Bowel Cancer Screening:
Effective and Expanding
Dr. Hooi Ee Gastroenterologist, SCGH
Lead Clnician,
WA Bowel Cancer Screening Implementation Team
Bowel (Colorectal) Cancer
• Second commonest internal cancer after
prostate
• Commonest cancer affecting Men and Women
– Risk = 1 in 12 by 85 yrs
• Risk: M = 1:10 F = 1:15
• 1330 new cases in WA in 2010
• 420 deaths in WA per year
Australian Institute of Health and Welfare. National Bowel Cancer Screening Program
monitoring report: phase 2, July 2008- June 2011. Cancer Series No. 65 CAN 61.
Canberra; 2012
Bowel cancer in Australia
• Incidence markedly increases after 50 yo
0
100
200
300
400
500
600
0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84
New
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es
pe
r 1
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ers
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Colorectal cancer: age-specific incidence rates, Australia 2008
Men
Women
Persons
Australian Institute of Health and Welfare. National Bowel Cancer Screening Program
monitoring report: phase 2, July 2008- June 2011. Cancer Series No. 65 CAN 61. Canberra;
2012
Adenoma Carcinoma 5 - 20 year sequence
Symptoms present late
• 50% presenting with it will die from it
• > 95% need surgery
• < 5% small enough to be removed by
colonoscopy
• Most bowel cancers present too late
EARLY BOWEL CANCER HAS NO SYMPTOMS
Bowel cancer is ideal for screening
• Common serious disease
• No symptoms during early phases
• Removing precursors prevents cancer
• Earlier detection makes treatment simpler
• Earlier detection improves survival
• Safe, effective, screening tests available
• Widespread screening saves lives
What is cancer screening?
• Population screening is:
• Systematic application of a
• Suitable screening test to identify
• Individuals at risk of a condition to warrant
• Intervention
• Participants have no symptoms
Symptoms (NOT screening)
Need colonoscopy
• Age over 40 years
• Recent symptoms (6-12 months):
– Bleeding (needs explanation at all ages)
– Anaemia, especially iron deficiency
– Altered bowel habit, especially looseness
– Abdominal pain
Screening/surveillance (NHMRC)
Asymptomatic
• Average Risk: 50-74 year old
– Biennial faecal occult blood test (FOBT)
• Increased risk Colonoscopy
– First degree relative
National
Bowel
Cancer
Screening
Program
Program Roll-out in WA
Phase 1
• 55 & 65 y.o.
• Jan 07 – June 08
Phase 2
• 50, 55, 65 y.o.
• July 08 - June 13
Phase 3
• 50, 55, 60, 65 y.o.
• July 13 – June 15
FOBT Kit Canberra wishes you a Happy Birthday!
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Immunochemical FOBT performance
• Sensitivity: – 70% for cancer, 27% for advanced adenoma
• Positive predictive value: – 5% for cancer, 20% for advanced adenoma
• Positive FOBTs require colonoscopy – but >90% will not have cancer
FOBT is not the most accurate test
but
FOBT is the best screening test
Screening Pathway
Kit sent in mail
Perform test at home and mail to lab
FOBT (-) FOBT (+)
Submit Assessment Form
Recommend repeat
in 2 years
(not funded)
Colonoscopy (if needed)
Therapy (if needed)
NBCSP:
Current state
NBCSP Participation
• Low overall -
NBCSP Outcomes
• 7.8% of FOBTs are positive
• ~50% have polyps/adenomas
• 3.0% of positives FOBT have cancer
Australian Institute of Health and Welfare. National Bowel Cancer Screening Program monitoring
report: phase 2, July 2008- June 2011. Cancer Series No. 65 CAN 61. Canberra; 2012
NBCSP: Effective
Stage shift
South Australia
• Stage A
–NBCSP: 35% vs non-NBCSP: 19%*
• Stage D
–NBCSP: 3% vs non-NBCSP: 12%*
*p
Stage shift
14
%
31
%
24
%
15
%
16
%
40
%
25
%
25
%
3%
8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
A B C D Unknown
Pe
rce
nta
ge
Cancer Stage
Screening vs Symptoms: cancer stage at diagnosis1
Not NBCSP
NBCSP
Ananda et al, MJA 2009, 191:378
NBCSP: Expanding
• 2006 – 55 & 65 yo
• 2008 – 50, 55, 65 yo
• 2013 – 50, 55, 60, 65 yo
• Anyone born in or after 1967 will be offered full biennial screening from age 50.
Already being screened
2015 50, 55, 60, 65 70, 74
2016 50, 55, 60, 65, 70, 74 72, 64
2017 50, 55, 60, 64, 70, 72, 74 68, 58, 54 65
2018 50, 54, 58, 60, 64, 68, 70, 72, 74 62, 66 55
2019 50, 54, 58, 60, 62, 64, 66, 68, 70, 72, 74 52, 56
2020 First year of full implementation with no additions
Acknowledgements
• WA Bowel Cancer Screening Implementation Team
– Kath O’Connor
– Sarah Fisher
• Cancer Council WA
– Dayna Cenin
– Melissa Ledger
• WA Cancer and Palliative Care Network