Elsevier

Surgery (Oxford)

Volume 27, Issue 9, September 2009, Pages 397-400
Surgery (Oxford)

Screening
Bowel cancer screening

https://doi.org/10.1016/j.mpsur.2009.08.013Get rights and content

Abstract

The efficacy of colorectal cancer screening has been proven by randomized control trials. England is one of several countries that have commenced population screening. The structure and philosophy of the NHS facilitates comprehensive reach to the target population. Screening for colorectal cancer commenced in England in July 2006 and implementation for all 60–69 year olds is expected to be completed by the end of 2009. The programme is currently available on request to those 70 years of age and above and invitations for screening will be extended up to 74 year olds from 2010. The NHS Programme currently uses a guaiac-based faecal occult blood test and a complex testing algorithm which can require the participant to provide a total of 18 samples from nine stool samples. The positivity of the test in the South of England is 1.63% with 58% of the population responding to the test invitation. Colonoscopy is provided by registered Screening Colonoscopists from local accredited Screening Centres. 12% of those who have a colonoscopy are diagnosed with cancer, 13% with high-risk lesions and only 28% show no abnormality at all. All elements of the screening process are recorded on a national screening database that is used for programme organization and quality assurance purposes.

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.

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