Cruz AJ, Gurram S, Obias I, Luo A, Salmastyan G, Rajagopalan A, Bui S, Sharifi R, Kumar N, Hui C, Cruz Grave E, Yang E, Erondu A, Griggs T. Foregut malignancy after discordant fecal immunochemical test: A cohort study at a United States safety-net hospital. World J Gastrointest Oncol 2026; 18(11): 123432 [DOI: 10.4251/wjgo.123432]
Corresponding Author of This Article
Andrew John Cruz, MD, Department of Medicine, University of Southern California/Los Angeles General Medical Center, 2020 Zonal Avenue, Los Angeles, CA 90033, United States. andrewjohn.cruz@med.usc.edu
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Gastroenterology & Hepatology
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Cruz AJ, Gurram S, Obias I, Luo A, Salmastyan G, Rajagopalan A, Bui S, Sharifi R, Kumar N, Hui C, Cruz Grave E, Yang E, Erondu A, Griggs T. Foregut malignancy after discordant fecal immunochemical test: A cohort study at a United States safety-net hospital. World J Gastrointest Oncol 2026; 18(11): 123432 [DOI: 10.4251/wjgo.123432]
World J Gastrointest Oncol. Nov 15, 2026; 18(11): 123432 Published online Nov 15, 2026. doi: 10.4251/wjgo.123432
Foregut malignancy after discordant fecal immunochemical test: A cohort study at a United States safety-net hospital
Andrew John Cruz, Sandeep Gurram, Isabel Obias, Allen Luo, Gevork Salmastyan, Aravind Rajagopalan, Stefanie Bui, Roxanna Sharifi, Nikhilesh Kumar, Chester Hui, Erick Cruz Grave, Eric Yang, Amarachi Erondu, Theodor Griggs
Andrew John Cruz, Sandeep Gurram, Isabel Obias, Allen Luo, Gevork Salmastyan, Aravind Rajagopalan, Stefanie Bui, Nikhilesh Kumar, Erick Cruz Grave, Eric Yang, Amarachi Erondu, Theodor Griggs, Department of Medicine, University of Southern California/Los Angeles General Medical Center, Los Angeles, CA 90033, United States
Roxanna Sharifi, Chester Hui, Keck School of Medicine, Los Angeles, CA 90033, United States
Author contributions: Cruz AJ designed the study, collected and analyzed the data, performed the statistical analysis, and drafted the manuscript; Gurram S, Obias I, Luo A, Salmastyan G, Rajagopalan A, Bui S, Sharifi R, Kumar N, Hui C, and Cruz Grave E performed chart review and data abstraction; Yang E performed chart review, data abstraction, and detailed malignancy case review; Erondu A contributed to data collection and critical revision of the manuscript; Griggs T conceived and supervised the study, provided mentorship, and critically revised the manuscript for important intellectual content; all authors have read and approved the final manuscript.
AI contribution statement: The authors did not use any AI tools in the preparation of this manuscript. All data analysis, writing, and revision were performed entirely by the authors.
Institutional review board statement: This study was approved by University of Southern California Institutional Review Board (No. HS-25-00684).
Informed consent statement: Informed consent was waived by the IRB given the retrospective, de-identified nature of the study.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.
Data sharing statement: The dataset is available from the corresponding author upon reasonable request.
Corresponding author: Andrew John Cruz, MD, Department of Medicine, University of Southern California/Los Angeles General Medical Center, 2020 Zonal Avenue, Los Angeles, CA 90033, United States. andrewjohn.cruz@med.usc.edu
Received: May 19, 2026 Revised: July 2, 2026 Accepted: July 28, 2026 Published online: November 15, 2026 Processing time: 162 Days and 16.3 Hours
Abstract
BACKGROUND
Whether fecal immunochemical test-positive (FIT+) patients whose colonoscopy does not identify a bleeding source should undergo esophagogastroduodenoscopy (EGD) is unclear. Prior data report foregut cancer rates below 1% in population screening cohorts, but yield by colonoscopy concordance has not been directly compared, particularly in United States safety-net Hispanic populations.
AIM
To compare the yield of EGD between FIT+ patients with discordant (non-explanatory) and concordant (explanatory) colonoscopy at a safety-net hospital.
METHODS
We performed a retrospective cohort study of FIT+ adults aged ≥ 45 years who underwent colonoscopy (2019-2025) and EGD within one year at Los Angeles General Medical Center, a safety-net hospital. Colonoscopy was classified as concordant if it identified a lesion plausibly explaining a FIT+ result, including colorectal neoplasia, vascular lesions, or colitis. Foregut malignancy and other EGD findings were compared between groups. Firth penalized logistic regression (exploratory) adjusted for age, sex, anemia, foregut symptoms, nonsteroidal anti-inflammatory drug/aspirin use, and cirrhosis.
RESULTS
Of 379 FIT+ patients (172 discordant, 207 concordant), 11 foregut malignancies occurred in the discordant group (6.4% vs 0%; P < 0.001; Firth adjusted odds ratio = 26.14, 95%CI: 2.16-315.82). Premalignant lesions were more common in concordant patients (7.7% vs 2.3%, P = 0.02); other EGD findings did not differ significantly between groups. Foregut symptoms were equally prevalent in both groups (44.2% vs 38.2%, P = 0.25), indicating that symptom-driven referral does not account for the observed difference. Among the 11 malignancy patients, 0 were ever-smokers and All patients underwent EGD for standard clinical indications; the observed association reflects a clinically selected cohort rather than protocolized EGD for all discordant patients.
CONCLUSION
In a clinically selected safety-net cohort, all foregut malignancies occurred exclusively among discordant FIT+ patients despite similar symptom profiles between groups, suggesting that discordant colonoscopy may help stratify foregut malignancy risk in populations with elevated gastric cancer burden.
Core Tip: At a United States safety-net hospital, all 11 foregut malignancies in fecal immunochemical test-positive patients occurred in those whose colonoscopy did not explain the positive result (6.4% vs 0%), including patients without symptoms or anemia. This association persisted after multivariable adjustment (adjusted odds ratio = 26.14) and across multiple sensitivity analyses. Foregut symptoms were equally prevalent in both groups, and all patients underwent esophagogastroduodenoscopy for standard clinical indications rather than discordant fecal immunochemical test status alone. None of the malignancy patients were smokers or heavy drinkers. These hypothesis-generating findings warrant confirmation in multicenter prospective studies.
