10 July 2017

Why the bowel-screen program is falling short

Cancer Government Public Health

Tens of thousands of preventable deaths could occur in the next two decades if GPs continue to be overlooked in the implementation of the National Bowel Cancer Screening Program, medical experts warn.

New modelling led by researchers at Cancer Council NSW shows that while the current uptake of 40% will have a major impact on bowel cancer rates, another 25,000 lives could be saved between now and 2040 if uptake rates could be increased to 60%.

At the moment, uptake in Australia is lower than other colorectal screening programs and internationally accepted targets.

According to AMA vice president Dr Tony Bartone, a major reason for the poor uptake rates has been that the program was introduced without much collaboration with general practitioners.

“When we understand the target group, over-50s, they have a very strong relationship with their GPs,” he said. “And it would have made more sense to bring GPs into the equation up front.”

“Whenever [GPs] send a patient off for a referral for an FOBT there’s a high rate of compliance because there is a messaging factor and there is obviously a symptom that’s presented,” he said.

But the current program does not alert GPs when someone is sent a test, only when it is completed, and even this is fractured further because this is sometimes sent as snail mail and other times sent as a secure smart form, Dr Bartone said.

This year, Australians aged 50, 54, 55, 58, 60, 64, 68, 70, 72 and 74 years will be sent the free immunochemical bowel cancer screening kit in the mail, but by 2019 the program will increase the testing to every two years.

Dr Bartone said that the additional money for testing needed to be accompanied by significant public-health messaging, collaboration with general practice and better infrastructure to track patients.

While it might not be possible to alert a GP the first time somebody was invited to undergo the test, Dr Bartone said that once the person was in the system and had nominated a GP, it would be useful to send the practitioner a notification each time the test was sent.

In addition, the government could work with practice management software companies to develop regular reminders to leverage the important role GPs played in preventive health, he said.

“It needs a multipronged approach,” he said. “If you just focus on one side of the equation and hope that other people come on board, you don’t get the bang for your buck – and this is too big an issue not to be taken more seriously.”

Colorectal cancer is the third most common cancer in Australia, and the second highest cancer killer, after lung cancer.

A study, which was published in Lancet Public Health, validated the introduction of the scheme, and estimated it would prevent 92,000 cancer diagnoses and 59,000 deaths between 2015 and 2040.

This would save $1.7 billion in health expenditure over the period, or $2.1 billion if participation rates could be increased to 60%.

“Despite its preventive effect, the model predicts that screening at the current participation level will not bring the number of colorectal cancer diagnoses and deaths per annum below current numbers,” Dutch experts wrote in an accompanying editorial.

However, gastroenterologist Dr Cameron Bell said the current uptake figure of 40% was likely to be an underrepresentation of the true number of individuals being screened for bowel cancer.

The reality was a substantial number of people in the community were having FOBTs or colonoscopies as surveillance  of previous polyps or screening due to strong family history, and understandably throwing their FOBT kits away when they received it, said Dr Bell, a spokesperson for the Gastroenterological Society of Australia.

He was positive about the uptake and efficacy of  the program so far. He suggested that some people might be being screened with regular colonoscopies unnecessarily, either because they had a weak family history, or because there was a misconception that FOBT was inferior to colonoscopy.

“Of people who have been screened recently with an FOBT as part of the program, the chance of having bowel cancer in the next two years is one in 1000,” Dr Bell said.

To ensure the program reached its full potential, patients needed to be reassured that the FOBT was a powerful and effective screening tool, he said.