Blackwell tft
`Synergy %1
`
`November 2005
`Volume 100
`Number 11
`
`The American
`Journal of
`Gastroenterology
`
`OFFICIAL PUBLICATION OF THE AMERICAN COLLEGE OF GASTROENTEROLOGY
`
`I°
`
`Editors: Joel E. Richter, MD, MACG Nicholas J. Talley, MD. PhD, FACG
`EBL1NG LIBRARY
`,Z.NIVERSITY OF WISCONSIN
`NOV 1 2005
`750 .-iighland Avenue
`Madison, WI 53705
`
`AJG Leading Articles of the Month
`
`hageal
`
`Functional GI Disorders
`
`Prolonged pH Monitoring Using the Bravo System
`J.M. Reines-Troche, J. lbarra-Palomino,
`R.I. Carmona-Sanchez, et al.
`
`2510 Tumor Necrosis Factor-Alpha and Interleukin 10 Gene Polymorphisms
`In IBS
`PPJ. van der Veek, M. van den Berg, Y.E. de Kroon, et al.
`
`;ach
`
`Randomized Trial of Esomeprazole- vs. Pantoprazole-based Triple
`Therapy for H. pylori
`P-I. Hsu, K-H. Lai. C-K. Lin, et al.
`e Accompanying Editorial
`
`oscopy
`
`Urgent Colonoscopy for Acute Lower GI Hemorrhage
`? T. Green, D.C. Rocket' G. Port wood, et a/.
`See Accompanying Editorial
`'eta-Analysis of Capsule Endoscopy in Obscure GI Bleeding
`L. Triester, J.A. Leighton, G I Leontiadis, et 8/
`"andomlzed, Double-Blind, Placebo-Controlled Trial of Endoscopic
`erolds for Recalcitrant Esophageal Peptic Strictures
`Ramage, Jr, A. Rumalla, TH. Baron, et al
`
`Blliary Tract
`1 ournal Impact Factor as a Predictor of Trial Quality and Outcomes
`Gluud, TI.A Sorensen, PC. Getzsche. et al.
`Accompanying Editorial
`se of Hepatitis C Genotype-4 Naive Patients to 24-Weeks
`Interferon-a2b/Ribavirin or Induction-Dose
`.,:erferon-rab/Rlbavidn/Amantadlne
`=? E!-Zayadi, M. Attia, E.M.F Barakat, et al.
`
`I
`
`rnatory Bowel Disease
`
`Delayed-Release Oral Mesalamine at 4.8 glday (800 mg tablet) for
`de ra te I y Active Colitis: ASCEND II Trial
`i:3 Hanauer W.J. Sandborn, A. Kornbluth, et al.
`
`See Accompanying Editorial
`
`Colon
`
`2519 An Automated, Quantitative, Immunochemical, Fecal Occult Blood
`Screening Test
`A. Vilkin, P Pozen, Z. Levi, et al
`Inappropriate Colorectal Cancer Screening
`D.A. Fisher, L. Judd, N.S Sanford
`
`2526
`
`Pancreas
`
`2540 Small Gallstones and Acute Pancreatitis: Potential Benefits of
`Prophylactic Cholecystectomy?
`N.G. Venneman, E. Buskens, M.G.H. Besselink, et al.
`
`Pathology
`
`2551 Expression of Fas Llgand by Hepatic Macrophages In Fulminant
`Hepatic Failure
`A. Mita, Y Hashikura, Y-I. Tagawa, et al.
`
`Reviews
`
`2560
`
`Interactions Between Commensal Bacteria and Gut Sensorimotor
`Function
`G. Barbara, V Stanghellini, G. Brandi, et al.
`2569 Management of Polycystic Liver Disease
`H.L. Arnold. SA. Harrison
`2583 Milk Thistle for Alcoholic and/or Hepatitis B or C Liver Diseases
`A. Rambaldt, B.P Jacobs, G. laqumto, et al.
`
`See Full Table of Contents Inside
`
`http://www.amjgastro.com
`
`Geneoscopy Exhibit 1005, Page 1
`
`

`

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`Geneoscopy Exhibit 1005, Page 2
`
`

`

`American Journal of Gastroenterology
`2005 by Am. Coll. of Gastroenterology
`Published by Blackwell Publishing
`
`ISSN 0002-9270
`doi: 10.11116.1572-0241.2005.00231.x
`
`Performance Characteristics and Evaluation of an
`Automated-Developed and Quantitative, Immunochemical,
`Fecal Occult Blood Screening Test
`
`Alex Vilkin, M.D., I Paul Rozen, MB., BS.,1' 2 Zohar Levi, M.D.,' Amal Waked, B.Sc.,1 Eran Maoz, M.D.,3
`Shlomo Birkenfeld, M.D.,3 and Yaron Niv, M.D. l ' 2
`'Gastroenterology Department, Rabin Medical Center, Beilinson Hospital, Petach Tikva; 2 Tel Aviv University
`Medical School, Tel Aviv, Israel; and 3 Gastroenterology Units, Clalit Health Services, Tel Aviv, Israel
`
`OBJECTIVES:
`
`METHODS:
`
`RESULTS:
`
`Guaiac fecal occult blood colorectal cancer (CRC) screening tests (FOBT) are faulted for low
`sensitivity and nonspecificity for human hemoglobin (Hb). Automated-developed, immunochemical,
`human Hb FOBT (I-FOBT) is specific, eliminates diet restrictions, and Hb quantification allows
`selection of a threshold for colonoscopy. Aims were to determine 1) test reproducibility; 2) test
`stability; 3) intrapatient daily I-FOBT variation; 4) test sensitivity and specificity for neoplasia in 500
`symptomatic/high-risk patients undergoing colonoscopy; and 5) to correlate fecal Hb measurements
`with findings.
`
`The desktop instrument OC-Sensor (Eiken, Japan) automatically develops and quantitates 50
`tests/h for Hb. Patients prepared three tests, which were quantified and then 1) repeatedly
`re-examined; 2) stored at 4°C or 20°C or 28°C and repeatedly examined; and 3) fecal Hb levels were
`correlated with colonoscopic findings.
`
`Five I-FOBTs re-examined five times in 1 day had no significant measurement changes. Thirty tests
`stored for 21 or more days had a decay/day of 0.3% ± 0.4 at 4°C (NS), 2.2% ± 1.7 at 20°C (NS),
`and 3.7% ± 1.8 at 28°C (p < 0.05). There were intrapatient variations between the three daily
`I-FOBTs (NS). At the recommended 100 ng Hb/mL threshold, all six cases of CRCs and 20 out of 28
`cases of advanced adenomas were detected; evaluated together their sensitivity and specificity were
`76.5% and 95.3%.
`
`CONCLUSIONS: Desktop, automated-developed, quantitative I-FOBT is now available. Refrigerated OC-Sensor
`samples are stable for 21 days, easy to prepare and develop and, at the 100 ng Hb/mL threshold,
`have high sensitivity, specificity, and negative predictive values for significant neoplasia. Suitability
`for population CRC screening awaits further evaluation.
`
`(Am J Gastroenterol 2005;100:2519-2525)
`
`The standard guaiac fecal occult blood test (G-FOBT) is
`faulted for its low sensitivity for significant colorectal neo-
`plasia [colorectal cancer (CRC) and advanced adenomatous
`polyps (AAP)], and low specificity due to nonspecificity for
`human hemoglobin (Hb); sec reference (I). It is also faulted
`by the possibility of inaccurate development and evaluation
`by inadequately trained personnel (2-4).
`The
`introduction of central
`laboratory and office-
`developed, immunochemical, fecal occult blood tests (I-
`FOBT) specific for human Hb improved specificity (5-11).
`However, for the office-developed tests, the I-FOBT man-
`ufacturers have predetermined the degree of sensitivity for
`Hb, and the occasional experience with more complex office-
`development was not conducive for large-scale screening and
`maintaining quality control (1-4, 8, 11).
`
`The automated-developed and quantitative 1-FOBT is hu-
`man Hb specific, eliminates the need for diet restrictions, and
`the Hb quantification allows selection of a suitable threshold
`level for follow-up colonoscopy (5-7, 9-12).
`The introduction of such methodology, for large-scale
`screening, requires evaluation of the instrument and its per-
`formance characteristics. In addition, we need to evaluate
`its true sensitivity and specificity for colorectal neoplasia
`versus colonoscopy in different clinical settings and de-
`termine which level of fecal Hb should trigger follow-up
`colonoscopy.
`Specific aims were to determine I) test-development repro-
`ducibility; 2) effect of temperature and duration of storage
`on fecal sample stability; 3) intrapatient daily I-FOBT test
`variation; 4) sensitivity and specificity for neoplasia found
`
`This material may be protected by Copyright law (Title 17 U.S. Code
`
`2519
`
`Geneoscopy Exhibit 1005, Page 3
`
`

`

`2520
`
`Vilkin et al.
`
`Sample cup part
`
`Filter
`
`Scraper
`
`Spiral
`groove
`
`-0%
`
`Figure 1. Left: Stool probe and fecal sample storage tube. The closed tube is 8 cm long, 2 cm wide. On each tube there is a unique bar code
`and space to write name and date. Right: Desktop instrument and accessories. The instrument is 32 cm wide, 53 cm deep, and 42 cm high.
`
`in persons also undergoing colonoscopy; and 5) to correlate
`fecal Hb levels with clinical findings.
`
`METHODS
`
`Patients
`These were ambulatory persons who were symptomatic and
`scheduled for colonoscopy, or asymptomatic persons at high-
`risk for CRC and invited for colonoscopy. The latter included
`surveillance postpolypectomy and those having a family his-
`tory of colorectal neoplasia. Exclusions included visible rec-
`tal bleeding, known diagnosis of inflammatory bowel disease,
`hematuria, menstruation, and noncooperation with preparing
`a fecal test.
`All participants received an oral and/or telephone expla-
`nation of the tests and written instructions on preparing the
`I-FOBTs.
`Colonoscopy was to the cecum or up to an obstructing
`carcinoma if present. Otherwise, an incomplete examination
`was repeated or excluded from analysis. All lesions were
`noted, biopsied, or removed. Patients' electronic data files
`were available from the three participating endoscopy units
`belonging to the same medical organization.
`Numbers of polyps were noted as were their sites. Pathol-
`ogy reports were available and pathology specimens re-
`viewed when necessary. Polyps were classified as non-
`adenomas or adenomas. Adenomas were grouped by size:
`<5 mm, 5-9 nun, >10 mm; and also by their histology:
`tubular, tubulo-villous, villous; dysplasia was classified as
`low-grade dysplasia (LGD) or high-grade dysplasia (HGD).
`"Significant" neoplasia included CRC or advanced adeno-
`matous polyps (AAP); this latter category included adeno-
`mas >10 mm, or having more than 20% of villous his-
`tology or any amount of HGD independent of size. All
`AAF's <10 nun were re-examined to confirm their histology
`diagnosis.
`
`Patients with symptoms or having a positive I-FOBT unex-
`plained by their colonoscopy findings continued their inves-
`tigations. These included upper-gastrointestinal endoscopy
`and small bowel investigation when appropriate.
`The study was approved by the Ethics Committee of the
`Rabin Medical Center in 2004. All participants gave an in-
`formed, signed consent for the I-FOBT and colonoscopy ex-
`amination.
`
`Fecal Sampling
`The fecal test sampling device is shaped like a small test
`tube with the fecal probe inserted into it and sealing it. The
`probe has a serrated tip, which is poked into the stool and
`then pushed back into the tube, past a scrapper, and through
`a membrane into the sample cup. These remove most of the
`excess feces and leave the stool collected (about 10 mg) into
`the serrations (Fig. 1). The tip is then put in a closed amount
`of Fib stabilizing buffer. Each sample tube has a unique bar
`code and before preparing the sample the patient writes his
`name and date on the tube. The examinee is requested to pre-
`pare three consecutive daily samples during the week before
`colonoscopy examination. Samples are double-closed in zip-
`lock bags and kept in the refrigerator until returned to the
`developing laboratory where they are also kept at 4°C until
`development.
`
`Instrument and Testing and I-FOBT Analysis and Control
`The instrument used for developing and quantification of the
`I-FOBT is OC-Sensor, Eiken, Japan. This is a desktop instru-
`ment weighing 26 kg, and is 32 cm wide, 53 cm deep, and
`42 cm high. It is self-contained with reagent, buffer, washing
`and fluid-disposal bottles, and requires access to a standard
`power supply (Fig. 1). Ten of the patient-prepared fecal sam-
`ple tubes are loaded into the sample rack, and in parallel
`there is another rack with disposable reaction cells. The in-
`strument automatically mixes the fecal buffer solution with
`the latex—antihuman HbA antibody reagent. Following the
`development cycle, there is automatic flushing of the system.
`
`Geneoscopy Exhibit 1005, Page 4
`
`

`

`Automated FOBT Evaluation
`
`2521
`
`100
`
`80
`
`60
`
`as
`t> 40
`U
`1:7
`4.)
`7.G > 20
`cts
`E
`
`—20
`
`-40
`
`4°C (N=12)
`
`20°C (N=10)
`
`28°C (N=9)
`
`[1:11weekl woek2 laweek3
`
`Figure 2. Progressive changes in fecal lib measurements at end of the first, second, and third weeks' storage at 4°C, 20°C, and 28-30°C.
`The cumulative changes (decay) at 28°C were significantly different (p < 0.05) from the initial measurements.
`
`The flocculation is read as an optical change and compared to
`a standard calibration curve. Calibration is prepared for each
`day's analysis, using the provided known high- and low-value
`control test fluids. The range of measurements is 50-2000 ng
`Hb/mL, approximately equivalent to 40-400 ktg Hb/g feces.
`
`RESULTS
`
`Test Reproducibility
`Five prepared I-FOBT samples were quantified and repeat-
`edly examined five more times in 1 day. They had no signifi-
`cant variation in measurements, F(5,20) = 0.24, p = 0.66.
`
`Evaluations Performed
`Five I-FOBT samples were each repeatedly re-examined five
`more times in 1 day. Thirty 1-FOBT samples, having >100
`ktg lib/mL initial measurements, were stored at 4° or 20° C or
`at ambient summer room temperature (28-30°C). They were
`repeatedly re-examined every second day for 3 wk. Further
`12 samples, having low but elevated initial Hb levels between
`100 and 200 ng/mL, were stored at 4°C and re-examined as
`above.
`
`Analysis and Statistical Methods
`All statistical analyses were performed using the SAS system
`for Windows, version 8.01. Results are given as mean ± stan-
`dard deviation (SD). Stability of the test measurements and
`effects of duration of storage and temperature were analyzed
`by analysis of variance with repeated measurements. Weekly
`changes in the stored I-FOBTs were determined by compar-
`ing the lowest value measured in week 1, 2, and 3 with the
`initial values measured.
`For clinical correlation to I-FOBT levels, the most severe
`pathology finding (histology and polyp size) recorded was
`used for each examinee.
`Persons having only hyperplastic polyps were included in
`the group not having neoplasia. For analysis of adenomas,
`the analysis included AAP and was then repeated without
`them. For the category of "significant" colorectal neoplasia,
`the analyses included only CRC or AAP or both together.
`I-FOBT analysis was based on the 100 ng Hb/mL thresh-
`old. These analyses were then repeated at increments of 25 ng
`Hb/mL down to 50 ng and up to 200 ng Hb/mL for analyses
`correlating I-FOBT results and presence of neoplasia.
`
`Test Stability
`Thirty I-FOBT samples, positive for Hb and stored at 4°C,
`20°C, or 28-30°C, were repeatedly re-examined. Their ini-
`tial values ranged from 1032 ± 783 to 787 ± 393 ng Hb/mL.
`The decay/day was 0.3% ± 0.4 at 4°C (NS), 2.2% ± 1.7 at
`20°C (NS), and 3.7% ± 1.8 at 28°C (p < 0.05). Their cumu-
`lative weekly change in I-FOBT measurements is shown in
`Figure 2. At 4°C, all these I-FOBT samples maintained their
`elevated fecal Hb levels for 21 or more days.
`We repeated the study with a further 12 I-FOBT samples,
`stored at 4°C, having low but elevated initial measurements
`ranging from 104 to 233 ng Hb/mL. In two samples, with
`the lowest initial values, the repeated measurements were
`<100 ng Hb/mL by 3 wk from the time of preparation by the
`patient.
`
`Patient and Colonoscopy Results
`I-FOBTs were prepared by 521 patients. However 21, having
`a negative FOBT but incomplete colonoscopy examination,
`were excluded from this analysis. They confirmed their neg-
`ative colonic examination by radiology.
`The complete data from the initial 500 examinees were
`analyzed. They include 53.2% males, with a mean age of 62.1
`± 12.6 yr. The symptomatic patients coming for colonoscopy
`were of average risk in 57.5% while 32.7% had a family
`history of CRC and 53.4% of the latter were asymptomatic.
`(hyperplastic)
`Colonoscopy detected non-neoplastic
`polyps in 12.8% and adenomas in 22.4% of the examinees.
`They included tubular adenomas in 18.8%, tubulo-villous in
`3.2%, and villous adenomas in 0.4%. It was observed that
`58.8% of the adenomatous polyps were <5 mm, 21.1% were
`
`Geneoscopy Exhibit 1005, Page 5
`
`

`

`2522
`
`Vilkin et al.
`
`Table 1. Fecal Occult Blood Levels Detected According to
`Colonoscopy and Pathology Findings
`Fecal Hb (ng/mL)
`(Mean ± SD)
`29.1 ± 103.8
`
`No.
`381
`
`Diagnosis
`Normal'
`Adenomas
`All
`Non-AAP
`AAP
`Cancer
`CRC + AAP
`AAP =-- advanced adenomatous polyps; CRC = colorectal cancer.
`As compared to the normal group.
`Includes 64 patients with only hyperplastic polyps.
`
`113
`85
`28
`6
`34
`
`231.9 ± 567.5
`58.0 ± 156.5
`759.8 ± 935.7
`1154.3 ± 793.0
`829.4 ± 913.8
`
`Significance*
`
`NS
`NS
`P < 0.01
`p < 0.01
`p < 0.01
`
`The I-FOBT results according to endoscopy and pathology
`diagnosis are given in Table 1. The mean I-FORT values from
`patients having significant colorectal neoplasia were signif-
`icantly different from those having a normal colonoscopy
`examination; p < 0.01 (Figures 3 and 4).
`
`Correlations of I-FOBT with Diagnosis
`CANCER. Six patients with CRC were identified by
`colonoscopy. They were identified by utilizing all three I-
`FOBTs. Five were identified by sample 1, four by sample 2,
`and all six by sample 3.
`
`ADVANCED ADENOMATOUS POLYPS. Twenty-eight
`patients were identified by endoscopy and 20 of them by
`utilizing the measurements of all three I-FOBTs.
`
`SIGNIFICANT NEOPLASIA. These include the six pa-
`tients of CRC and 28 patients of AAP, and of these 34, 26
`were identified by utilizing the measurements of all three I-
`FOBTs. Eighteen patients were identified by both samples
`1 and 2, 21 by sample 3. The sensitivity and specificity re-
`sults of the I-FOBTs at the standard 100 ng Hb/mL threshold
`were 76.5% and 95.3%, respectively (Figs. 3 and 4). Simi-
`lar analyses at lower and higher I-FOBT Hb thresholds and
`identification by the three I-FOBTs is given in Table 2.
`
`INTRAPATIENT I-FOBT VARIATION. The relative sensi-
`tivity of each of the three I-FOBTs for CRC or CRC and AAP,
`at the 100 ng Hb threshold, and their additive values are given
`in Table 3. The best results were obtained when all three tests
`were performed and utilized for analysis.
`
`POLYPS. This refers to the most significant polypoid le-
`sion identified in the screenee. In 175 of the 500 examinees,
`
`6-9 mm, and 20.2% were >10 mm; 11.4% of the patients
`had single adenomas, 11.6% had multiple adenomas. LGD
`was reported in 13.4% examinees, and HGD or cancer in
`3.2% of the examinees.
`Significant neoplasia was found in 34 patients (6.8%).
`These included 6 with CRC and 28 with AAP and were sig-
`nificantly more males (p = 0.01) and older than 65 yr of age
`(p < 0.01).
`
`Fecal Occult Blood Results
`For the entire population undergoing colonoscopy, the mean
`I-FOBT measurement was 49.0 ± 216.5 ng Hb/mL for sam-
`ple 1, 41.0 ± 207.1 for sample 2, and 51.3 ± 237.6 for sample
`3 (p = 0.5). At the Hb threshold of 100 ng Hb/mL, the over-
`all positivity was 9.6%, rising to 15.0% at the 50 ng Hb/mL
`threshold. Conversely, positivity fell to 7.8% at the 200 ng
`Flb/mL threshold.
`
`3000
`
`B 1500
`
`1000
`
`Norml,NonAd (N.3111)
`
`Non-AAP 0000
`
`AAP IN•n)
`
`CRC (N.10
`
`AAP•CPC 00341
`
`Figure 3. Box plots of fecal Hb values for each diagnostic category. Dark line indicates median Hb value, colored block covers the upper
`and adjacent two lower quartiles, bars are the maximum and minimum levels measured. CRC and/or AAP measurements are significantly
`elevated as compared to the normal-hyperplastic polyp group, p < 0.01.
`
`Diagnosis
`
`Geneoscopy Exhibit 1005, Page 6
`
`

`

`Automated FOBT Evaluation
`
`2523
`
`«.--•-.—..-•-.--.
`
`-.4,
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`A
`
`--40-CRC 014)
`
`-61-AAP 04. 111
`
`A All Maven.% 91.113)
`
`10%
`
`20%
`
`30%
`
`50%
`40%
`- Specificity
`
`60%
`
`70%
`
`80%
`
`90%
`
`100%
`
`100%
`
`80%
`
`` 60%
`
`(0 40%
`
`II
`
`20%
`
`0%
`0%
`
`Figure 4. Receiver—operator characteristic curve for sensitivity and specificity for each diagnostic category at the 100 ng Hb/mL threshold
`for fecal blood measured. There is high sensitivity for CRC and also AAP, with low sensitivity for adenomas as a category.
`
`a polypoid lesion was identified. In 64, the polyp was not
`an adenoma but a hyperplastic polyp. In 93 screenees, the
`polyp was a tubular adenoma, whereas 16 had tubulo-villous
`and 2 had villous adenomas; the remaining 7 had not been
`recovered for full histological examination.
`The sensitivity of the I-FOBT for identifying an ade-
`nomatous polyp is shown in Figures 3 and 4. There was
`a low sensitivity for adenomatous polyps sized <10 mm.
`Utiliiing the results of all three I-FOBTs, at the 100 ng
`Hb/mL threshold, the sensitivity for adenomas >10 mm was
`82.6%, 6-9 mm was 20.8%, and <5 mm was 9.0%. There
`was no significant difference in the mean I-FOBT mea-
`surements, whether the adenomas were single or multiple
`(p = 0.4).
`
`107 to a high of 3050 ng Hb/mL (mean 1056 ng). The other
`eight, with low 1-FOBT values, had only a mean of 19 ng
`Hb/mL.
`Conversely, 21 screenees, without significant colorectal
`neoplasia, had an I-FOBT measurement >100 ng Hb/mL,
`while the entire normal group had mean measurement of
`47.2 ng Hb/mL. These 21 patients are being evaluated and
`followed up clinically. Five had known iron-deficiency ane-
`mia; 10 had adenomas <10 mm in diameter, 1-6 in number.
`All 21 screenees had had a gastroscopy examination, and in
`15 there were significant findings (including multiple find-
`ings): esophagitis (2), hiatus hernia (1), gastritis (8), status
`postgastric surgery (3), gastric carcinoid (1), and duodenitis
`(4).
`
`Screenees with False-Negative or False-Positive
`I-FOBT Results
`This group refers to the eight screenees with AAP who had
`I-FOBT levels <100 ng 1-113/mL. Of the 28 screenees found
`by colonoscopy to have an AAP, 20 had I-FOBT measure-
`ments >100 ng Hb/mL. The values ranged from a low of
`
`Table 2. Sensitivity and Specificity for Significant Colorectal Neo-
`plasia, (N = 34)' at Differing Fecal Hb Levels (N = 500)t
`Fecal Fib
`Specificity
`(ng/mL)
`(%)
`50
`89.7
`75
`93.3
`100
`95.3
`125
`95.7
`150
`95.9
`200
`96.3
`
`Sensitivity
`(%)
`79.4
`76.5
`76.5
`70.6
`70.6
`64.7
`
`•Six colorectal cancers and 28 advanced adenomatous polyps.
`lUtilizing the highest of the three I-FOBT measurement in each patient.
`
`DISCUSSION
`
`This colonoscopy-controlled study allowed for a detailed
`evaluation of an automated desktop instrument for quanti-
`tative, immunochemical determination of fecal occult blood.
`The clinical evaluation demonstrated a high sensitivity of
`76.5% for all significant colorectal neoplasia and acceptable
`specificity of 95.3%.
`The technical evaluation included studies of reproducibil-
`ity of the instrument in developing and evaluating the tests
`
`Table 3. Sensitivity for Significant Colorectal Neoplasia (N = 34)'
`for Each I-FOBT1 Prepared
`I-FOBT Positive
`Cancer (%)
`Sample 1
`83.3
`Sample 2
`66.7
`Sample 3
`100
`Samples 1 and 2
`83.3
`100
`Samples 1, 2, and 3
`•Six colorectal cancers (CRC) and 28 advanced adenomatous polyps (AAP).
`tAt the 100 ng Hb/mL threshold.
`
`Cancer + AAP (%)
`52.9
`52.9
`61.8
`64.7
`76.5
`
`Geneoscopy Exhibit 1005, Page 7
`
`

`

`2524
`
`Vilkin et al.
`
`and stability of the prepared fecal occult blood tests. Because
`of our high ambient temperature this latter point was care-
`fully evaluated, and we showed that the prepared I-FORT
`could be kept up to 3 weeks in refrigeration without sig-
`nificant degradation of the test antigen. As we have seen,
`for low-elevated levels, the measurement could drop be-
`low the 100 ng Hb/mL threshold by 3 weeks even when
`refrigerated. It is important to emphasize, to the patient
`and to the medical service, the correct storage and dura-
`tion of storage. The time period of 2 weeks from prepara-
`tion is adequate for batch processing of accumulated test
`samples.
`For many years, office-developed I-FOBTs have been avai-
`lable in Japan; because of their high peroxidase-containing
`diet, these tests were found to be more suitable than G-FOBTs
`(7, 13). For the same reason this was also found to be true in
`Hong Kong (10). In a population eating a Western-type diet,
`the problems with dietary peroxidases can be overcome by
`dietary restrictions and adaptations to the G-FOBT develop-
`ment protocol (1, 14).
`The I-FORT card, laboratory or office-developed, is com-
`monly used in Japan and has become available in the United
`States, Israel, Italy, and Australia (1, 3, 8, 9, 11, 15-17).
`However, even though it is more specific than the G-FOBT,
`because of its manufacturer's-determined fixed sensitivity we
`did not find it more sensitive than a cheaper G-FOBT of sim-
`ilar sensitivity (8).
`The introduction of the instrument-developed, quantita-
`tive, fecal occult blood testing allows the physician to choose
`the optimal fecal Hb threshold level that triggers a follow-
`up colonoscopy. To validate this premise, we performed
`this study in high-risk and symptomatic patients undergoing
`colonoscopy. From this study, we confirmed that the I-FOBT
`threshold of 100 ng Hb/mL allowed us to detect all the can-
`cers and the majority of advanced adenomas, giving together
`a sensitivity of 76.5%. Conversely, it provided an acceptable
`specificity of 95.3% (1). This means that in this group of
`high-risk and symptomatic patients, all cases of cancer and
`most advanced adenomas would be detected and a negative
`test would provide a very high degree of certainty that there
`was no clinically significant colorectal neoplasia at this round
`of screening.
`At present, we will continue with collecting three annual
`fecal tests, as we have confirmed the additive clinical value
`of repeated occult blood testing in this high-risk population.
`This is in contrast to the annual 2-day, average-risk population
`I-FOBT collection, as routinely used in Japan, United States,
`and Australia and 1-day biennial testing as performed in Italy
`(11, 12, 16-18).
`The decision on the number of fecal samples to be ob-
`tained and optimal fecal Hb threshold chosen for screening
`an average risk population will also involve an evaluation
`of cost-benefit. This will require a prospective colonoscopy
`controlled or clinical follow-up study in our own popula-
`tion. In Japan, the number of samples collected and thresh-
`
`old chosen were different from those in Italy, namely 2 an-
`nual samples and 150 ng/mL fecal Hb threshold in Japan
`versus 1 biennial sample and 100 ng/mL threshold in Italy
`(19, 20, 21).
`We will now extend this screening study to include
`asymptomatic but high-risk persons undergoing surveillance
`colonoscopy, at set intervals, because of a family history
`of colorectal cancer or follow-up of past colorectal neo-
`plasia (22). The results might influence future screening
`and follow-up policy and obviously reduce costs, patient in-
`convenience, as well as demands on medical priorities and
`services.
`The goal will be to extend this automated-developed, quan-
`titative, I-FOBT to colorectal neoplasia screening in the
`asymptomatic average-risk population. This has been done
`with the InSure (Enterix, United States, and Australia) test
`in pilot studies in Australia and also in the United States (9,
`11). Another automated test is Magstream (Fujirebio, Japan)
`developed in Japan and also being evaluated in Aus