more_vert
RECENT data on bowel cancer in younger adults should be cause for concern for both medical practitioners and public health advocates.
As an anatomical pathologist that specialises in gastrointestinal pathology, it’s alarming to me that the incidence of bowel cancer in Australians under 50 years of age is rising.
A study published recently by The Lancet showed bowel cancer cases in people under 50 years have risen by 2.9% over the past 10 years in Australia. The study examined data from seven high income countries and found similar increases in Denmark, New Zealand and the UK.
I know from personal experience how important it is that symptoms in younger people are not overlooked.
At the age of 35 years, with no family history of bowel cancer, I experienced a persistent change in bowel habits that sent me to the doctor. Fortunately for me, I was referred for a colonoscopy to investigate.
The scope revealed an adenoma, which was removed from my bowel at the time of the colonoscopy. It is difficult to say if my symptoms were due to the adenoma, which was pre-malignant, but the discovery was still a surprise at my age. It was fortuitous that I had that scope that may have prevented a subsequent bowel cancer.
It’s important to note that some of the symptoms of early bowel cancer such as a change in bowel habit may seem relatively minor, particularly in a young, otherwise well patient. But it is critical that symptoms in younger patients which may seem relatively minor are not dismissed.
Early detection of cancer relies on vigilance – both on the part of patients and their doctors. Patients are told all the time by medical practitioners and public health campaigns to pay attention to their bodies and not overlook symptoms. It’s equally important for clinicians to take heed of red flag symptoms when they arise and to take the appropriate steps when patients present.
It’s particularly important that, if a patient does take heed of this advice and presents to their GP or specialist, these symptoms are not dismissed. When the risks of cancer in younger patients seems small, it is a temptation to reassure patients without further investigation. Not only can this be a missed opportunity to make a critical early diagnosis, it may result in a patient disregarding worsening symptoms over time.
Age alone should not preclude investigation of symptoms, and the value of a negative result in providing peace of mind also cannot be underestimated.
However, younger patients and their doctors are not the only ones who need to increase their vigilance when it comes to bowel cancer.
Reaching the milestone of 50 years has taken on a whole new significance with data clearly showing an increased risk of bowel cancer from this age – hence the invitation to participate in the bowel cancer screening program.
Due to my previous adenoma, I recently had my regular surveillance colonoscopy. But were it not for this existing monitoring, when the bowel cancer screening kit came in the mail, I would certainly be sending off a faecal sample to my local pathology laboratory.
When you consider that stage I bowel cancers have a 5-year survival rate of 99% and stage II 89%, and compare that with just 13% 5-year survival for stage IV, it is astounding that more people are not having the test.
The latest report by the Australian Institute of Health and Welfare released in June 2019 shows bowel cancer screening participation rates are far too low. In the 2-year period 2016–2017, just 41% of people invited for screening took part.
Key findings from the National Bowel Cancer Screening Program monitoring report 2019:
- overall participation rate for 2-year period 2016–2017 was 41%;
- men (39%) had a lower participation rate than women (43%);
- participation rate was poor (30%) in the younger age group 50–54 years;
- men aged 50–54 years had a screening participation rate of less than 30%;
- participation increased with age, and 53% of people in the 70–74 years age group undertook testing; and
- in 2017, about 69 000 participants returned a positive screening test, giving a 7.9% screening positivity rate.
This is one of the cancers that we are able to screen for, so we must do everything we can to reduce the risk of having advanced disease. Furthermore, the faecal occult blood test is an easy test that is collected in the home without requiring a visit to a doctor or an invasive procedure. There really is no excuse for not participating.
We know there’s a “yuck” factor with the test, but some people tend to make far too big a deal of having to sample their own faeces. An important role for all medical practitioners is to point out to all our patients that the test is actually pretty simple, and to highlight that the test is free of charge, is non-invasive and there is no need to leave the house to collect a sample. This advice can help to influence reluctant patients.
As well as the worryingly low overall participation rate, it is concerning that of those in the youngest age group (50–54 years) only 30% took part in screening. This is despite the recent data showing that the incidence of bowel cancer in younger adults is increasing.
It is not only the risk of late stage cancer we should be thinking about; any delay in diagnosis can mean far more significant treatment options are required. This could mean a more significant operation or adjuvant treatments such as chemotherapy or radiation treatment, with the unwanted side effects.
Our best chance to avoid these is to improve the screening rate for those eligible, and keeping bowel cancer in mind with younger patients so that lesions are detected at the earliest possible stage.
If a patient presents with symptoms, no matter their age, then we must do everything necessary to get to the bottom of it.
Dr Nick Musgrave is an anatomical pathologist specialising in gastrointestinal pathology, and an ambassador for Pathology Awareness Australia. He is particularly interested in oesophageal disease, colonic polyps and inherited colon cancer syndromes. He is Pathologist-in-Charge of Sullivan Nicolaides Pathology’s Histopathology Department, Brisbane.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
I think the FOBT is a rotten test. To get a positive test the lesion whether it be a benign polyp, a dysplastic polyp or a carcinoma must be actively bleeding at the time of testing and this certainly is not the case in many patients. Also false positives can occur with simple haemorrhoids.
My own experience was a colonoscopy in my early fifties which disclosed 3 polyps with dysplastic features in the absence of any symptoms and this scenario was repeated with another non genetically related family member.
I know of many patients with advanced colonic cancer who are diagnosed too late and but for my early colonoscopy I could have shared their fate.
I think it is high time we got reaiistic about this disease and promoted colonoscopy as the diagnostic procedure of choice. There is NO substitute for direct visualisation and immediate biopsy for colonic lesions in asymptomatic patients.
Hi Elsa. While there’s definitely a need to investigate symptoms the stats don’t support FOBT screening in asymptomatic people under 50 years of age. But equally we can’t afford to dismiss symptoms just because of age.
Thank you Nick. What do you think about 2-yearly FOBT’s in those under 50 if they are willing?
the biggest issue with the NBCS is that it bypasses GPs – so while I can encourage my patients to do the test, they still have to wait until it actually arrives, or the previous kit sits around and has expired. Why they have not organised a similar pathway like the pap smear/CST screening is a mystery to me. Any decent GP would see in their notes if the patient has done it/is due for a screening FOBT and can easily give the kit to take home then and there. this would increase the uptake rate dramatically. Currently I am in the position that I DO give the kits every two years and some poor bugger does it twice as the NBCS kit arrives a few months later – no harm done but a waste of taxpayers money. my take on this – involve the GPs or ignore them at public healths peril.
The national bowel cancer screening program ( faecal occult blood test) was introduced and heavily publicised without factoring in the availability of colonoscopies for uninsured patients. The gold standard is a colonoscopy within three months of a positive test, yet many will wait much longer even to get an outpatient appointment in the public system, and may end up waiting a year or more to get their ‘scope. This is risky and also psychologically harmful. My experience was that many patients elected to pay and have it done privately rather than wait for a public colonoscopy. But many will wait too long, with the potential for disease progression.
Screening is something we must or should do, for too long women have been told we must or should do this or that test, usually with no real information on risks and actual benefit. (and any information we do get is heavily biased toward screening) Screening carries risk and ends up harming some people, some even lose their life. Only one person can say the risks exceed the benefits, the individual person, and so the law and proper ethical standards say informed consent is a must – especially when we’re offering something that carries risk to an asymptomatic person.
I’ve been dismayed at the way screening has been forced onto women, coercion has even been a tactic, no Pill without a pap test is a good example, the clinical requirement for the Pill is your medical history and a blood pressure test. Mammograms have a huge black cloud hanging over them, I’d urge all women to read the summary prepared by the Nordic Cochrane Institute…over-diagnosis and over-treatment is a serious concern.
Targets have always been the focus in women’s health and that has to change…too many women have been worried sick and harmed, physically and psychologically, thanks to these so-called simple screening tests and in many cases, the woman did not consent to the test or did not provide informed consent.
Screening is my choice, give me the real information, for and against, (not spin, threats, misleading stats, celebrity endorsement etc.) and leave the decision to me.
Thank you Nick for these valuable observations and sage advice.
I participated in the National Bowel Screening Program at 50 when my birthday package arrived. At 55 life and work was extremely busy and stressful (including working with families that had been affected by bowel cancer) and the screening kit sat unopened. Luckily for me, the national screening program has recently changed to every two years and another arrived in March this year following my 58th birthday. I was referred for a colonoscopy following a positive screening result and was diagnosed with a sigmoid tumour.
I am just now back at work following a sigmoid colectomy for my Stage 1 cancer and will remain on a surveillance program.
It is hard to put into words the feeling that if the program had remained at every 5 years what my story might have been at age 60. Equally, what might my story have been if the test kit had not remained unopened at 55…
DO THE TEST.