscopic findings by OcculTech and by
Instant-View ( P = 0.002 for OcculTech and P = 0.0009 for
We evaluated whether the OcculTech test was influenced Instant-View).
by temperature or time using four fecal specimens that The diagnostic validities with 95% CI of individual and
produced positive results by all three IFOBTs. We prepared combination tests for clinically significant neoplasia (adeno-
two aliquots of each specimen and stored these at 48C or at mas z1 cm and/or cancers) are summarized in Table 3.
room temperature for 10 days. We examined each aliquot Sensitivity was highest for the manual tests (58.3% vs.
after 1, 3, 5, 7, and 10 days of storage using OcculTech and 33.3% for HM-Jack, P = 0.0007). Decreased sensitivity for
Instant-View. combination with HM-Jack (58.3% vs. 44.4% with HM-
Jack, P = 0.046) was observed.
Endoscopic examination No cross-reactivity or interference with animal Hbs was
observed. The intensity of red coloration appearing in the test
After standard bowel preparation, all patients underwent line was proportional to an Hb concentration below 20,000
colonoscopy. If a colorectal neoplasia including adenoma Ag human Hb/g feces. Above 20,000 Ag human Hb/g feces,
or cancer was detected, the site was recorded and a the intensity of red coloration was rather decreased by
pathologic specimen was taken. Adenomas were classified interference due to antigen excess but the red coloration was
as b1 cm or z1 cm. Patients with diverticula, hyperplastic distinguishable at a maximum concentration of 200,000 Ag
polyps, or hemorrhoids were classified as having normal
colonoscopic findings.
Table 2
Positivity of immunochemical fecal occult blood tests by lesion type
Statistical analysis
Finding No (%) Positive IFOBT
HMJ OT IV
Sensitivity, specificity, and positive predictive value
were determined as follows: sensitivity = number with a Normal colonoscopy 32 (37.6) 4 (12.5) 5 (15.6) 4 (12.5)
Adenoma b1 cm 16 (18.8) 2 (12.5) 5 (31.3) 4 (25.0)
true-positive test / number with a true-positive test + Adenoma z1 cm 6 (7.1) 1 (16.7) 2 (33.3) 2 (33.3)
number with a false-negative test; specificity = number Cancer 6 (7.1) 3 (50.0) 5 (83.3)T 5 (83.3)T
with a true-negative test / number with a true-negative Colitis 9 (10.6) 4 (44.4) 5 (55.6) 5 (55.6)
test + number with a false-positive test; positive Others 16 (18.8) 2 (12.5) 4 (25.0) 4 (25.0)
predictive value = number with a true-positive test / HMJ, HM-Jack; OT, OcculTech; IV, Instant-View immunochemical fecal
number with a true-positive test + number with a false- occult blood test (IFOBT). Numbers in parenthesis in the positive IFOBT
columns are positive percentages bNormalQ includes patients with
positive test [8]. To calculate adenoma specificity, we
diverticulosis, hyperplastic polyps, or hemorrhoids. bOthersQ includes
excluded the results of those persons with cancer from the nonspecific inflammation (n = 13), vascular ectasia (n = 1), and melanosis
calculation. Statistical analysis was performed using the coli (n = 2).
SAS program (version 8.1, SAS Institute Inc., Cary, NC, T P b 0.05 compared to the same test for bnormal colonoscopyQ.
398 H.Y. Woo et al. / Clinical Biochemistry 38 (2005) 395–399

Table 3
Comparative sensitivity and specificity of immunochemical fecal occult blood tests for adenomas z1 cm and cancers
HMJ OT IV Combination
HMJ+OT OT+IV
Sensitivity (%)
Adenoma 13.6T (3.59–36.0) 31.8 (14.7–54.9) 27.3 (18.6–39.2) 16.7 (4.4–42.3) 28.6 (12.2–52.3)
Cancer 50.0T (13.9–86.1) 83.3 (36.5–99.1) 83.3 (36.5–99.1) 75.0 (21.9–98.7) 83.3 (36.5–99.1)
Combined 33.3T (11.3–64.6) 58.3 (28.6–83.5) 58.3 (28.6–83.5) 44.4T (15.3–77.3) 58.3 (28.6–83.5)

Specificity (%)
Adenoma 82.5 (69.6–90.8) 78.9 (65.8–88.2) 77.2 (63.8–86.8) 83.0 (69.7–91.5) 79.6 (66.1–88.9)
Cancer 83.5 (73.1–90.6) 75.9 (64.8–84.6) 75.9 (64.8–84.6) 83.1 (71.9–90.6) 77.3 (65.9–85.9)
Combined 83.6 (72.7–90.9) 76.7 (65.1–85.5) 76.7 (65.1–85.5) 83.3 (71.7–91.0) 78.9 (67.3–87.3)

Positive predictive value (%)

Adenoma 23.1 (6.2–54.0) 36.8 (17.2–61.4) 31.6 (13.6–56.5) 25.0 (7.0–57.2) 35.3 (15.3–61.4)
Cancer 18.8 (5.0–46.3) 20.8 (7.9–42.7) 20.8 (7.9–42.7) 20.0 (5.3–48.6) 22.7 (8.7–45.8)
Combined 25.0 (8.3–52.6) 29.2 (13.4–51.2) 29.2 (13.4–51.2) 26.7 (8.9–55.2) 31.8 (14.7–54.9)
Numbers shown in parenthesis represent 95% confidence intervals. HMJ, HM-Jack; OT, OcculTech; IV, Instant-View.
T P b 0.05 vs. OT.

human Hb/g feces. Of eight aliquots divided from four fecal
specimens stored at room temperature or 48C, only one
aliquot stored at room temperature converted to negative after
storage for 2 days and the remainder showed no conversion to
negative by OcculTech testing. In terms of Instant-View, two
aliquots converted to negative after 1 day; these two were of a
single fecal specimen stored at the two temperatures.
Discussion
We evaluated the diagnostic validity of a new IFOBT for
colorectal neoplasia in patients undergoing colonoscopy and
compared the new test with two other commercially
available IFOBTs: a manual IFOBT cleared by the FDA
and an automated fecal occult blood analyzer.
The specificity of the newly developed IFOBT, Occul-
Tech, was lower than that of immunochemical tests
previously reported (88%–99%) [9–13]. The reasons for
this may have been due to: differences in the inclusion
criteria used, the size of the population studied, and the test
principle. We adopted a prospective study to establish the
actual diagnostic validity of the tests, in patients not
investigated for the presence of colorectal neoplasia or
any other colorectal diseases. The 11.8% of patients that
produced positive test results with OcculTech in the present
study had a bleeding focus other than one due to colorectal
neoplasia, whereas patients with active colonic diseases
such as ulcerative colitis, a history of recent hematochezia,
and infectious colitis were excluded in the majority of other
studies [9–13]. Therefore, the number of false positives in
the present study was higher and the specificity was lower.
An extremely high specificity of 99% was obtained in a
study of a population in which only 3% were symptomatic
[11]. In the present study, by reanalyzing specificity after
excluding patients showing a bleeding focus other than
colorectal neoplasia, we obtained a specificity of 89.3%,
which is comparable to the values quoted by other studies.
The study by Greenberg et al. [10] was very similar to our
investigation in respect to the study design, population
studied, and the measuring principle of IFOBT (FlexSure)
evaluated. The specificity of the FlexSure was 88% in that
study, which was almost the same value as our corrected
one, 89.3%.
In screening programs, sensitivity is more crucial and the
sensitivity of the OcculTech test was 58.3%, which was
similar to values obtained previously (35%–68.8%). Fecal
occult blood tests are relatively insensitive for the detection
of cancers and of large adenomas because of intermittent
bleeding with cancer, or in the case of adenomas, small
amounts of bleeding [14]. In general, relatively higher
sensitivities were observed in a symptomatic hospital
population than in the asymptomatic ambulatory population
[11].
Positivity in patients with normal colonoscopic findings
was 15.6% in 32 patients and this rate was higher than those
previously reported (Table 4). This was attributed firstly to
the reason mentioned above, i.e., that the population in our
study was not a screening of the asymptomatic population,
but instead of a symptomatic population. Seven (21.9%) of
the patients with a normal colonoscopic finding had
hemorrhoids or diverticulosis and 21 patients (65.6%) had
gastrointestinal symptoms. Some of the patients with
symptoms may have ingested medications, such as: non-
steroidal anti-inflammatory drugs that can cause gastro-
intestinal irritation and subsequent bleeding. Secondly,
racial differences can be a cause of high false positivity.
High false positivity (10%) was also observed in a study of
an automated IFOBT in the Chinese population, which
supports the effect of racial differences between Asian and
Western populations [13]. However, in view of the low false
positivity in a Japanese population [12], more data on racial
differences are needed. Although HemeSelect, an IFOBT,
showed high false positivity (11.5%) in a study by Green-
 H.Y. Woo et al. / Clinical Biochemistry 38 (2005) 395–399
berg et al. [10], other IFOBTs tested in that study showed
low false positivity, thus some intrinsic properties of
HemeSelect are more likely to be responsible for this high
false positivity.
No advantage over individual tests was found when
combinatorial test approaches were analyzed. This finding
may be due to the fact that all tests were immunochemical-
based tests that used highly specific antibodies against the
human Hb antigen. In other comparative studies of
immunochemical-based tests and guaiac-based tests,
improved specificities were observed by combining the
two test types [9,10].
Although fecal Hb rapidly loses its antigenicity at room
temperature, probably due to the large amount of bacteria in
feces [15], we confirmed the stability of the specimens
prepared with the collection devices of OcculTech during 10
days of storage at 48C. Therefore, we recommend that the
tests be conducted immediately after preparing specimens or
specimens should be stored at 48C until tested in the case of
the OcculTech test.
According to the report by the World Health Organiza-
tion (WHO) and the World Organization for Digestive
Endoscopy (OMED), the choice of a fecal occult blood test
should take into account population dietary compliance and
the availability of colonoscopy resources [16]. Korean
people eat large amounts of vegetables and fruits that may
cause a high false positive rate for the guaiac-based test, and
colonoscopy resources are readily available in Korea, thus
immunochemical-based tests are preferred to guaiac-based
tests. Actually, IFOBTs are becoming more popular among
Korean hospitals. Although we did not find any statistically
significant differences between the diagnostic validities of
the three IFOBTs, it is desirable that test endpoint readings
and sample processing for large-scale screening be con-
ducted automatically. Both manual tests are acceptable for
small-scale in-office use.
In conclusion, the newly developed IFOBT, OcculTech,
was found to have performance characteristics comparable
to other IFOBTs. Therefore, our study confirms the
usefulness of OcculTech for screening of colorectal neo-
plasia. Although we believe that inclusion criteria caused a
falsely low specificity, more research with a larger
399
population size is required to identify the causes of its false
positivity.
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