SCREENING – THE BIG ISSUE AUSTRALIAN/INTERNATIONAL PERSPECTIVE

1. SCREENING – THE BIG ISSUEAUSTRALIAN/INTERNATIONAL PERSPECTIVE Andrew Luck Colorectal Surgeon Northern Adelaide Colorectal Unit Adelaide, South Australia Honorary Secretary, Colorectal Surgical Society of Australia and New Zealand CSSANZ representative, National Bowel Cancer Screening Program Advisory Group CANCER SOCIETY OF NEW ZEALAND, WELLINGTON June 2009

3. DIAGNOSING COLORECTAL CANCER • Symptomatic • Rectal bleeding • Change in bowel habit • Abdominal pain and/or mass • Unexplained loss of weight • Anaemia • Symptoms due to metastases • All symptoms should be investigated, especially in over 40 year olds

4. SYMPTOMS

5. DIAGNOSING ASYMPTOMATIC CRC • Screening of high risk groups • Familial syndromes • Familial adenomatous polyposis • Hereditary Non-polyposis colorectal cancer • Family history • Surveillance of high risk groups • Past history of CRC or adenomatous polyps • Long standing ulcerative or Crohn’s colitis • Screening of the average risk population

6. Quantifying risk based on family history of CRC(NHMRC Guidelines 2005) RR • No family history of CRC 1 • One 1o relative CRC >55 2 • One 2o relative CRC 1.5 • One 1o relative CRC <55 3-6 • Two 1o or one 1o and one 2o relative CRC at any age 3-6

7. Quantifying risk based on family history of CRC(NHMRC Guidelines 2005)

8. Category 1: Those at or slightly above average risk • No personal history of bowel cancer, advanced adenoma or chronic ulcerative colitis • Either no close relatives with CRC or one 1o OR 2o relative diagnosed >55

9. Screening recommendation for Category 1 patients • Faecal occult blood testing (FOBT) every second year from the age of 50 years (NBCSP) • ie NOT all patients with a first degree relative with CRC qualify for colonoscopic screening

11. Category 2: Those at moderately increased risk • One 1o relative CRC <55 • Two 1o relatives or one 1o and one 2o relative on the same side of the family CRC diagnosed at any age

12. Screening recommendation for Category 2 patients • Colonoscopy • Every 5 years • Starting at age 50, or ten years younger than the age of first diagnosis in the family, whichever comes first • If adenomatous polyps found at colonoscopy, perform next colonoscopy at shorter interval

13. Category 3: Those at potentially high risk • Three or more 1o and 2o relatives on the same side of the family with CRC (suspect HNPCC) • Two or more 1o and 2o relatives on the same side of the family with CRC and one or more of the following features • Multiple cancers in one person • CRC before the age of 50 years • Another relative(s) with related malignancy • Endometrium, ovary, stomach, small bowel, renal pelvis, ureter, biliary tract or brain

14. Category 3: Those at potentially high risk • At least one 1o relative with a large number of adenomas throughout the large bowel (suspected FAP) • A relative in whom the presence of a mutation in the adenomatous polyposis coli (FAP) gene or one of the mismatch repair genes (HNPCC) has been identified

15. Screening recommendations for Category 3 patients • FAP suspected • Flexible sigmoidoscopy annually (+/- dye spray chromoendoscopy or narrow band imaging) from 12-15 years to 30-35 years • Genetic testing for mutation on Chromosome 5q • If positive, • prophylactic total colectomy and ileorectal anastomosis or restorative proctocolectomy and ileal pouch anal anastomosis • Annual endoscopy of upper GI and rectum or pouch for life

16. Screening recommendations for Category 3 patients • HNPCC suspected • Genetic testing for HNPCC • Immunohistochemistry or MSI testing of family members’ cancers and polyps, then gene testing if positive • If gene mutation established, genetic testing of family members • If positive • Yearly colonoscopy • Regular assessment of other organs • Change of surgical approach if cancer detected • More extensive colectomy • ? Prophylactic colectomy • If negative ??

17. SCREENING OF THE AVERAGE RISK POPULATION • Faecal occult blood test every 2 years starting at age 50 • Immunological test (tests for human haemoglobin) • National Bowel Cancer Screening Program

18. NATIONAL BOWEL CANCER SCREENING PROGRAM • 2003 • Pilot • Mackay, Queensland • North East Melbourne • South West Adelaide • Via electoral role FOBT sent to all people turning 55 or 65 in a 10 month period • Reminder letter at 8 weeks

19. NATIONAL BOWEL CANCER SCREENING PROGRAM • If positive, recommended to visit GP to organise colonoscopy via public or private systems (Usual care model) • If negative, recommended to repeat FOBT in 2 years

20. NATIONAL BOWEL CANCER SCREENING PROGRAM • On basis of pilot results, in the 2005-6 federal budget, the Howard government • $45 million • FOBT kits to all Australians turning 55 or 65 between 1/7/06 and 30/6/08 • Rescreening kits for pilot participants • Reinvitation to pilot invitees who did not participate in pilot • Some infrastructure • Data managers etc • $6.60 to fill out forms!! • Not colonoscopy or pathology services (Usual Care Model!)

21. PARTICIPATION RATES • Crude rate 38.4% (as at Feb 2009) • 593,929 from 1,545,528 invitations • Kaplan-Meier assessment (Dec 2008) • Australia 42.9% • States Tas 48.4% Qld 43.6% SA 47.1% Vic 43.0% WA 47.1% NSW 40.0% ACT 45.6% NT 34.6%

22. PARTICIPATION RATES Subgroups • 55 year olds 39.9% • 65 year olds 47.7% • Males 39.2% • Females 46.7% • Pilot participants 83.0% • Pilot invitees (who declined 2002) 21.0%

23. FOBT POSITIVITY • Persons 7.5% 27,342/362,477 • 55 6.4% • 65 9.0% • Males 8.9% • 55 7.5% • 65 10.6% • Females 6.4% • 55 5.5% • 65 9.0%

24. FOBT POSITIVITY • Asymptomatic 82.9% • Rectal bleeding (<6/12) 5.2% • Rectal bleeding (>6/12) 6.5% • Change in bowel habit 3.0% • Iron deficiency anaemia 1.3% • Abdominal pain 3.4%

25. REFERRAL FOR COLONOSCOPY • GP visits* 43.2% • Likely data collection issue • Queensland 58.1% • NSW 37.9% • Referral for colonoscopy 90.7% • Reasons for non referral • Colonoscopy within 18/12 42.5% • Medical co-morbidities 35.4% • Patient declines 34.3%

26. COLONOSCOPY RESULTS* • Cancer 752 5.3% • Polyps* 7379 52.5% • Adenoma 1784 12.7% • Awaiting path 5595 39.8% • Normal 5938 41.1%

27. COLONOSCOPY RESULTS Cancer (%) Polyps (%) • Persons 5.3 53.8 • 55 4.0 52.2 • 65 6.1 57.3 • Males 5.5 62.9 • 55 4.4 61.0 • 65 6.3 64.6 • Females 4.7 45.3 • 55 3.6 42.7 • 65 5.8 47.9 • Pilot Rescreeners 6.0 47.0

28. RESECTION RESULTS Personal results 2007/2008 ACPS stage NBCSP Other Total O 8 8 16 A 7 7 14 B 4 24 28 C 5 14 19 D 2 11 13 Total 26 64 90

29. 2008/9 FEDERAL BUDGET • 87.4 million dollars (until end 2010) • Add 50 year olds to 55 and 65 • Nurse pathway coordinators • BUT • No rescreening • No money in forward estimates

30. LESSONS FROM AUSTRALIAN PROGRAM • Lives can be saved • Start out with the full program in place • Staged invitations • Rescreening in place from outset • Robust data collection • Doctors will not fill out forms without good reason • Screening centres (a la UK model/Breast Screen Australia) • Electronic collection from GP/colonoscopy unit/pathologist • Link data collection to remuneration for procedure • Collect data on resection results