Risk score for development of HCC: ready for use in practice?

www.thelancet.com/oncology Vol 12 June 2011 517 often as recommended by the manufacturer, and simply report results as positive or negative. This approach down grades hard-won quantitative data into simple quali tative testing; eff ort is needed to address how to use numerical faecal haemoglobin concentrations to improve screening programme performance in the future. Much is known about outcomes for participants with positive FIT results; however, there are few reports on subsequent development of colorectal neoplasia in participants with initially negative results. In this issue of The Lancet Oncology, Chen and colleagues explore baseline faecal haemoglobin concentration as a pre dictor of incident colorectal neoplasia. 44 324 participants with negative fi ndings at the fi rst screen were followed up to fi nd cases of colorectal neoplasia, and the association between baseline faecal haemoglobin concentration and risk of neoplasia was investigated. In participants with negative results, baseline haemoglobin concentration was predictive of the risk of adenoma and subsequent progression to cancer. It is already well documented that faecal haemoglobin concentrations are related to disease, with values increasing from normal, through low-risk to high-risk adenoma to cancer, although there is overlap between these groups. Chen and colleagues extended this knowledge, showing that baseline faecal haemoglobin was related to outcomes over time at lower haemoglobin concentrations. Taking these data together, there is likely a continuum of risk of colorectal neoplasia as faecal haemoglobin increases from zero. Chen and colleagues’ study provides implications for the design of screening programmes. Faecal haemoglobin concentration at baseline could provide a means for determining risk; low, intermediate, highrisk, and extremely high-risk groups could be defi ned, which would allow for individually tailored screening strategies, as discussed by the authors. With modern information technology, fl air, and imagination, risk-adapted strategies could be adopted in future screening programmes. New data on associations between faecal haemoglobin concentration and demographic characteristics should also aff ect programme design. Colorectal cancer screening using faecal tests has become much less straightforward.