ScreeningBowel cancer screening
Introduction
In July 2006, England embarked on the ambitious task of providing colorectal cancer screening to the whole population. The decision was based on the results of four large randomized controlled trials (RCTs), including one in Nottingham,1 where a 16% reduction in mortality was associated with the implementation of a screening programme. Scotland and then Wales followed England in providing population screening, and Northern Ireland and the Republic of Ireland programmes are in preparation.
Although several European countries have commenced colorectal cancer screening, none as yet reach the whole population, although many have the ambition to do so. Australia commenced screening following completion of a pilot in 2004, the New Zealand government has committed to screening and Japan has screened a selected population for some 10 years. Whilst the USA has various colorectal screening programmes, they do not provide comprehensive screening.
Section snippets
The case to screen
As outlined by Wilson and Jungner,2 the criteria for screening (Table 1), which have been adopted by the WHO, demonstrate that colorectal cancer qualifies for screening.
Whilst deaths from colorectal cancer in the UK have fallen from 19,598 in 1992 to 16,007 in 2007, it is still the third most common type of cancer in the UK (after breast and lung), is the second highest cause of cancer mortality (after lung), and amongst non-smoking men, it is the primary reason for cancer deaths.
A test for colorectal cancer
Colonoscopy is the best means we have to detect colorectal cancer and it provides an opportunity for therapeutic intervention, which is not possible with virtual colonoscopy (computerized tomography colonography). Whilst the morbidity and mortality associated with investigative and therapeutic colonoscopy might be considered acceptable for patients with signs and symptoms of the disease, they are unacceptable for first line population screening. Flexible sigmoidoscopy carries a significantly
The English Bowel Cancer Screening Programme
In 1998 the NHS Cancer Screening Programme embarked on a process of developing colorectal screening using a testing model described in the Nottingham RCT.1 In 2000, Dundee and Coventry, each with a population of 0.5 million, commenced screening as pilot sites. The uptake of the test, following an initial invitation, was 56.8% with a distinct difference in uptake between males and females (F > M), an age related increase in uptake (69 > 60 year olds), and marked ethnic differences (Caucasian >
Screening quality and quality assurance
Hubs are subject to external quality assessment and 2-yearly Clinical Pathology Accreditation review and accreditation visits. Analysts are trained and registered and their performance is checked before each screening episode. A break from screening is necessary every 60 min.
SCs must achieve a high score on the endoscopy Global Rating Scale (GRS) and are subject to inspections by the JAG on Gastrointestinal Endoscopy. Screening Colonoscopists must have experience of a minimum of 1000
Outcomes
The English programme will reach the whole population by the end of 2009. 9.7 million people are currently served by the Southern Hub, which has a response to invitation rate of 58% and test positivity rate of 1.63%. The proportions of positive tests from the 1st, 2nd and 3rd test kits are 14%, 61% and 25%, respectively. Some 10% of people with positive test results choose not to progress to colonoscopy. In Southern England, following colonoscopy, 11.5% are diagnosed with cancer and 12.7%,
The future
This is a young screening programme. The uptake and outcomes will change as it moves from the prevalent to the incident round. It will take several years to see its effect on the burden of cancer in the population. Future adoption of the iFOBT will reduce the complexity of the testing algorithm and, we hope, increase uptake.
References (5)
- et al.
Randomised controlled trial of faecal-occult-blood screening for colorectal cancer
Lancet
(1996 Nov 30) - et al.
Principles and practice of screening for disease
Chron World Health Organ
(1968)
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