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Licensed Unlicensed Requires Authentication Published by De Gruyter April 22, 2020

Faecal haemoglobin distributions by sex, age, deprivation and geographical region: consequences for colorectal cancer screening strategies

  • Gavin R.C. Clark , Judith A. Strachan , Alisson McPherson , Jayne Digby , Craig Mowat , Robert J.C. Steele and Callum G. Fraser ORCID logo EMAIL logo



Faecal immunochemical tests for haemoglobin (FIT) are becoming widely used in colorectal cancer (CRC) screening and assessment of symptomatic patients. Faecal haemoglobin concentration (f-Hb) thresholds are used to guide subsequent investigation. We established the distributions of f-Hb in a large screening population by sex, age, deprivation and geography.


Single estimates of f-Hb were documented for all individuals participating in the first 18 months of the Scottish Bowel Screening Programme (SBoSP). The distributions of f-Hb were generated for all participants, all men and women, and men and women by age quintile and deprivation quintile. Distributions were also generated by geographical region for all participants, men and women, and by deprivation. Comparisons of f-Hb distributions with those found in a pilot evaluation of FIT and three other countries were performed.


f-Hb was documented for 887,248 screening participants, 422,385 men and 464,863 women. f-Hb varied by sex, age, deprivation quintile and geographical region. The f-Hb distributions by sex and age differed between the SBoSP and the pilot evaluation and the three other countries.


f-Hb is higher in men than in women and increases with age and deprivation in both sexes. f-Hb also varies by geographical region, independently of deprivation, and by country. The f-Hb distribution estimated by pilot evaluation may not represent the population distribution. Decision limits have advantages over reference intervals. Use of partitioned f-Hb thresholds for further investigation, based on the data generated, has advantages and disadvantages, as do risk scores based on a spectrum of influencing variables.

Corresponding author: Prof. Callum G. Fraser, Centre for Research into Cancer Prevention and Screening, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland, UK, Phone: +44 (0)1382 553799, E-mail:

  1. Author contributions: CGF, GRCC and RJCS conceived and planned the study. GRCC generated the data and calculated the f-Hb distribution centiles. JAS is Director of the Scottish Bowel Screening Laboratory, responsible for oversight of the generation of all f-Hb results. AMcP is responsible for the day-to-day running of the SBoSL and the generation of the f-Hb results. JD is research fellow funded by Bowel Cancer UK, the funder of this study. CM is consultant gastroenterologist and provided expertise in the potential clinical applications of the results. RJCS is Director of the SBoSP. All authors contributed to the data analysis. All authors provided significant input to interpretation of the data and to the writing of the paper. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  2. Research funding: JD is supported by a grant from Bowel Cancer UK (Funder Id:,

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CGF has undertaken paid consultancy with Hitachi Chemical Diagnostics Systems, Co., Ltd, Tokyo, Japan. Other authors have no interests to declare. Research funding played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

  6. Informed consent: Informed consent was not required from individuals included in this study.

  7. Ethical approval: Neither ethical approval nor individual informed consent were required since this study used only data that were integral components of the Scottish Bowel Screening Programme.


1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394–424.10.3322/caac.21492Search in Google Scholar PubMed

2. Allison JE, Fraser CG, Halloran SP, Young GP. Population screening for colorectal cancer means getting FIT: the past, present, and future of colorectal cancer screening using the fecal immunochemical test for hemoglobin (FIT). Gut Liver 2014;8:117–30.10.5009/gnl.2014.8.2.117Search in Google Scholar PubMed PubMed Central

3. Westwood M, Lang S, Armstrong N, van Turenhout S, Cubiella J, Stirk L, et al. Faecal immunochemical tests (FIT) can help to rule out colorectal cancer in patients presenting in primary care with lower abdominal symptoms: a systematic review conducted to inform new NICE DG30 diagnostic guidance. BMC Med 2017;15:189.10.1186/s12916-017-0944-zSearch in Google Scholar PubMed PubMed Central

4. Digby J, Cleary S, Gray L, Datt P, Goudie DR, Steele RJ, et al. Faecal haemoglobin can define risk of colorectal neoplasia at surveillance colonoscopy in patients at increased risk of colorectal cancer. United Eur Gastroenterol J 2020;2050640620913674. doi:10.1177/2050640620913674. [Epub ahead of print].10.1177/2050640620913674Search in Google Scholar PubMed PubMed Central

5. McDonald PJ, Strachan JA, Digby J, Steele RJ, Fraser CG. Faecal haemoglobin concentrations by gender and age: implications for population-based screening for colorectal cancer. Clin Chem Lab Med 2011;50:935–40.10.1515/cclm.2011.815Search in Google Scholar PubMed

6. Fraser CG, Rubeca T, Rapi S, Chen LS, Chen HH. Faecal haemoglobin concentrations vary with sex and age, but data are not transferable across geography for colorectal cancer screening. Clin Chem Lab Med 2014;52:1211–6.10.1515/cclm-2014-0115Search in Google Scholar PubMed

7. Fraser CG, Auge JM, PROCOLON Group. Faecal haemoglobin concentrations do vary across geography as well as with age and sex: ramifications for colorectal cancer screening. Clin Chem Lab Med 2015;53:e235–7.10.1515/cclm-2014-1172Search in Google Scholar PubMed

8. Digby J, McDonald PJ, Strachan JA, Libby G, Steele RJ, Fraser CG. Deprivation and faecal haemoglobin: implications for bowel cancer screening. J Med Screen 2014;21:95–7.10.1177/0969141314535388Search in Google Scholar PubMed

9. Symonds EL, Osborne JM, Cole SR, Bampton PA, Fraser RJ, YoungGP. Factors affecting faecal immunochemical test positive rates: demographic, pathological, behavioural and environmental variables. J Med Screen 2015;22:187–93.10.1177/0969141315584783Search in Google Scholar PubMed

10. Moss S, Mathews C, Day TJ, Smith S, Seaman HE, Snowball J, et al. Increased uptake and improved outcomes of bowel cancer screening with a faecal immunochemical test: results from a pilot study within the national screening programme in England. Gut 2017;66:1631–44.10.1136/gutjnl-2015-310691Search in Google Scholar PubMed

11. Kapidzic A, van der Meulen MP, Hol L, van Roon AH, Looman CW, Lansdorp-Vogelaar I, et al. Gender differences in fecal immunochemical test performance for early detection of colorectal neoplasia. Clin Gastroenterol Hepatol 2015;13:1464–71.e4.10.1016/j.cgh.2015.02.023Search in Google Scholar PubMed

12. Symonds EL, Cole SR, Bastin D, Fraser RJ, Young GP. Effect of sample storage temperature and buffer formulation on faecal immunochemical test haemoglobin measurements. J Med Screen 2017;24:176–81.10.1177/0969141316686808Search in Google Scholar PubMed

13. Selby K, Levine EH, Doan C, Gies A, Brenner H, Quesenberry C, et al. Effect of sex, age, and positivity threshold on fecal immunochemical test accuracy: a systematic review and meta-analysis. Gastroenterology 2019;157:1494–505.10.1053/j.gastro.2019.08.023Search in Google Scholar PubMed PubMed Central

14. Brenner H, Qian J, Werner S. Variation of diagnostic performance of fecal immunochemical testing for hemoglobin by sex and age: results from a large screening cohort. Clin Epidemiol 2018;10:381–9.10.2147/CLEP.S155548Search in Google Scholar PubMed PubMed Central

15. Usher-Smith JA, Walter FM, Emery JD, Win AK, Griffin SJ. Risk prediction models for colorectal cancer: a systematic review. Cancer Prev Res (Phila) 2016;9:13–26.10.1158/1940-6207.CAPR-15-0274Search in Google Scholar PubMed PubMed Central

16. Steele RJ, McClements PL, Libby G, Black R, Morton C, Birrell J, et al. Results from the first three rounds of the Scottish demonstration pilot of FOBT screening for colorectal cancer. Gut 2009;58:530–5.10.1136/gut.2008.162883Search in Google Scholar PubMed

17. Fraser CG, Digby J, McDonald PJ, Strachan JA, Carey FA, Steele RJ. Experience with a two-tier reflex gFOBT/FIT strategy in a national bowel screening programme. J Med Screen 2012;19:8–13.10.1258/jms.2011.011098Search in Google Scholar PubMed

18. Steele RJ, McDonald PJ, Digby J, Brownlee L, Strachan JA, Libby G, et al. Clinical outcomes using a faecal immunochemical test for haemoglobin in a national colorectal cancer screening programme constrained by colonoscopy capacity. United Eur Gastroenterol J 2013;1:198–205.10.1177/2050640613489281Search in Google Scholar PubMed PubMed Central

19. Clark GR, Strachan JA, Carey FA, Godfrey TG, Irvine A, McPherson A, et al. Transition to quantitative faecal immunochemical testing from guaiac faecal occult blood testing in a fully rolled-out population-based national bowel screening programme. Gut 2020;gutjnl-2019-320297. doi:10.1136/gutjnl-2019-320297. [Epub ahead of print].10.1136/gutjnl-2019-320297Search in Google Scholar PubMed

20. Information Services Division, NHS National Services Scotland, Scotland. Bowel Screening Programme. (accessed 21 February 2020).Search in Google Scholar

21. (accessed 21 February 2020).Search in Google Scholar

22. Fraser CG, Benton SC. Detection capability of quantitative faecal immunochemical tests for haemoglobin (FIT) and reporting of low faecal haemoglobin concentrations. Clin Chem Lab Med 2019;57:611–6.10.1515/cclm-2018-0464Search in Google Scholar PubMed

23. Fraser CG. Assessment of faecal haemoglobin concentration distributions is vital for faecal immunochemical test (FIT)-based colorectal cancer screening programmes. J Med Screen 2016;23:52–3.10.1177/0969141315597017Search in Google Scholar PubMed

24. Brenner H, Haug U, Hundt S. Sex differences in performance of fecal occult blood testing. Am J Gastroenterol 2010;105: 2457–64.10.1038/ajg.2010.301Search in Google Scholar PubMed

25. Sadik R, Abrahamsson H, Stotzer PO. Gender differences in gut transit shown with a newly developed radiological procedure. Scand J Gastroenterol 2003;38:36–42.10.1080/00365520310000410Search in Google Scholar PubMed

26. Tillou J, Poylin V. Functional disorders: slow-transit constipation. Clin Colon Rectal Surg 2017;30:76–86.10.1055/s-0036-1593436Search in Google Scholar PubMed PubMed Central

27. Libby G, Fraser CG, Carey FA, Brewster DH, Steele RJ. Occult blood in faeces is associated with all-cause and non-colorectal cancer mortality. Gut 2018;67:2116–23.10.1136/gutjnl-2018-316483Search in Google Scholar PubMed PubMed Central

28. Scottish Government, Obesity indictors 2018. [accessed 06 March 2020].Search in Google Scholar

29. Scottish Government. Scottish Health Survey 2018. volume-1-main-report/ [accessed 06 March 2020].Search in Google Scholar

30. Food Standards Scotland. Latest estimation of food and nutrient intakes in Scotland. [accessed 06 March 2020].Search in Google Scholar

31. Passamonti B, Malaspina M, Fraser CG, Tintori B, Carlani A, D’Angeloet V, et al. A comparative effectiveness trial of two faecal immunochemical tests for haemoglobin (FIT). Assessment of test performance and adherence in a single round of a population-based screening programme for colorectal cancer. Gut 2018;67:485–96.10.1136/gutjnl-2016-312716Search in Google Scholar PubMed

32. Grobbee EJ, van der Vlugt M, van Vuuren AJ, Stroobants AK, Mundt MW, Spijker WJ, et al. A randomised comparison of two faecal immunochemical tests in population-based colorectal cancer screening. Gut 2017;66:1975–82.10.1136/gutjnl-2016-311819Search in Google Scholar PubMed

33. Fraser CG. Comparison of quantitative faecal immunochemical tests for haemoglobin (FIT) for asymptomatic population screening. Transl Cancer Res 2016;5:S916–9.10.21037/tcr.2016.10.22Search in Google Scholar

34. Goulding A, Clark GR, Anderson AS, Strachan JA, Fraser CG, Steele RJ. Changes in prevalence of faecal occult blood positivity over time. J Med Screen 2019:969141319866880. doi: [Epub ahead of print].10.1177/0969141319866880Search in Google Scholar PubMed

35. Toes-Zoutendijk E, van Leerdam ME, Dekker E, van Hees F, Penning P, Nagtegaal I, et al. Real-time monitoring of results during first year of Dutch colorectal cancer screening program and optimization by altering fecal immunochemical test cut-off levels. Gastroenterology 2017;152:767–75.e2.10.1053/j.gastro.2016.11.022Search in Google Scholar PubMed

36. Clinical Laboratory Standards Institute. C28-A3. Defining, establishing and verifying reference intervals in the clinical laboratory: approved guideline-third edition. Wayne, PA: CLSI, 2008.Search in Google Scholar

Supplementary Material

The online version of this article offers supplementary material (

Received: 2020-03-06
Accepted: 2020-04-02
Published Online: 2020-04-22
Published in Print: 2020-11-26

©2020 Walter de Gruyter GmbH, Berlin/Boston

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