The National Bowel Cancer Screening Program: time to achieve its potential to save lives

Abstract

Objectives: Bowel cancer is the second most common cause of cancer deaths in Australia, affecting both men and women. The National Bowel Cancer Screening Program (NBCSP) began in 2006 with the aim of reducing the morbidity and mortality from bowel cancer in Australia. It is based on level I evidence of mortality reduction with screening using the faecal occult blood test (FOBT). Type of program or service: The NBCSP is a world-first national program using the immunochemical FOBT (iFOBT), beginning as a staged rollout limited to people aged 55 and 65 years. By 2020, rollout will be complete, with biennial screening for people aged between 50 and 74 years. The program is managed by the Australian Government Department of Health, in partnership with the states and territories. Methods: Mailing of iFOBT kits is organised through a national register and participants with a positive test are recommended for colonoscopy by the usual care pathway. Outcomes are reported to a national register, with the Australian Institute of Health and Welfare providing crucial support with data monitoring and analyses. This paper analyses the program's implementation and outcomes to date, and looks at whether it is on track to reach its full potential. Results: Program participants have been shown to have earlier cancer diagnoses and a 15% mortality reduction after accounting for lead-time bias. Modelling analyses predict that increasing participation from the current 41% will result in further reductions in mortality and improvements in cost-effectiveness, which should eventually deliver net savings to the Australian Government. Lessons learnt: The initiation and success of the NBCSP has been founded on strong evidence, but there remain areas for improvement, including capture of outcomes data and timely colonoscopy access. On current evidence, increasing participation among the established 50-74-year-old cohort will yield the strongest investment in improved outcomes. Future technological change could present opportunities in risk-based, personalised prevention and screening. Expanding the age range, for example, by starting screening at 45 years, is currently under review. Importantly, maintenance and development of the program should be driven by strong evidence to ensure its ongoing success as a major Australian health initiative.

Benefits, harms and cost-effectiveness of cancer screening in Australia: an overview of modelling estimates

“…As reported by Ee and St John in this issue, the NBCSP, introduced incrementally from 2006, has the potential to have a major impact in Australia and save many thousands of lives. 41 From 2019, the program provides biennial screening using immunochemical faecal occult blood testing (iFOBT) to people aged 50-74 years. 42 Using a comprehensively calibrated microsimulation model, Policy1-Bowel, the NBCSP was estimated to prevent 97 000 colorectal cancers and 57 100 colorectal cancer deaths in 2020-2040 at the observed ~40% participation rate, equivalent to more than 4000 colorectal cancers and more than 2500 colorectal cancer deaths prevented annually (Table 1).…”

Is this the end of colonoscopy screening for colorectal cancer? An Asia‐Pacific perspective

“…Pivoting back to the APAC region, despite being trend‐setters, that is, implementing the world's first national CRC screening program based on FIT in Japan since 1992, 9 and arguably the world's first screening program with distribution of FIT kits by postal mail in Australia, 10 organized screening has not been universally adopted across the entire region (Fig. 1).…”

AI and Clinical Decision Making: The Limitations and Risks of Computational Reductionism in Bowel Cancer Screening

“…While such results are exciting and show some promise in improving patient outcomes, it is also important to recognise that one of the biggest influences on CRC-related mortality is not fundamentally due to the nature of the current technology, but rather due to the prevalence of low rates of participation in CRC screening [118]. Various studies from Australia, which implemented one of the first national approaches to bowel cancer screening, have suggested that at the current participation rate of ~40%, a 15-36% reduction in CRC-related mortality can be expected, and if participation rates in the screening population were to increase to 70%, a 59% reduction in CRC-related mortality would be observed [119][120][121][122][123][124]. The problem is that several high-income nations have failed to reach their desired target of 65-80% screening coverage, even in the presence of wide-scale public health campaigns to raise awareness about its importance [81,125].…”