Bowel cancer screening
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On 30 May 2008, the Minister of Health, Hon David Cunliffe, and the Associate Minister of Health, Hon Damien O’Connor, announced that the Government was committed to acting as quickly as possible to set up a bowel cancer screening programme in New Zealand. View the Minister's media release on the Beehive.govt.nz website - Government fast tracks Colorectal Screening (Beehive.govt.nz).
More information on this decision and the development of the bowel cancer screening programme in New Zealand is provided below:
Bowel Cancer Screening programme decision
Background to this decision
First Screening programme for New Zealand men
What is required for a bowel cancer screening programme?
Work underway
Timeframes
Expert advice
Funding
Next steps
Communications
OECD Comparisons of Bowel (Colorectal) Cancer 5 year survival rates
Colorectal cancer screening report
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Bowel Cancer Screening programme decision
The key reasons for a national bowel cancer screening programme include:
- 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 newly registered bowel cancer cases each year.
- International evidence from randomised clinical trials shows that a screening programme has the potential to save up to 100 lives a year, and the programme could reduce the death rate from bowel cancer by 10% to 15%.
- There are clear inequalities in bowel cancer between Maori and non-Maori. While Maori are less likely to be diagnosed with bowel cancer, they are more likely to die from bowel cancer than non-Maori and have poorer survival outcomes. It is important that the design and development of the bowel cancer screening programme improves outcomes for Maori.
The government has been reviewing options for bowel cancer screening for a number of years. The first New Zealand report from the National Health Committee in 1998 advised that, based on the evidence, the benefits were insufficient to recommend a national programme at that time. In 2006 the Colorectal Cancer Screening Advisory Group recommended that a feasibility/pilot study should be conducted to determine how a national screening programme would be implemented.
A further report in 2007 from the National Screening Advisory Committee to the Director-General of Health advised caution in the introduction of a bowel screening programme because of health system capacity issues. It also recommended a feasibility/pilot study.
In March 2007, the Government committed to the development of a feasibility/pilot study and the Ministry commissioned a scoping report. The scoping report provided recommendations on the design and conduct of a pilot/feasibility study and identified the key steps for the study’s implementation. The feasibility/pilot study was recommended to enable testing of the processes along the screening pathway and provide information on participation, test positivity, economics, potential equity effects and health service implications of a national programme.
Since the early 2000s, there have been significant developments in bowel cancer screening internationally, including the establishment of programmes in countries such as Australia and the United Kingdom. New Zealand can benefit from the lessons learnt from the evaluation of these overseas studies and this will enable a more rapid pathway to implementation.
First Screening programme for New Zealand men
This programme will be the first population screening programme that includes men. As shown in the following graph, men have much higher rates of bowel cancer than women. In 2004, the male registration rate for bowel cancer was 46.1 compared to the female rate of 38.9 per 100,000. Men also have a greater likelihood of dying from bowel cancer than women: male death rate 18.3 compared to the female death rate of 15.4 per 100,000.
What is required for a bowel cancer screening programme?
A screening programme is more than a simple screening test. It requires the development of a carefully coordinated pathway from the invitation to participate, taking the screening test, the subsequent colonoscopy if the screening test is positive, and treatment if bowel cancer is confirmed. The initial screening test is a faecal occult blood test (FOBT). A positive result is followed up with a diagnostic colonoscopy.
- Key requirements for a national programme are:
- An agreed pathway for the screening process and treatment
- A population based register and information system to manage invitation, recall and tracking of participants through the pathway
- Additional workforce capacity and facilities to perform colonoscopy and manage subsequent care of those confirmed to have bowel cancer Sufficient laboratory capacity for faecal occult blood testing and histology reporting from colonoscopy biopsies.
Work on these and other requirements is already underway. The Ministry of Health has commenced a programme to support the health sector to build the capacity and capability to support a pilot programme and the implementation of a national screening programme.
This work programme includes:
- increasing the colonoscopy capacity by funding District Health Boards (DHBs) for additional colonoscopy procedures
facilitating additional training for colonoscopists - developing guidelines for people with suspected cancer, including bowel cancer
- undertaking an audit of bowel cancer surgery
- the development of a National Familial Bowel Cancer Registry and national surveillance programme for high risk populations.
Planning is underway for a pilot programme to commence in 2009. A site or sites for the study are yet to be identified but an area with a population of at least 400,000 to provide 60,000 eligible people and proportionately high Maori and Pacific populations (to assess the impact of a screening programme for those populations) will be required.
Preparation for the pilot programme will take one year. Although it could take up to eighteen months to develop the information infrastructure required for the programme the Ministry is looking at options to develop the information infrastructure in tandem with the pilot study.
The pilot programmes in Australia and the UK have taken at least four years to roll out nationally and the advice received by the Ministry of Health is that the pilot study will take four years to ensure completion of two rounds of screening. However, given the good evidence for screening to reduce morbidity and mortality, and the potential to learn from the UK and Australian pilots, the Government is committed to aim for a national roll out before 2014.
A Bowel Cancer Screening Taskforce is being established. Its membership will include expertise in bowel cancer, screening and primary health care and it will provide advice on the programme’s development. This group will report to the Minister and Associate Minister of Health. A small expert reference group already exists in an interim form, but it will be important that members of this Taskforce have the right skills to both progress the pilot and the parallel actions required to increase capacity for the delivery of colorectal cancer treatment services.
The Ministry of Health has secured funding internally for work in the 2008/09 year. A budget bid will be prepared by the Ministry of Health for consideration in Budget 2009 for programme’s roll out.
The next steps being undertaken to progress the pilot study include:
- Establishing the leadership structure, decision-making and stakeholder engagement processes
- Finalising the screening pathway, the eligible age-group and FOBT test to use
- Developing the information system infrastructure (programme register) to facilitate invitation, recall, follow-up and recording results of people screened
- Selection of the site/s for the pilot study
- Developing policies, procedures, quality measures and standards, monitoring and evaluation frameworks
- Developing laboratory services
- Promoting workforce training, development, accreditation and audit
- Developing health education and health promotion resources.
A communication strategy is being developed to keep the public informed of progress with the national rollout of a bowel cancer screening programme.
Updates can be accessed through the Cancer Control section of the Ministry of Health’s website www.moh.govt.nz/cancercontrol or this website.
OECD Comparisons of Bowel (Colorectal) Cancer 5 year survival rates
Change over time in colorectal cancer five-year relative survival rates, men and women combined
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This graph shows that despite higher mortality rates in comparison to many countries New Zealand 5 year survival rates from colorectal cancer are very favourable in comparison to other OECD countries and that over the last decade there has been a small but significant improvement.
Colorectal cancer screening report
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.