Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4):244-255. doi:10.7326/0003-4819-146-4-200702200-00003.

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Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / Study flow diagram.I-FOBT = immunochemical fecal occult blood test; IBD = inflammatory bowel disease. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / Folded paper “float” opened (left) and placed in toilet bowl (right).After defecation and fecal sampling, the participant flushes the float into the toilet. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / Stool probe and fecal sample storage tube.The patient removes the fecal probe that has a serrated tip that accumulates the fecal sample. The probe is then reinserted deeper into the tube past a scraper and through a membrane that removes excess feces. The bottom compartment of the tube contains a 2-mL buffer solution for stabilizing the fecal specimen in the tip serrations. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / Histograms of fecal hemoglobin density.Using a log 2 scale, the analysis demonstrates statistically significantly different values for advanced polyps, cancer, or clinically significant neoplasia compared with normal and hyperplastic polyps or nonadvanced polyps, with little overlap of the latter 2 conditions. The mean fecal hemoglobin value (SD) and 95% CI are indicated for each category. The 75-ng/mL hemoglobin threshold for calling a test result positive or negative is indicated in each category (dashed lines). The vertical bars represent the proportion that has the specified immunochemical fecal hemoglobin level. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / Scatterplot illustrating the joint distribution of the first 2 immunochemical fecal occult blood test (I-FOBT) measurements on a log 2 -transformation scale.The internal lines are at a 75-ng/mL hemoglobin threshold for calling a test result positive or negative, and numbers in each section show classifications of patients based on this cutoff. Each symbol represents a pair of first and second fecal hemoglobin measurements for one patient. A total of 847 patients without colorectal cancer (CRC) or advanced adenomatous polyps (APs) (open circles) were classified below the 75-ng/mL value as having negative test results for both measurements, while 37 patients with CRC or AP (open triangles) also had negative test results. Twenty-one patients without CRC or AP were classified above the threshold as having positive test results both times, as were 32 patients with CRC or AP. Seventeen and 20 patients without CRC or AP were below the cutoff value for 1 measurement but were above the cutoff value for the other measurement. This also occurred for 11 patients with CRC or AP. The correlation coefficient for the first and second I-FOBT (I-FOBT 1 and I-FOBT 2, respectively) samples was Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / Receiver-operating characteristic curves for sensitivity and specificity for colorectal cancer (top) and clinically significant neoplasia (cancer and advanced polyps) (bottom).Each line represents the highest fecal immunochemical hemoglobin measurement from the specified sequence of fecal samples collected and their added value to provide maximum sensitivity and specificity. I-FOBT 1 = first immunochemical fecal occult blood test collected; I-FOBT 2 = first 2 I-FOBTs collected; I-FOBT 3 = all 3 I-FOBTs collected. Overall, there was no difference between collecting 2 or 3 I-FOBTs. However, the highest sensitivity was obtained when the fecal hemoglobin measurements of all 3 I-FOBTs were used at a 75-ng/mL threshold for calling a test result positive or negative (Appendix Table 2). AUC = area under the curve. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / The posttest probability after a positive test result (top) and negative test result (bottom) for clinically significant neoplasia (colorectal cancer or advanced adenomatous polyps).The values are presented as a function of the immunochemical fecal occult blood test (I-FOBT) threshold for calling a test result positive or negative, with alternate pretest probabilities of colorectal cancer or advanced adenomatous polyps of 0.05, 0.10, 0.25, 0.50, and For every I-FOBT threshold value, the sensitivity and specificity (also presented on the receiver-operating characteristic curve) were calculated, as well as positive and negative likelihood ratios. Posttest probabilities for a positive I-FOBT result (top) and for a negative I-FOBT result (bottom) were calculated. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / Fagan nomogram.The nomogram provides a graphical tool for estimating how much the result of a test changes the probability that a patient has the disease. To use the nomogram, one should first estimate the probability of the disease before testing, which is often the disease prevalence, although it may be increased or decreased on the basis of clinical findings in the patient population or in a particular patient. The next step is to determine the likelihood ratio corresponding to the diagnostic test result. A line is drawn connecting the pretest probability and the point on the middle vertical line corresponding to the likelihood ratio for the test result (represented by a range of test results [boxes]). This line is extended to intersect with the right-hand vertical line, which gives the posttest probability. This point is the new estimate of probability that the patient has the disease. For example, in this heterogeneous-risk, symptomatic study sample, clinically significant neoplasia was found in 91 of 1000 patients (prior probability, 0.091). For a patient with an immunochemical fecal occult blood test (I-FOBT) result greater than 150 ng/mL, the sensitivity and specificity of the test were 54% and 95%, respectively, providing a likelihood ratio of (0.54/[1 − 0.95]), and posttest probability was 52% (dashed line). However, a patient with a pretest probability of 0.002, which is similar to that in a low-risk screening population, and an I-FOBT result between 51 and 75 ng/mL, for which the likelihood ratio is 1.92, would have a posttest probability of advanced neoplasia of 0.38% (dotted line). These demonstrate and emphasize how the level of I-FOBT influences the posttest probability of clinically significant neoplasia. The clinical observations behind the likelihood ratios in the nomogram are available in Appendix Table 3. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

Date of download: 7/1/2016 From: A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia Ann Intern Med. 2007;146(4): doi: / The desktop OC-MICRO instrument.The instrument is 32 cm wide, 53 cm deep, and 42 cm high. The top left bottle contains diluting solution, the center bottle contains cleaning fluid, and the right bottle contains distilled water. Two trays are loaded into the instrument. One tray holds 10 patient-prepared immunochemical fecal occult blood test tubes, and the other tray is for tubes where the immunochemical fecal occult blood test– antibody reaction occurs. The hemoglobin value is automatically calculated from the resulting turbidity. (The OC-MICRO is manufactured by Eiken Chemical Co., Tokyo, Japan.) Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

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