Impending or pending? The national bowel cancer screening programme
Authors: Wendy S Atkin
Journal: BMJ (2006)

The government has, on several occasions, made a strong case for a national bowel cancer screening programme1 2 and in 2004 it committed to providing £37.5m (€54m; $65.5m) over two years for a programme to begin in April 2006.3 4 This deadline cannot be met, because it will take around six months to commission the screening centres, and no funding has yet been provided. The NHS financial crisis is clearly the cause of the delay, but it is unclear if this is a temporary hiccough or a shelving of the programme.

The case for screening is clear. Bowel cancer is second only to lung cancer as a cause of cancer deaths in the United Kingdom. Furthermore, in 2004 the number of deaths from bowel cancer (16 148) exceeded the number from breast cancer (12 347) and cervical cancer (1093), diseases for which there are already effective, well run screening programmes. Five year survival rates for bowel cancer, although increasing, remain below 50%. Improving on the main determinant of survival—the stage of the disease at diagnosis—remains a huge challenge.

The government has introduced ambitious targets for maximum waiting times of 18 weeks for diagnosis and treatment of cancer. But the most effective way to improve survival is to diagnose bowel cancer while the disease is still asymptomatic, which is possible only by screening the general population.

Perhaps most importantly, several randomised trials and a Cochrane review have yielded high quality evidence that offering screening for bowel cancer, using the guaiac faecal occult blood (FOB) test every two years for men and women aged between 50 and 69, reduces mortality from bowel cancer by about 16%.5 6 The guaiac FOB test is not perfect and could be seen as a first generation bowel cancer screening test. Other contenders for screening include immunochemical FOB tests, flexible sigmoidoscopy, colonoscopy, virtual colonoscopy (colonography using computed tomography), and faecal DNA tests. However, none of these tests has the same level of evidence to support its efficacy in reducing mortality from bowel cancer as the guaiac FOB test.

England is not alone in introducing bowel cancer screening based on FOB testing. A national programme is being rolled out in France, which is currently screening people aged 50-74 in 34 of its 95 departments and intends to cover all of the country by 2007. Israel and Finland offer screening to all in a similar age range, as will Scotland from March 2007. Regional programmes are underway in Italy (Tuscany), Spain (Catalonia), Hungary, Bulgaria, Romania, Czech Republic, and Australia. Finally, the United States has been recommending annual FOB screening from age 50 since the 1980s,7 and national surveys indicate that around 40% of the eligible population comply with this advice.8

Building on a successful, ongoing pilot programme in the West Midlands, the UK government plans to roll out the screening in phases to achieve complete coverage of the English population by 2010. Men and women aged 60 to 69 will be offered screening initially, to allow for the gradual build-up of resources for colonoscopy. Assuming that 60% of those offered screening take it up, the programme—with its restricted age range—will generate an extra 30 000 colonoscopies in an already overstretched service. It is essential that people with positive FOB test results, who may be anxious, do not have to wait long for investigative colonoscopy. Equally, screened patients should not be given priority over patients with symptoms of bowel cancer, which would create a two tier system. Restriction of screening to an older age group is also more cost effective because cancer is most common in this age group.9

The national bowel cancer screening programme will be the first NHS cancer screening programme in England for men as well as women, with costs comparable to the breast screening programme. As with breast screening, the benefits will extend far beyond the programme and will be an important opportunity to reverse the low ranking of our bowel cancer survival rates in comparison with the US and several European countries.10 For example, preparation for the introduction of FOB screening and a tight deadline (April 2006) have both given impetus to the urgent upgrading of colonoscopy services. A survey undertaken by the British Society for Gastroenterology had highlighted shortcomings in the competence and training of UK endoscopists.11 All endoscopy units and individual endoscopists wishing to participate in the screening programme will have to undergo a thorough process of assessment leading to accreditation,12 which may become a national standard. However, this is work in progress, and doubts about the speed of introducing the programme risks harming the professional goodwill and motivation that have driven service improvements.

There is still time to introduce the programme in 2006. The government's short term financial difficulties should not be permitted to erode national confidence in its commitment to tackling bowel cancer death rates.