Impending or pending? The national bowel cancer screening programme
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38797.494757.47 (Published 30 March 2006) Cite this as: BMJ 2006;332:742All rapid responses
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Atkin bemoans the delay in starting the national bowel cancer
screening programme [1], but the additional time could be devoted to
giving the public balanced information on the likely harms and benefits.
If this were done by a disinterested party it would avoid the conflict of
interest seen in breast cancer screening [2].
Extra time may, indeed, be necessary to explain why 109 more people
died in the screening group than in the control group during the trial she
cites (the largest so far undertaken)[3].
1. Atkin WS. Impending or pending? The national bowel cancer
screening programme. BMJ 2006; 332:742.
2 Jørgensen KJ, Gøtzsche PC, Content of invitations for publicly
funded screening mammography. BMJ 2006;332: 538-41.
3 Hardcastle J, Chamberlain J, Robinson M, Moss S, Amar S, Balfour T,
et al. Randomised controlled trial of faecal-occult-blood screening for
colorectal cancer. Lancet 1996;348:1472-7.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR - The editorial by Professor Atkin is right to emphasise the
case for population bowel cancer screening.1 Bowel cancer is an important
public health problem and a common cause of cancer related death. The
major determinant of survival is disease stage. Early presentation (Dukes’
Stage A) can result in up to 83% five year survival.2 The most effective
way of improving survival outcomes for bowel cancer is early diagnosis.
Primary care plays a pivotal role in encouraging earlier presentation by
patients with bowel symptoms, compliance with ‘Urgent Referral’ criteria2
and primary prevention.
However the fact is that the present financial crisis in the NHS has
resulted in a delay in the commencement of the national bowel cancer
screening programme. This is disappointing news both nationally and
locally. In the meantime, this presents a further opportunity for local
health services to develop and/or refine their implementation plans for
the roll out of the screening programme.
In Wolverhampton, the Primary Care Trust’s Public Health Department
has developed an initial implementation plan in conjunction with the Local
Screening Centre (LSC), primary care and potential screening participants.
A discussion of the impending NHS Bowel Cancer Screening Programme (NHS
BCSP) at a recent Wolverhampton Over 50’s Forum raised some important
issues. First, the acceptability of the faecal occult blood test (FOBt) to
individuals was mixed. Men in particular expressed concern about using the
testing kit. Individuals with common pre-existing bowel conditions, such
as irritable bowel syndrome, wanted to know whether or not they should
participate in screening. Concerns were also expressed regarding the risks
associated with colonoscopy. Encouragingly however, the main focus of
discussion related to preventative measures that could be taken, such as
dietary control, physical activity, weight management and a reduction in
both tobacco use and alcohol consumption.
The UK Screening Pilots3 show several factors that affect FOBt uptake
rates, including deprivation and ethnicity. These factors are of
particular concern in Wolverhampton. For example, the city is host to the
fourth biggest Sikh community in the country.4 This intervening period
presents us with a further opportunity to raise awareness of bowel cancer
with disparate groups through existing primary care and local authority
networks and communication channels. New ways of presenting health
promoting and bowel cancer screening material are being explored, such as
through the local Asian media and faith organisations.
Our local general practitioners (GPs) also believe that the new
programme will have an impact on their workload. Resources can be directed
towards establishing helplines for both professionals and the general
public in order to provide appropriate advice and information on the
screening programme. Locally, education events aimed at GPs and other
health professionals will continue as planned.
The government has confirmed that it is committed to a national bowel
cancer screening programme.5 This period of delay can be used to continue
work that will not only maintain existing improvements in bowel cancer
survival rates but also create an environment that will assist the
implementation of the national screening programme, when this ultimately
takes place.
Ros Jervis,
Specialist Trainee in Public Health,
Wolverhampton City Primary Care Trust
Dr Gurmukh Singh Kalsi,
Consultant in Public Health,
Wolverhampton City Primary CareTrust
References
1. Atkin W. S. Impending or pending? The national bowel cancer
screening programme. BMJ 2006; 332:742.
2. NICE. Guidance on Cancer services – Improving Outcomes in Colorectal
Cancers. Manual Update. May 2004. ISBN 1-84257-620-8.
3. The UK CRC Screening Pilot Evaluation Team. Evaluation of the UK
Colorectal Cancer Screening Pilot – Final Report. May 2003. University of
Edinburgh.
4. Wolverhampton Public Health. Annual Report 2005. Wolverhampton City
Primary Care Trust
5. Winterton R. Hansard. House of Commons Daily Debates. 27 March 2006:
Column 780W. Available at:
http://www.publications.parliament.uk/pa/cm200506/cmhansrd/cm060327/text...
Competing interests:
None declared
Competing interests: No competing interests
As a trainee in general surgery in Scotland with an interest in
colorectal surgery, the advent of our national screening programme next
March is one that I greet with considerable enthusiasm; it is an exciting
time to be involved in colorectal cancer care and no doubt we will be
presented with the opportunity to answer a great many questions in the
treatment, prevention and molecular genetics of adenomas and
adenocarcinomas of the colon and rectum.
The FOB is a crude and simple test but has proved itself worthy of use as
evidenced by the mortality reductions convincingly shown by the Minnesota
study in 1993 (1) and also by Hardcastle (2) and Kronborg (3) in 1996.
As a profession we must embrace this screening programme and instead of
focusing on the negatives, be they either the considerable number of false
negatives or negative opinions about colorectal cancer screening and
instead turn our focus onto maintaing pressure on the government.
There is no doubt that we need to continue to actively search for either a
better stool or serum biomarker or a better investigation but we cannot
let another ten years pass us by before we force the politicians to fund
this programme.
1. Mandel, J.S. et al. Reducing mortality from colorectal cancer by
screening for fecal occult blood. Minnesota Colon Cancer Control Study. N
Engl J Med 328, 1365-71 (1993).
2. Hardcastle, J.D. et al. Randomised controlled trial of faecal-occult-
blood screening for colorectal cancer. Lancet 348, 1472-7 (1996).
3. Kronborg, O., Fenger, C., Olsen, J., Jorgensen, O.D. & Sondergaard,
O. Randomised study of screening for colorectal cancer with faecal-occult-
blood test. Lancet 348, 1467-71 (1996).
Competing interests:
None declared
Competing interests: No competing interests
A large administrative, financial and manpower input is needed to
realise the small but definite gains to be obtained from colon cancer
screening using guaiac-based faecal occult blood (FOB) testing (1). Since
a 16% reduction in colorectal cancer deaths is achievable, 84% of
colorectal cancer deaths are not prevented by such a screening programme.
To date there has been little focus on the perception of false
results by screened individuals. For every 10 individuals who screen FOB
positive, one may have bowel cancer, 4 may have adenomatous polyps of
various sizes and 5 will have a false positive result. Professor Atkin
emphasises that prompt colonoscopy is needed for positive
FOB individuals in order to allay anxieties (1).
False negative results are perhaps more concerning. While a negative
screening test result might be expected to be reassuring, many patients
who are FOB negative will nevertheless be harbouring a colon cancer. FOB
fails to detect 25-50% of colon cancers and up to 75% polyps. Interval
cancers after negative FOB results were common in the Nottingham study
(2).
Since doctors themselves are often falsely reassured by negative FOB
results in individual patients, how can members of the public be educated
about the concept of a false negative result? Misunderstandings about
false negative results in cervical and breast cancer screening programmes
have often led to furore and unwelcome media and legal attention (3). In
colon cancer screening this issue is going to be on a greater scale, and
potential screenees must be advised that a negative FOB result is not a
guarantee that they do not have colon cancer.
References
1. Atkin WS. Impending or pending? The national bowel cancer
screening programme. BMJ 2006; 332:742.
2. Hardcastle JD, Chamberlain JO, Robinson MHE et al. Randomised
controlled trial of faecal-occult-blood screening for colorectal cancer.
Lancet 1996; 348: 1472-77.
3. Wilson RM. Screening for breast and cervical cancer as a common
cause of litigation. BMJ 2000; 320:1352-3.
Competing interests:
None declared
Competing interests: No competing interests
To the Editor:
I'm surprised to see BMJ, a leader in promoting statistical literacy,
publish an editorial with such an obvious misuse of a statistic. 5-year
survival is of no value in assessing the effectiveness of a cancer
screening program. Any screening program will improve 5-year survival
simply by detecting cancers earlier, thereby starting the 5-year clock
earlier, whether or not there is any true mortality benefit to the
program. This will be true even in the absence of effective therapy, or
of any therapy at all.
Likewise, it is not surprising that stage of disease at diagnosis
would be the main determinant of 5-year survival, but again this tells us
nothing about the value of the screening program. What is relevant is the
effect of the program on overall mortality.
--Brian Jackson
Competing interests:
None declared
Competing interests: No competing interests
The Importance of 'Pooh-Sticks'
EDITOR- Following Professor Atkins’ editorial I’m writing to add my
concerns at the delay in introducing the national bowel screening
programme.1 I have been very fortunate in living in the North East of
Scotland which has had a pilot bowel screening programme for those aged 50
to 69 years for over 5 years now. At aged 52, almost two years ago, my
small asymptomatic but Dukes C colonic carcinoma was picked up as a result
of screening. After six months of adjuvant chemotherapy I am well with
now, an excellent prognosis. I would not be but for my address and I’m
sure there are patients in the west midlands who feel the same. I have
encouraged all my family in non screening areas to have screening guaiac
FOB (faecal occult blood) tests through their GP’s which they have done.
Two have required further investigation with colonoscopy.
The 60% take up of screening is disappointing with the extremely high
incidence of bowel cancer. As an associate specialist in oncology and
haematology I carried out a straw poll amongst my colleagues on their take
up of the screening programme. It was also no higher than 60%. This was
due to a combination of “knowing” that any positive FOB would be the
result of bleeding haemorrhoids and a certain reluctance to have GI
colleagues know them any better than they did already! However, after my
experience, and with the tragic consequences of a close friend in the
department who declined screening, take up of screening in the unit has
improved significantly this year.
The national bowel cancer screening programme is extremely important
and must not be delayed. The plans to initially exclude the 50 to 60 year
group I cannot accept. With the increasing cost of chemotherapy and
monoclonal antibody regimens for advanced colonic carcinoma the government
must surely realise the financial benefit of preventative screening.
1 Atkin W S. Impending or pending? The national bowel cancer
screening programme. BMJ 2006;332:742
Competing interests:
None declared
Competing interests: No competing interests