Take fear out of faeces

GPs are key to lifting the uptake of bowel cancer screening tests, with the biggest barrier to uptake being the public’s “reluctance to engage with their faeces”, according to leading gastroenterologists.

Dr Katie Ellard, secretary of the Gastroenterological Society of Australia (GESA), said the current 33.5% uptake of the National Bowel Cancer Screening Program (NBCSP), was “far too low”. (1)

Research published today by the MJA, which modelled expansion scenarios of the NBCSP using a well established, validated computer simulation model for bowel cancer screening, concluded that “accelerating the expansion of the program to achieve biennial screening by 2020 would prevent more than 70 000 deaths” by 2055. (2)

Currently the NBCSP is structured to prevent 35 169 bowel cancer deaths by 2055. The NBCSP invites people aged 50, 55, 60 and 65 years to have a free faecal occult blood test (FOBT), with plans to add 70-year-olds next year. Full implementation of biennial screening is planned by 2020.

The researchers modelled five scenarios: “current” — the existing screening program, including the addition of 70-year-olds in 2015; “slow” — the 2012–13 Budget proposal to add one age cohort every 2 years, starting with 70-year-olds in 2015, with subsequent age cohorts added every other year until full implementation by 2035; “annual” — an acceleration of “slow”, adding one age cohort every year; “multiple” — an acceleration of “annual”, adding two age cohorts every year; and “5-year” — implementation completed by 2020.

Dr Ellard, while agreeing that the research was strong, said human beings, rather than the NBSCP’s structure, were the biggest barrier to increasing uptake of FOBT screening.

“People have a reluctance to engage with their faeces”, Dr Ellard told MJA InSight. “It’s going to take a general culture shift, and GPs are in the best position to facilitate that.”

Conversations between GPs and their patients and family members were critical to spreading the word about bowel cancer, particularly that it is highly treatable if caught early, Dr Ellard said.

“People are used to seeing publicity about breast cancer screening, cervical cancer screening and even prostate cancer now. But bowel cancer doesn’t attract that kind of attention, even though it is the ideal screening cancer — we can really intervene effectively if we find it early on.”

Professor Terry Bolin, president of the Gut Foundation, said he felt the modelling research was “unrealistic” and agreed that the best hope for increased uptake of the FOBT was through GPs.

“The fact is uptake has fallen and is continuing to fall”, Professor Bolin told MJA InSight.

“[The researchers] are looking for a 60% uptake — I don’t know how you get to that with just a letter drop. Bowel cancer screening should be done by GPs as part of a regular prevention program, in the same way as breast cancer and cervical cancer are.”

Professor Graeme Young, chair of global gastrointestinal health at Flinders University in Adelaide, said accelerating the NBCSP was vitally important.

“The benefit is there to be had now”, he told MJA InSight.

“Two risks arise if we roll it out too slowly. First, the benefit to Australia will be less and delayed. Second, new improved technologies may be developed and we might be locked into a proven but not optimal technology.”

He agreed that stool testing remained a barrier “for at least one-third of people”.

“This will reduce with time due to awareness and convenience but we need more research done on how best to overcome this problem.

“Fatalism is also an issue in some population subgroups — some people just cannot conceive that cancer is curable and preventable.”

In an editorial also published by the MJA today, Professor Ian Olver, CEO of Cancer Council Australia, and Paul Grogan, the council’s director of advocacy and policy, wrote that GPs were “well placed” to help improve the “unacceptably low” uptake of the NBCSP’s FOBT program. (3)

“A large-scale communications campaign, during program expansion and after full implementation, will be needed to improve participation rates”, they wrote.

“GPs have been identified as critical partners … [and] it will become increasingly important to consult closely with the primary care sector and provide support to GPs to facilitate their role in the expanded NBCSP.”

1. AIHW 2014; NBCSP: monitoring report 2012‒2013
2. MJA 2014; Online 13 October
3. MJA 2014; Online 13 October

(Photo: Arno Massee / Science Photo Library)