Systematic review
12506
Comparison of the accuracy of CT colonography and
colonoscopy in the diagnosis of colorectal cancer
J. E. Martın-L
opez, C. Beltr
an-Calvo, R. Rodrıguez-L
opez and T. Molina-L
opez
Andalusian Health Technology Assessment (AETSA), Seville, Spain
Received 4 June 2013; accepted 3 September 2013; Accepted Article online 3 December 2013
Abstract
Aim The available evidence was reviewed to compare
the effectiveness of CT colonography with that of colo-
noscopy for colorectal cancer (CRC) screening.
Method An electronic search was conducted using
PubMed, EMBASE, the Cochrane Library and Centre
for Reviews and Dissemination databases, from incep-
tion to July 2009. Studies were included if investiga-
tions used CT colonography for CRC screening in
asymptomatic populations. Studies were excluded if
investigations were conducted for the diagnosis of CRC
or in elderly, high-risk or symptomatic populations.
Results Of the 213 references identified, nine studies
were included. The specificity of CT colonography in
screening for CRC was high, although it decreased with
decreasing diameter of polyp to be detected. The sensi-
Introduction
Colorectal cancer (CRC) is the third most common can-
cer in men worldwide and the second in women with
over 1.2 million new cases estimated to have occurred in
2008 [1]. In many cases malignant lesions arise from a
preexisting adenoma [2] and the American Cancer Soci-
ety [3] has published recommendations for CRC screen-
ing according to stratification of individuals based on
risk. Patients are placed into three groups at average
(age ≥ 50 years), moderate (family history of CRC, per-
sonal history of small adenomatous polyps or CRC) or
high risk (inflammatory bowel disease, family history of
familial adenomatous polyposis or nonpolyposis colon
cancer). Many tests are available for CRC screening with
the aim of detecting early stage cancer or adenomas, but
each has some disadvantages. Colonoscopy has become
popular for screening and allows direct visualization of
Correspondence to: Juliana Ester Martın-L opez, Physician and Researcher,
Andalusian Health Technology Assessment (AETSA), Avenida de la
Innovacion s/n, Seville, Spain.
E-mail: esther.martin.lopez.sspa@juntadeandalucia.es
O82 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, O82–O89
doi:10.1111/codi.
tivity of CT colonography for the detection of polyps
< 6 mm in diameter was low and heterogeneous,
although it was higher for polyps > 10 mm. The main
factors contributing to a greater sensitivity of CT colo-
nography were the inclusion of only populations with an
average CRC risk and colonic insufflation with CO2. The
incidence of adverse effects was very low for both tests.
Conclusion CT colonography has high specificity but
heterogeneous sensitivity, although in most cases it is
not as sensitive or specific as conventional colonoscopy.
CT colonography could therefore be useful as a screen-
ing test for populations with an average risk of CRC.
Keywords Colonography, computed tomographic,
colonoscopy, early detection of cancer, colorectal neo-
plasms
the colonic mucosa with the option of taking a biopsy or
excising polyps and early cancers. However, it fails to
visualize the caecum in 5–10% of cases [4]. Computed
tomography (CT) colonography is minimally invasive but
has the disadvantage of a cumulative radiation dose when
repeatedly performed [5]. Although it has the advantages
of requiring no sedation and being non-invasive, current
clinical practice guidelines do not include specific recom-
mendations on CT colonography for screening [6]. It is
therefore uncertain whether CT colonography is prefera-
ble to colonoscopy in this context. In an attempt
to answer this question a systematic review and meta-
analysis was conducted to determine the accuracy and
safety of CT colonography compared with colonoscopy
for detecting CRC in populations of individuals with an
average risk of CRC.
Method
A systematic search for primary studies was conducted
in MEDLINE (PubMed), EMBASE, the Cochrane
Library and Centre for Reviews and Dissemination
J. E. Martın-L
opez et al. Accuracy of CT colonography and colonoscopy in CRC diagnosis

databases (CRD), Clinical Evidence, UptoDate, Emer-
gency Care Research Institute, Drug Effectiveness
Review Project, Hayes, Technology Evaluation Center
and Web of Knowledge and the Global Health Library.
The search strategies combined MeSH (medical subject
headings), Emtree terms and text words to define the
population, index test, gold standard and outcome
(PICO format: patient/population, intervention, com-
parison and outcome) (Table 1) with restrictions related
to study design (comparative and prospective studies).
There were no language restrictions and searches were
carried out from 1994 (when CT colonography was first
described) up to January 2012. Additionally, the refer-
ence lists from the final selection of articles were
checked manually to identify other relevant papers.
Titles and abstracts of all retrieved articles were scanned
for inclusion by one reviewer with reference to a second
reviewer when there was any doubt about their eligibil-
ity.
When information given in titles/abstracts suggested
that the study included patients who underwent CT
colonography for the screening of colorectal polyps and
cancer with subsequent colonoscopy and assessed the
test for accuracy and safety, full paper articles were
retrieved for further assessment. If there was doubt
regarding inclusion from the title and abstract, the full
article was obtained for clarification. Stringent inclu-
sion/exclusion criteria were applied to the full paper to
obtain the final set of included studies. Inclusion criteria
were prospective or randomized trials with populations
without abdominal symptoms of average age ≥ 50 years
who underwent CT colonography and colonoscopy
within 3 months for CRC screening. Eligible studies
had to report the detection of colorectal polyps,

Table 1 Population characteristics, CRC risk, age, allocation and selection criteria.

Average age
Study (years) Risk stratification* Allocation Selection criteria

Graser et al. [18] 60.5 Average Consecutive Asymptomatic. Age > 50 years
Johnson et al. [16] 65.0 Average Consecutive Asymptomatic. Age ≥ 40 years
Johnson et al. [12] 58.3 Average (89%), NR Asymptomatic. Age ≥ 50 years. Colonoscopy
moderate (10%) programmed
and high (1%)
Juchems et al. [13] 62.6 Average NR Asymptomatic. Age 55–75 years. No personal
history of colon adenomas and/or CRC in
first-degree relatives before 60 years
David and Kim [19] 57.6 Average (95%) Consecutive Age ≥ 50 years or ≥ 40 years with familial CRC
and high (5%) history. Average CRC risk
Macari et al. [17] 55.0 Average Consecutive Asymptomatic. Age ≥ 50 years. FOBT negative
results. No familial CRC history. No personal
history of colorectal polyps or sigmoidoscopy
Pickhardt et al. [14] 57.8 Average (97.4%) Consecutive Age 50–79 years with average CRC risk.
and moderate (2,6%) Age 40–79 years with familial CRC history
Regge et al. [20] 60.0 Moderate (63%) and Relative contacts Group 1: first-degree relatives of patients with
high (37%) advanced colorectal neoplasia diagnosed before
the age of 60 years and aged 40–65 years
(family history group)
Group 2: individuals entered a colonoscopy
surveillance programme after endoscopic removal
of colorectal adenomas and were aged 18–70
years (postpolypectomy group)
Group 3: individuals with positive results from
FOBT who were aged 59–69 years and
participating in a CRC screening programme
(FOBT positive group)
Vogt et al. [15] 58.0 Moderate Consecutive Average CRC risk referred for colonoscopy
because of nonspecific abdominal symptoms
(chronic constipation or chronic abdominal pain)

*Colorrectal cancer risk stratification according to American Cancer Society guidelines [3].
FOBT, faecal occult blood test; CRC, colorectal cancer; NR, not referred.

Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, O82–O89 O83
Accuracy of CT colonography and colonoscopy in CRC diagnosis
advanced neoplasia and CRC and had to include true-
positive, true-negative, false-positive and false-negative
values.
Studies were included if the reference standard test
used to define the true disease status was histological
diagnosis and/or colonoscopy for verification. Studies
with an excessively high cancer prevalence because of a
priori patient selection, e.g. previous endoscopy, were
excluded, as well as studies that included individuals
with a confirmed diagnosis of CRC. Systematic assess-
ment of the quality and documentation of the selected
articles was performed. To grade the quality of the
study the quality assessment (QUADAS) tool was used
with special focus on the time interval between tests.
The technical quality of the CT colonography technique
was assessed with reference to the European procedure
guideline [7] (Table 2) and with particular reference to
patient position during the test, the use of spasmolytic
drugs, bowel insufflation with CO2 or the use of intra-
venous contrast. Data extraction was performed using
predefined data extraction forms. For each primary
study the following data were abstracted:
1 Study population: mean or median age with age
range, method of allocation whether consecutive or
not, CRC risk, country, inclusion/exclusion criteria
and the indication for CT colonography.
2 Imaging features: bowel preparation, dietary restric-
tions, tagging and bowel distension, use of spasmo-
lytic drugs and type of CT system and CT
parameters (radiation dose), the positioning of the
patient, the use of intravenous contrast medium dur-
ing CT colonography and complications.
3 Colonoscopy: type of bowel preparation, use of drugs,
clinical experience of professional who interpreted the
images, dietary restrictions and complications.
4 Imaging and diagnostic criteria: experience of the radi-
ologist reading the CT colonography, the grade of the
Table 2 The number of patients/lesions in the main groups for analysis.
Number of Comparator
Study Patients Lesions
Graser et al. [18] 307 511
Johnson et al. [16] 150 186
Johnson et al. [12] 2531 547
Juchems et al. [13] 58 218
Kim et al. [11] 241 421
Macari et al. [17] 68 98
Pickhardt et al. [14] 1233 1310
Regge et al. [20] 937 347
Vogt et al. [15] 115 150
O84 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, O82–O89
J. E. Martın-L
opez et al.
professional who interpreted the images, use of sec-
ond-look colonoscopy, determination of size on CT
colonography, positive test criteria and histopathologi-
cal confirmation. The number and location of tumours
detected by CT colonography were documented.
Histologically proved cancers were considered on CT
colonography if they were detected prior to colonos-
copy, surgery and/or pathological confirmation. Results
at colonography were considered a true-positive result if
they were identified at initial blinded endoscopy before
the unblinding of CT colonography results. The sensi-
tivity of colonoscopy could only be assessed for studies
where this condition was applied. CT colonography and
colonoscopy were considered as independent technolo-
gies for analysis. For the analysis per patient and per
lesion, 2 9 2 contingency tables were constructed to
allow the calculation of sensitivity and specificity. Data
extracted were as follows: polyp size 5–7, 8–10 and
≥ 10 mm, based on the associated potential CRC risk.
The analysis for polyps < 5 mm was not considered in
this work because most included studies did not report
on it.
Statistical analysis
REVIEW MANAGER 5.0 was used to produce a methodo-
logical quality summary table and forest plots of sensi-
tivity and specificity for each test as well as to present
meta-analytic results in receiver operating characteristic
(ROC) space. Data presented on a patient and lesion
basis were considered separately in the analysis. Patient-
based data were used as the basis for the main analysis
and for the investigation of heterogeneity. Per patient
and per lesion sensitivity and specificity values for CT
colonography and colonoscopy for colorectal polyps
and cancer were summarized using the software META-

DISC (http://www.hrc.es/incestigacion/metadisc_htm).
Analysis
CT Per Per
colonography Colonoscopy patient lesion
U U U
U U U
U U
U U U U
U U U
U U
U U U
U U
U U U
J. E. Martın-L
opez et al. Accuracy of CT colonography and colonoscopy in CRC diagnosis

Heterogeneity between primary studies was assessed
by using the I2 statistic, so that I2 values equal to 25,
50 and 75% were assumed to represent low, moderate
and high heterogeneity. The aspects that could have dif-
fered between test procedures under investigation were
eligible for sensitivity analysis, including patient posi-
tion, routine use of intravenous contrast material, bowel
insufflation or spasmolytic drugs. Other analyses were
conducted to investigate factors that may have been
sources of heterogeneity related to population selection
for faecal occult blood test (FOBT) results and CRC
risk of the population.
Results
The initial search yielded 260 articles (Fig. 1), and after
duplicates were excluded 230 articles remained. After
Identification
nonpertinent articles were excluded on the basis of their
title and abstract, 26 studies were considered for
inclusion. From these 26 potential full text articles, 17
articles, including three meta-analyses [8–10], were
excluded owing to the inclusion of asymptomatic popu-
lations [10]. This left nine articles [11–18,20] for inclu-
sion in this systematic review and meta-analysis with a
total of 5640 asymptomatic patients aged between 57
and 65 years (mean 59.4) and with different CRC risks
(71.5% average, 21.5% moderate and 7% high)
(Table 1).
Table 2 shows the number of studies and patients/
lesions in the main groups for analysis. All participants
received CT colonography and colonoscopy on the
same day. In most cases the reference standard was a
combination of histology and colonoscopy results; three
studies [11–13] used only histology and two [14,15]

Articles identified through

database searching
(n = 260)

Articles after duplicates

removed
(n = 230)
Screening

Articles
Articles screened
excluded
(n = 230)
(n = 204)

Full-text articles Full-text articles

assessed excluded (n = 17):
Selection

for eligibility (n = 26)

Symptomatic
population included
(n = 7)
No adequate
Studies included in comparator (n =1)
qualitative synthesis Insufficient accuracy
(n = 9) data (n = 4)
Others (n = 5)
Inclusion

Studies included in
qualitative synthesis
(meta-analysis)(n = 9)

Figure 1 PRISMA flow diagram.

Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, O82–O89 O85
Accuracy of CT colonography and colonoscopy in CRC diagnosis J. E. Martın-L
opez et al.

used only colonoscopy results as the reference standard. 1

Four studies [12,15–17] used the colonoscopy results
0.9
without knowledge of the CT colonography findings
and five [13,14,18–20] used colonoscopy after unblin- 0.8
ding as the reference standard. Six studies used 4 l
0.7
of polyethylene glycol for bowel preparation
[12,13,15,16,18,19]. two studies used a sodium phos- 0.6

phate preparation [14,17] and no specific colon cleans-
ing directions were given in the remaining study [20].
Five studies used oral tagging [12,13,14,16,20] and
one used an intravenous contrast medium [19] . The
use of tagging was not specified in three studies
[15,17,18]. Methods used for bowel distension varied.
Five studies used CO2 insufflation [11,12,18,20] com-
bined with butylscopolamine bromide [13,20] or gluca-
gon hydrochloride [12] as a spasmolytic drug. In two
[18,19] no spasmolytic drug was administered. In the
remaining studies, manual insufflation with room air
was used [13–17]. Both supine and prone images were
acquired in seven of the nine studies, while in the
remaining two studies [11,15] only one position was
used. In five studies [12,13,15–17] the images were
interpreted by experienced radiologists, and in one the
only reader had 5 years experience in CT colonographic
data interpretation [17]. The size of the polyp was
determined by the pathologist [12,13,16–20] , elec-
tronic callipers [14] or consensus between readers based
on visual criteria [15].
The estimated sensitivity of pooled CT colonography
(n = 4) and colonoscopy (n = 3) was 66.8% [95% confi-
dence interval (CI) 62.7–70.8%] and 92.5% (95% CI
89.0–95.2%) (Fig. 2). Figure 3 shows the ROC analysis
of the sensitivity and specificity for CT colonography
and colonoscopy. Heterogeneity between studies (I2)
was 40.2%. The estimated pooled sensitivity of CT colo-
Sensitivity
0.5
0.4
0.3
0.2
0.1
0
1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
Sensitivity
Legend
Colonoscopy CT colonography
Figure 3 Comparative patient-based data for the sensitivity
and specificity of CT colonography (red) and accuracy of colo-
noscopy (black). ○,Colonoscopy; ♢, CT colonography.
nography (n = 4) was 80.3% (95% CI 77.7–82.8%) and
the specificity (n = 3) was 73.2% (95% CI 67.7–78.1%).
The estimated sensitivity of the pooled CT colonog-
raphy (n = 2) was 60.9% (95% CI 53.4–68.0%) and
88.7% for colonoscopy (n = 2) (95% CI 83.3–92.8%).
The estimated specificity of pooled CT colonography
was 25.2% (95% CI 17.5–34.4%) and 90.3% (95% CI
82.9–95.2%) for colonoscopy (n = 2). Tables 3 and 4
show the accuracy of CT colonography and colonos-
copy by patient and by lesion for different polyp sizes.

Colonoscopy

Study 0 TP FP FN TN Sensitivity Specificity Sensitivity Specificity

Graser 110 78 3 116 0.97 [0.92, 0.99] 0.60 [0.53, 0.67]
Juchems 43 2 2 11 0.96 [0.85, 0.99] 0.85 [0.55, 0.98]
Kim 132 0 18 91 088 [0.82, 0.93] 1.00 [0.96, 1.00]
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
CT colonography

Study TP FP FN TN Sensitivity Specificity Sensitivity Specificity

Graser 95 102 18 92 0.84 [0.76, 0.90] 0.47 [0.40, 0.55]
Juchems 40 7 5 6 0.89 [0.76, 0.96] 0.46 [0.19, 0.75]
Kim 83 60 67 31 0.55 [0.47, 0.63] 0.34 [0.24, 0.45]
Regge 151 26 93 667 0.62 [0.55, 0.68] 0.96 [0.95, 0.98]
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
Figure 2 Comparative patient-based data for CT colonography and colonoscopy (TP, true positive; FP, false positive; FN, false
negastive; TN, true negative). Studies cited are Graser et al. [18], Juchems et al. [13], Kim et al. [11] and Regge et al. [20].

O86 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, O82–O89
J. E. Martın-L
opez et al. Accuracy of CT colonography and colonoscopy in CRC diagnosis

Table 3 The sensitivity and specificity of CT colonography

Sensitivity analysis
and colonoscopy.
Table 5 shows the relative accuracy of CT colonography
CT colonography Colonoscopy
according to sensitivity analysis. Factors contributing to
increased sensitivity of CT colonography (Fig. 4) were
Global
the inclusion of populations with average CRC risk and
Sensitivity 66.8% (62.7–70.8%) 92.5% (89.0–95.2%)
Specificity 80.3% (77.7–82.8%) 73.2% (67.7–78.1%) colonic insufflation with CO2, followed by the use of
Subgroup analysis intravenous tagging and supine and prone patient posi-
Lesions between 5 and 7 mm tions during image acquisition. Factors such as FOBT
Sensitivity 77.1% (73.3–80.5%) 86.7% (81.3–91.0%) before intervention or use of spasmolytic drugs had no
Specificity 87.4% (86.3–88.4%) 98.0 (97.1–98.6%) impact on the sensitivity of CT colonography.
Lesions between 8 and 10 mm
Sensitivity 86.7% (81.7–90.7%) 88.5% (81.5–93.6%)
Specificity 90.0% (89.1–91.0%) 99.2% (98.6–99.5%) Complications
Lesions > 10 mm
Adverse events were reported in seven (0.12%) patients,
Sensitivity 91.2% (86.5–94.6%) 92.9% (86.0–97.1%)
but one study did not provide enough data [17] and
Specificity 87.3% (86.2–88.3%) 91.3% (89.9–92.5%)
two [13,18] reported no adverse effects for either inter-
vention. Unwanted effects included severe nausea and
vomiting for < 24 h after CT colonography (one
Table 4 The sensitivity and specificity of CT colonography patient) [12], haematochezia after snare polypectomy,
and colonoscopy. requiring 2 days’ hospitalization, bleeding after polypec-
tomy [20] (three patients) and hospitalization for
CT colonography Colonoscopy
Escherichia coli bacteraemia 24 h after both procedures
(one patient) [12]. An allergic reaction to the contrast
Global
medium occurred in two patients after CT colonogra-
Sensitivity 60.9% (53.4–68.0%) 88.7% (83.3–92.8%)
Specificity 25.2% (17.5–34.4%) 90.3% (82.9–95.2%)
phy [11]. No study reported the occurrence of colonic
Subgroup analysis perforation while performing colonoscopy. Endoluminal
Lesions between 5 and 7 mm artefacts were present in 28 (0.49%) patients [15,16],
Sensitivity 99.0% (98.0–100%) 85.0% (69.0–94.0%) leading to impaired evaluation in five. Extracolonic
Specificity 85.0% (69.0–94.0%) 100% (91.0–100%) findings were observed in two studies including 1727
Lesions between 8 and 10 mm participants (30.6%) [12,14], but only 15.5% were
Sensitivity 91.2% (86.5–94.6%) 92.9% (86.0–97.1%) deemed to require additional evaluation or urgent care
Specificity 87.3% (86.2–88.3%) 91.3% (89.9–92.5%) [12]. The more clinically relevant findings were unsus-
Lesions > 10 mm pected extracolonic cancer (five patients) and abdominal
Sensitivity 95.7% (85.5–99.5%) 100% (40–100%)
aortic aneurism [14]. The remaining studies did not
Specificity 65.5% (56.0–74.2%) 100% (95.0–100%)
provide data on extracolonic findings. Only two studies
[11,14] used a radiation dose exposure ≥ 100 mA/s.
Seven (78%) of nine studies found advanced neopla- No study analysed the long-term side effects derived
sia and CRC in the study population and provided from the total CT colonography radiation emitted.
enough data to allow the development of a sensitivity
analysis by patient. Estimated pooled CT colonography
Discussion
sensitivity per patient was 96.8% (95% CI 89.0–99.6%)
and estimated pooled CT colonography specificity was The meta-analysis shows that the estimated pooled
99.0% (95% CI 98.7–99.2%). The main characteristics sensitivity and specificity per patient for polyps in
of the only two cancers missed at CT colonography asymptomatic screened patients were 66.8 and 80.3%,
were a protrusive mass in the sigmoid colon and a ses- respectively, for CT colonography and 92.5 and 73.2%,
sile lesion in the caecum (30 and 20 cm in diameter) respectively, for colonoscopy. Analysis according to
[20]. Six studies [12,14,16,18–20] provided enough polyp size showed that the sensitivity of CT colonogra-
data to determine the accuracy of colonoscopy for can- phy increased with the diameter of the polyp, being
cer detection by patient. Estimated pooled colonoscopy 91.2% for polyps > 10 mm. The specificity of CT colo-
sensitivity and specificity by patient were 91.2% (95% CI nography also increased by the size of polyp to a value
80.7–97.1%) and 100% (95% CI 99.9–100%), respec- of 90.0% for polyps between 8 and 10 mm in diameter
tively. This relationship is less marked for colonoscopy, with a

Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, O82–O89 O87
Accuracy of CT colonography and colonoscopy in CRC diagnosis J. E. Martın-L
opez et al.

Table 5 The accuracy of CT colonography, sensitivity analysis.

Sensitivity Specificity

Sampling FOBT (n = 2) 68.9% (95% CI 63.8–73.7%) 85.6% (95% CI 83.1–87.8%)

Population with average CRC risk (n = 2) 85.4% (95% CI 79.0–90.5%) 47.3% (95% CI 40.4–54.4%)
Use of intravenous contrast agent (n = 3) 71.1% (95% CI 66.4–75.5%) 85.0% (95% CI 82.5–87.3%)
Patient position (n = 3) 71.1% (95% CI 66.4–75.5%) 85.0% (95% CI 82.5–87.3%)
Use of spasmolytic drug (n = 2) 66.1% (95% CI 60.3–71.5%) 95.3% (95% CI 93.5–96.8%)
Bowel insufflation with CO2 (n = 2) 92.0% (95% CI 88.1–95.0%) 72.6% (95% CI 67.1–77.7%)

Numbers in brackets in the left-most column are the number of studies included in the analysis.
FOBT, faecal occult blood test; CRC, colorectal cancer.

CT Colonography sensitivity copy for CRC were 96.1% (n = 49) and 94.7%
according to different factors analysed
(n = 25). There are a few explanations available for the
CT Colonography global
sensitivity differences between the greater sensitivity of CT colo-
100 nography than colonoscopy. The first is that inclusion
90
80 of symptomatic populations could be overestimating the
70
60 accuracy of CT colonography. The second could be the
50 use of populations with a different CRC risk profile.
40
30 The main methodological limitation found in primary
20
10 studies was the lack of information on clinical data.
0
g n nt on ug 2 This aspect is crucial, because in practice clinical data
in tio e iti dr O
pl ul
a ag s C
are available for radiologists, who might be underestimat-
am p st po y tic ith
s po tra nt ol w
ing the significance of the findings. The analysed studies
BT ris
k
co
n tie m io
n
FO Pa as at
s sp fl used two different methods of blinding. The first was
R
C
n ou of n su
e
C ve se e li segmental blinding in which the endocopist knew the
ag tra U w result of CT colonography after the examination of every
er i n Bo
Av of
se colonic segment. The other method was so-called opti-
U
mized blinding in which the endocopist looked at the
Figure 4 Sensitivity analysis. Factors influencing the accuracy colonoscopic images for discordance between the tests.
of CT colonography (FOBT, faecal occult blood test; CRC, The second method was considerably better given that it
colorectal cancer).
has a lower risk of bias and real blinding was impossible
for ethical reasons, although neither method could detect
sensitivity of 86.7% for lesions between 5 and 7 mm all lesions [21]. The sensitivity of CT colonography
and 92.9% for those > 10 mm. The maximum value for might have been underestimated in the studies because a
colonoscopy was for lesions between 8 and 10 mm colonoscopy is an imperfect reference.
(sensitivity 99.2%, specificity 91.3%). Although the spec- We included populations with different levels of risk,
ificity of CT colonography is higher than for colonos- which resulted in some homogeneity. It was neverthe-
copy, sensitivity is greater for colonoscopy. For the less reasonable to assume that the results could be
detection of CRC the pooled sensitivity of CT colonog- applied to the screening population. The small number
raphy (96%) was slightly higher than that for colonos- of included studies is another important limitation,
copy (91%). which renders the results of subgroup analysis uncer-
Our results are similar to previously published data. tain. Despite the large number of systematic reviews
A meta-analysis of 47 prospective studies of symptom- and meta-analyses on the accuracy of CT colonography,
atic patients [8] found a similar overall CT colonogra- no studies of an asymptomatic population were found.
phy sensitivity of 69% and specificity of 83%. Another One of the strengths of the present work is the likely
meta-analysis [10] of six prospective studies with popu- inclusion of most of the relevant literature. It comprised
lations with at least 50 asymptomatic individuals of five of the studies quoted in the most recent previous
average risk also found similar results for polyps with a systematic review [10] with an additional four included
sensitivity and specificity of 83.3 and 87.9% for polyps for the first time (which compared the diagnostic accu-
≥ 10 mm. In a recent study of symptomatic populations racy and safety of both tests). A second strength is that
[9], the sensitivities of CT colonography and colonos- only data on participants with an average risk were used

O88 Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, O82–O89
J. E. Martın-L
opez et al.
to assess the ability to identify all polyps as well as
CRC. Thus the study provides an estimate of the diag-
nostic value of CT colonography and colonoscopy over-
all and for subgroups according to lesion size in a
screening setting.
In conclusion, the pooled sensitivity of CT colonog-
raphy for polyps appears to be lower than that of colo-
noscopy, except in a specific subgroup with polyps
between 8 and 10 mm and according to analysis per
lesion. The pooled specificity of CT colonography was
higher than that of colonoscopy according to analysis
per patient, but not to analysis per lesion. The main
factors contributing to the increase in the sensitivity of
CT colonography were restricted to populations with
an average risk of CRC and for colonic insufflation with
CO2. The incidence of adverse events was very low.
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