Bowel Cancer Screening

Cancer Control in New Zealand

Bowel (Colorectal) Cancer Screening Programme for New Zealanders

The Ministry of Health is in the early stages of developing a bowel cancer screening programme. A number of different options are being considered as to how a screening programme would be implemented and when that might happen. Funding is yet to be secured.

The Ministry of Health’s Bowel Cancer Team is beginning to discuss ideas with health care providers. The first step is to ensure existing bowel cancer diagnostic, surveillance and treatment services are working effectively and to a high standard. Work is underway to identify and improve any existing problems. The current priority is to strengthen existing colonoscopy services and build the workforce in this area.

Options for bowel cancer screening have been explored for a number of years, following an increase in screening activity internationally in the past decade.

What is bowel cancer?
Bowel cancer is also called cancer of the colon, cancer of the rectum, or colorectal cancer. This cancer occurs when the cells in some part of the bowel grow abnormally and form a lump or tumour which has the ability to spread to other parts of the body.

Most bowel cancers are in the large bowel, which is made up of the colon and the rectum. Occasionally the cancer is in the small bowel, but this is quite unusual.

Usually bowel cancer starts in the cells of a polyp, a mushroom-like growth that occurs inside the bowel (colon or rectum). Only about 5% of polyps develop into cancer but all but the smallest polyps should be removed to ensure they don't turn into cancer.

Why is New Zealand planning a bowel cancer screening programme?
Bowel cancer is the most common cancer in New Zealand and we have one of the highest death rates from bowel cancer in the developed world.

There are approximately 1200 deaths each year and about 2700 new cases of bowel cancer each year. It may occur at any age, although 90 percent of cases are in individuals over the age of 50.

International evidence shows that a bowel cancer screening programme can reduce the death rate by 10 to 15%. In New Zealand there is the potential to save more than 100 lives every year

There are clear inequalities in bowel cancer outcomes and survival rates between Māori and non-Māori. Evidence shows that Maori are less likely to be diagnosed, and more likely to die from bowel cancer. Research indicates that this is due to inequitable access to and progress through existing cancer services. It is important that the design and development of the bowel cancer screening programme improves outcomes for Māori.

Why is bowel cancer screening important?
Screening is important because bowel cancer can develop without any early warning symptoms. The earlier bowel cancer is detected, the more successfully it can be treated. Bowel cancer screening can also detect polyps. These are not cancers, but may develop into cancers over time. They can easily be removed, reducing the risk of bowel cancer developing.

Why is a screening programme being developed now?
The Ministry of Health has regularly reviewed options for bowel cancer screening. Over the years there have been significant developments in bowel cancer screening internationally and evidence has emerged from randomised controlled trials and bowel screening pilots that screening improves population health outcomes from bowel cancer.

Do other countries have bowel cancer screening programmes?
Japan, England, Scotland, Wales, Australia, Finland and some states in Canada are all implementing population based bowel cancer screening programmes. The Netherlands, France and Italy have pilot programmes underway and are expected to begin national programmes soon.

What is involved in developing a national bowel cancer screening programme?
Establishing an effective screening programme involves much more than conducting a simple screening test. A successful screening programme has many facets, including surveillance, diagnosis and treatment services. Two years planning time has been recommended before the commencement of screening. The key requirements for a national programme are currently under development.

Before a screening programme can start it is essential to ensure that there is:

an agreed pathway for the screening and diagnostic process and for treatment
a population based register and information system to manage invitation, recall and tracking of participants
additional workforce capacity and facilities to perform colonoscopy and manage subsequent care of people diagnosed with bowel cancer
sufficient laboratory capacity for faecal occult blood testing and histology reporting from colonoscopy biopsies.
nationally agreed policy and quality standards for the programme (including an evaluation framework)

What type of work is already underway?
The Ministry of Health is supporting the health sector to build the capacity and capability needed for a national bowel cancer screening programme.

This work includes:

increasing colonoscopy capacity in District Health Boards (DHBs)
providing additional training for colonoscopists
developing guidelines for people with suspected bowel cancer
developing a New Zealand Familial Gastro-Intestinal Registry and national surveillance programme for high risk populations.

When will bowel cancer screening be available?
Based on overseas experience it can take over four years to develop and roll out a national bowel screening programme. At this stage the bowel cancer screening programme is in early stages of planning. It will be possible to give a clear timeframe of when screening will be available when the initial planning stages are completed

How long has New Zealand been considering a screening programme?
The first report into whether New Zealand should screen for bowel cancer was produced in 1998. Based on the evidence at the time, the report did not recommend a national screening programme.

In 2006 the situation was reviewed again and based on this new evidence the Bowel Cancer Screening Advisory Group recommended that New Zealand undertake a bowel cancer screening feasibility study.

In 2007, the Government committed to the development of a feasibility/pilot study and the Ministry of Health commissioned a scoping report. This report looked at what was happening with bowel cancer screening programmes overseas and what would be required to establish for a feasibility study in New Zealand.

The Government remains committed to introducing a bowel cancer screening programme as soon as possible.

Who is providing advice on the development of a Bowel Cancer Screening Programme?
A Ministerial taskforce has been appointed to provide expert advice to the Minister and the Ministry.

The Maori Equity Advisory Group is providing the Ministry with advice and recommendations on reducing inequalities in treatment and outcomes for people with bowel cancer. MEAG’s objectives are to ensure the Bowel Cancer Screening programme actively and intentionally reduces inequalities in bowel cancer for Maori, and does not inadvertently widen them.

What is the role of the Taskforce?
The Bowel Cancer Taskforce is responsible for providing advice and recommendations to the Minister of Health on a programme to improve bowel cancer outcomes for all New Zealanders. This includes:

providing strategic guidance on the direction and approach for establishing each component of the programme including:
- development and implementation of the steps required to provide a national bowel cancer screening programme in New Zealand
- delivery of screening to groups with increased risk
- improvement of treatment and diagnostic services for all people with bowel cancer, and
- development and implementation of the evaluation framework for the programme
monitoring progress with implementation, including reviewing project plans for each component of the programme and reporting to the Ministers on progress every four months.
providing other advice on bowel cancer as requested.

Members of the Bowel Cancer Taskforce are:

Shelley Campbell, Member, Cancer Control Council
Dr Susan Parry (Clinical Advisor Familial Bowel Cancer Registry, Genetic Services, Auckland City Hospital and Clinical Head, Dept Gastroenterology and Hepatology, Middlemore Hospital)
Dr John McMenamin (General Practitioner and Clinical Director, Wanganui Regional PHO)
Teresa Lynch (Charge Nurse Manager of Canterbury District Health Board’s Gastroenterology Day Unit)
Dr Diana Sarfati (Public Health Medicine Specialist at the University of Otago)
Associate Professor Chris Atkinson (Radiation Oncologist at Canterbury DHB and Chair of the Cancer Control Council)
Mr Ian Bissett (Associate Professor, University of Auckland and Consultant Colorectal Surgeon, Auckland City Hospital, Auckland)
Dr Clint Teague (Pathologist) – co-opted member
Dr John Childs, the Ministry of Health’s National Clinical Director, Cancer Programme, is an ex-officio member of the taskforce

Who is a bowel cancer screening programme for?
The bowel cancer screening programme is for both men and women. It is the first time that men will be part of a national screening programme in New Zealand. Overseas programmes usually screen people between the ages of 50 and 74 years, although this varies.

What is involved in the screening process?
The initial screening test used in overseas programmes is a faecal occult blood test (FOBT). This is a test for blood in the bowel motions where a small sample of bowel motion is collected and tested for the presence of non-visible, or hidden (occult) blood.

A person with a negative FOBT will be recalled on a regular basis for a repeat test. Overseas, the time between screening tests is usually two years.

A person with a positive FOBT result is followed up with a diagnostic colonoscopy. This is where the doctor inspects the entire length of your large bowel by gently inserting a long, flexible tube called a colonoscope into your back passage (rectum) and then into your colon. A sedative is given before the colonoscopy. The doctor may take a biopsy in the form of a small sample of tissue, which is examined under a microscope, or remove polyps. Other means of diagnostic testing also exist.

Can I be tested for bowel cancer now?
If you have any health concerns please contact your primary health provider or doctor.
Some people are at increased risk of bowel cancer, and should have colonoscopies to check their bowel every few years. Talk to your GP to see if this applies to you, if you have

a parent, brother, sister or child who has had bowel cancer
the rare genetic condition Familial Adenomatous Polyposis (FAP)
a genetic condition called Hereditary Non-Polyposis Colorectal Cancer (HNPCC)
had Crohn's Disease or ulcerative colitis for more than ten years.

What causes bowel cancer?
Scientists are still unsure what causes bowel cancer. It often starts as a benign (not cancerous) polyp that turns into cancer over time.

Who is most at risk of getting bowel cancer?
The incidence of bowel cancer increases with age and rises steeply from the age of 50. Bowel cancer affects more men than women.
Scientists believe a diet high in animal fats and low in fruit and vegetable fibre may contribute to the development of bowel cancer.
Risk factors include having:

a parent, brother, sister or child who has had bowel cancer
the rare genetic condition Familial Adenomatous Polyposis (FAP)
a genetic condition called Hereditary Non-Polyposis Colorectal Cancer (HNPCC)
had Crohn's Disease or ulcerative colitis for more than ten years.

What are the signs and symptoms of bowel cancer?
Common signs and symptoms of bowel cancer may include:

a change in bowel habit – i.e. your regular pattern of going to the toilet
diarrhoea, constipation, or feeling that your bowel doesn’t empty completely
blood in your bowel motion
bowel motions that are narrower than usual
general abdominal discomfort (frequent gas pains, bloating or
cramps) that can be confused with indigestion
unexplained weight loss
tiredness

Although these symptoms are usually caused by other conditions it is important to get them checked by your primary health care provider or doctor.

How do I find out more about colorectal (bowel) cancer screening?
This report reviews the current international status in relation to CRC screening, examines feasibility/pilot studies that have been conducted, looks at the information a feasibility study would provide New Zealand, provides an outline study design, and outlines the work that needs to be done prior to a feasibility study including an indicative timeline.

Disclaimer: This report was prepared under contract to the New Zealand Ministry of Health. The copyright in this report is owned by the Crown and administered by the Ministry. The views of the author do not necessarily represent the views or policy of the New Zealand Ministry of Health. The Ministry makes no warranty, express or implied, nor assumes any liability or responsibility for use of or reliance on the contents of this report.

Who can I contact if I have any questions about the programme?
Write to:
Bowel Cancer Team
Ministry of Health
PO Box 5013
WELLINGTON

Email:
bowelcancerteam@moh.govt.nz

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Page last updated: 16 November 2009