On Gender‐Specific FIT Cutoffs in the Swedish Colorectal Cancer Screening Program

Hreinsson et al. recently reported on participation, colonoscopy adherence, and diagnostic outcomes in the first 5 years of the nationwide Swedish colorectal cancer (CRC) screening program [1] in which men and women aged 60 or older are invited for biennial screening by fecal immunochemical test (FIT). In this program, a high participation rate could be achieved (64.3%), and colonoscopy adherence of FIT-positive individuals was 82%. The overall histopathologically verified detection rates at colonoscopy were 6.6% for cancer, 29.9% for advanced adenoma and adenocarcinoma, and 49.7% for overall adenoma detection, demonstrating excellent overall program performance. However, one specific feature of the Swedish CRC screening program deserves careful consideration, that is, the implementation of a higher FIT cutoff for men (80 μg hemoglobin per gram feces [μg/g]) than for women (40 μg/g). Both cutoffs are higher than those in most other countries which implemented FIT based screening [2], and no other country has implemented such gender-specific cutoffs. In Sweden, the use of a higher FIT cutoff for men was based on previous studies demonstrating that this approach equalizes the positivity rate and cancer detection rate between men and women [3]. However, equalization of the positivity rate may be a questionable criterion in selecting FIT cutoffs. In Sweden, like in most other countries, age-specific prevalence, incidence and mortality rates of colorectal neoplasia are higher among men than among women [4], leading to higher FIT positivity rates and higher prevalences of colorectal neoplasia among men at equal FIT cutoffs and equal ranges of FIT results. For example, in a recent analysis of data from the Swedish SCREESCO (screening of Swedish colons) trial, the prevalence of advanced neoplasia in the 40–80 μg/g FIT range was approximately 40% among men compared to approximately 30% among women [5]. Hence, a reverse pattern of FIT cutoffs, that is, a 40 μg/g cutoff for men and a 80 μg/g cutoff for women, would be expected to detect a substantially higher number of advanced neoplasia at an approximately equal number of follow-up colonoscopies, enhancing efficient use of colonoscopy capacities. If sufficient colonoscopy capacities are available, a lower cutoff for both men and women, as employed in most other countries, might also deserve consideration. In the SCREESCO trial, the prevalence of CRC, any advanced neoplasia, and any adenoma among colonoscopies conducted after FIT values between 20 and 40 μg/g (n = 891) was still as high as 1.5%, 22% and 43%, respectively [5]. The authors declare no conflicts of interest. The authors have nothing to report.