Policy context

National Bowel Cancer Screening Program

Bowel cancer screening in Australia is managed through the National Bowel Cancer Screening Program (NBCSP). The Australian Government introduced the program in 2006, following successful pilot studies demonstrating the potential effectiveness and feasibility of a national program for population bowel cancer screening.^[1] The program, based on Australians aged 50-74 being invited to screen every two years with iFOBT, will be fully implemented by December 2019.^[2]

The goals of the NBCSP are “to reduce the morbidity and mortality from bowel cancer by actively recruiting and screening the eligible target population aged 50-74 for early detection or prevention of the disease”.^[2]

Implementation

The Australian Government introduced the NBCSP in 2006, after successful pilot studies conducted between 2002-2004 concluded that a nationally coordinated bowel cancer screening program in Australia would be feasible, acceptable and cost-effective.^[1] The program was initially set up to offer a one-off FOBT to people turning 55 and 65 from August 2006. At the same time, the national bowel cancer screening register was established for issuing invitations and iFOBT kits, monitoring data and arranging follow-up notifications for participants who had positive iFOBT results.

A one-off FOBT for people turning 50 was added to the program in 2008.^[3] In 2012 a funding commitment was made to add FOBTs for people turning 60 in 2013 and those turning 70 in 2015.^[4]

Building on a 2013 federal election commitment, the Government announced in the 2014-15 federal budget a plan for full program implementation, with biennial screening of all Australians aged 50-74, by July 2020.^[5] This is consistent with Cancer Council Australia's pre-election submission^[4] and clinical practice guideline recommendations.^[6] Based on previous policy statements, this commitment brought forward the anticipated roll-out of the program by 14 years. The funding provided for the addition of new age groups in stages:^[5][7]

• 70 and 74 year olds were added in 2015;
• 72 and 64 year olds were added in 2016;
• 68, 58 and 54 year olds were added in 2017;
• 66 and 62 year olds added in 2018; and
• 56 and 52 year olds to be added from 2019.

Expanding the NBCSP is expected to increase awareness of bowel cancer screening, including among people not currently eligible for the program. Targeted, strategic communications will be critical for recruiting larger number of participants into the program and should be a priority during this interim phase.

GPs are well-placed to manage patients participating in bowel cancer screening according to the current guidelines.^[6][8] GP support is therefore an integral component of the program. See Role of GPs in screening for more information.

Participation

NBCSP participation among people aged 50-74 was 42% in 2017-2018.^[9] Participation rate was slightly higher than that of the previous year (2016-2017; 41%).^[10]

Despite men having higher rates of screen-detected bowel cancers, bowel cancer incidence and mortality, they were less likely to participate in screening (40%% compared with 45% among women). ^[9]Participation was highest among those aged 70-74 (53.1%) but those aged 50-54 had the lowest participation (31.9%). ^[9] Participation is also varied among states and territories with the highest rate reported by South Australia (48%) and the lowest rate reported by Northern Territory (29%).^[11]

In 2018, 7% of participants (78,600 people) had a positive screening result.^[11] Of these, 66% reported a follow-up diagnostic assessment.^[11] Of those who had a follow-up colonoscopy following a positive screening result, 251 were diagnosed with a confirmed bowel cancer and 1,432 with suspected bowel cancer.^[11] Adenomas were detected in 6,149 participants (1 in 8 participants assessed).^[11]

Program communications

An evidence-based framework for maximum participation including targeted communications and improved linkages with general practice is required to underpin program effectiveness of the NBCSP. To date, formal communications with GPs, who play a pivotal role in the program, have been limited. There has also been limited investment in national communication campaigns for the NBCSP. This is reflected in the low participation rates currently seen in target age groups.^[12] Long-term mass media campaigns to increase awareness of the benefits of participation in the program and support behaviour change at a population level have not been adequately funded.

The evaluation of the screening pilots showed that Indigenous Australians had low awareness of bowel cancer screening, which was a significant barrier to participation.^[13] Screening monitoring reports have demonstrated that Indigenous Australians are under-represented in screening participants.^[2] Culturally appropriate education and resources, as well as engagement with local health workers, are needed to address the particular needs of these communities and to ensure that their participation, or non-participation, is based on informed choice.^[13]

Cost-effectiveness

A range of studies have found population-based bowel cancer screening with iFOBT once every 2 years in people aged 50-74 years is cost-effective as discussed below.

A preliminary cost-effectiveness study of the NBCSP found that, over the lifetime and relative to no screening, the program was predicted to save 1,265 life years, prevent 225 bowel cancer cases and cost an additional $48.3 million, equivalent to a cost-effectiveness of $38,217 per life-year gained (LYG) at current participation levels. An analysis assuming full participation improved this to $23,395 LYG.^[14]

A 2017 cost-effectiveness study of the NBCSP found that biennial iFOBT screening is highly cost-effective and was predicted to be associated with a cost-effectiveness ratio of $2,693-$3,048 per life-year saved compared with no screening.^[15] The fully implemented NBCSP is estimated to reduce bowel cancer incidence by 23% and mortality by 36%.^[15] A subsequent study concluded that in comparison to other screening approaches (including no screening, colonoscopy, computed tomographic colonography, faecal DNA test, plasma DNA test and flexible sigmoidoscopy), the biennial iFOBT is highly cost-effective and the most cost-effective approach of all the screening scenarios considered.^[16]