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

cas

es

pe

r 1

00

,00

0 p

ers

on

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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