Bowel cancer screening – Health Report – 26 July 2010

Researchers at the University of Sydney say that around 1,000 bowel cancer deaths could be prevented if a fully-funded, evidence-based bowel cancer screening program was implemented by the Australian government.

Transcript

This transcript was typed from a recording of the program. The ABC cannot guarantee its complete accuracy because of the possibility of mishearing and occasional difficulty in identifying speakers.

Norman Swan: Hello and welcome. Today on the Health Report, an unusual event: we cover a randomised trial in surgery, comparing two ways of performing a hysterectomy. A new study looking at the influence of hope and optimism on cancer survival, and -

Rather than get party political in the lead-up to the election, I thought it might be best to steer clear of politicians but cover a couple of issues that might be important, like saving a large number of lives each week.

For many years the Australian government has provided ongoing funding for successful breast and cervical screening programs, which screen women every two years and have contributed to reductions in deaths from these cancers.

Bowel cancer on the other hand, kills more people than breast and cervical cancer combined, yet according to leading researchers we don’t have a proper screening program in Australia.

A paper that was published in the Medical Journal of Australia three weeks ago slammed both sides of politics for failing to implement an evidence-based National Bowel Cancer Screening Program in Australia, despite the fact that other countries have it. You might think that we have one, but actually we don’t, and anecdotally there’s a lot of unhappiness about it among people in the know.

Colorectal cancer is a common cause of death in Australia, yet it’s curable if caught early. The way it’s done in healthy people with no bowel symptoms and no strong family history of bowel cancer, is to test your poo for blood. It’s called a faecal occult blood test, and if it’s positive, have you referred for a colonoscopy.

Kathy Flitcroft is a Research Fellow in health policy in the School of Public Health at the University of Sydney.

Kathy and her colleagues investigated the document trail and interviewed many of the people, the experts in particular, who’d been involved over many years, often voluntarily, in trying to get a bowel cancer screening program going.

Kathy Flitcroft: The purpose was to actually tell the story of bowel cancer screening, because I had worked with a couple of colleagues who sat on these committees. They’ve been involved over a long period of time in attending meetings, where the evidence of our cancer screening was considered at great length, and they’d gone to a lot of trouble. The original committee recommended that a pilot study be undertaken; the review of the pilot study recommended that the program should be expanded, and then that didn’t happen.

Norman Swan: What is the evidence?

Kathy Flitcroft: There’s evidence from three major international randomised controlled trials that screening with faecal occult blood testing, even the old faecal occult blood test that they used previously, and we now have a better test, can reduce mortality from bowel cancer by up to 25%.

Norman Swan: If it’s implemented in what way?

Kathy Flitcroft: If there’s a good participation rate, and if it’s done bi-annually, so every two years, to a population aged between 50 and 74.

Norman Swan: So ideally, every adult aged between 50 and 74, has a faecal occult blood test done every two years, and if that’s done, then you would expect a 25% reduction in premature deaths from colon cancer?

Kathy Flitcroft: Yes, at a population level.

Norman Swan: and we’re not doing that in Australia.

Kathy Flitcroft: That’s correct, yes. and they are doing it overseas.

Norman Swan: So despite all this great fanfare that we’ve got a national bowel screening campaign, what do we actually do now?

Kathy Flitcroft: What we do at the moment is we screen people at age 50.

Norman Swan: once.

Kathy Flitcroft: once. once again at 55, and then once again 10 years later at 65. It’s a long way off what was recommended.

Norman Swan: So how did we get to this place?

Kathy Flitcroft: I do believe that the Howard government did plan to implement a full national bowel cancer screening program, but in the heat of the 2004 election, the costings that were done were very inaccurate, like way under estimated. So Tony Abbott, who was the Health Minister at the time, decided that bowel cancer screening looked like a good idea, yes, we should do that.

Norman Swan: as a federal election policy?

Kathy Flitcroft: Yes.

Norman Swan: and how much was it under-estimated?

Kathy Flitcroft: It’s difficult to say, but maybe in the order of 10 times under.

Norman Swan: OK, so under-budgeted.

Kathy Flitcroft: Under-budgeted, and when they realised that, ‘Oh, hang on a minute, the budget that’s been approved is way, way, way less than what we actually need.’ They did go back to Treasury and say, ‘Could we have some more money?’ and Treasury said No. Part of the problem I think is that the health system funding is really inflexible. It’s often the people who make these big decisions about what health policy are we going to fund, and not the people with the health expertise. So you have all these expert committees and you have epidemiologists, and clinicians and health economists…

Norman Swan: Giving freely of their time.

Kathy Flitcroft: That’s right. Giving this fantastic advice to the government, and even when you get a really supportive health minister, it took five years to get funding for the pilot to get up and running.

Norman Swan: and this is a program that could save 80 lives a week in Australia?

Kathy Flitcroft: well a thousand lives a year I think is probably a realistic estimate, yes.

Norman Swan: So they get back into power in 2004, what happens next?

Kathy Flitcroft: and they go, ‘OK, we’ve made an election promise to have a full bowel cancer screening program, but we don’t have anywhere near enough money; what will we do?’ who advised them on choosing the particular age groups, so with the Howard government they chose 55 year olds and 65 year olds? I’m not sure, I wasn’t able to find that out.

Norman Swan: for one-off testing.

Kathy Flitcroft: for one-off testing. but lots of people I spoke to said, ‘presumably it was we have this much money; how many people can you screen with that much money’?

Norman Swan: and something’s better than nothing.

Kathy Flitcroft: and that’s true. I mean they are finding some cancers, and some pre-cancerous things in the current limited program, but they could find so much more if they did it properly.

Norman Swan: then the Rudd government comes in in 2007; what happens next?

Kathy Flitcroft: They decide that they’ll continue to fund just for another three years, the existing program, and then they’ll extend it to include 50-year-olds as well. They may have done that on the advice of the Cancer Council, and if you’re going to have a full screening program, 50 is the age that you would start at. but if you’re not having a full screening program, then 50 doesn’t make sense, because you’re going to find more cancers in an older population.

Norman Swan: So that’s where the 50 year-old comes in, with a 5 year follow up at 55?

Kathy Flitcroft: Yes.

Norman Swan: and the other thing they did was they brought in a Medicare benefit.

Kathy Flitcroft: They did, so that if you go to the chemist you will get a rebate on purchasing a faecal occult blood test.

Norman Swan: If you want to do it for yourself.

Kathy Flitcroft: If you want to do it for yourself. So you can’t tell how effective the program has been because it’s been done outside the program.

Norman Swan: So at the moment, whilst they say they’ve got a national bowel screening program, we don’t.

Kathy Flitcroft: No, I don’t think we do. I don’t think you can honestly call a screening program that doesn’t include re-screening, a screening program.

Norman Swan: and the other thing is that they’re administering it differently from cervical cancer screening and breast cancer. My understanding is those two are State-run aren’t they, those two screening programs? and this is the only national screening program.

Kathy Flitcroft: It’s nationally funded, up to a point.

Norman Swan: The colonoscopies are picked up by the states.

Kathy Flitcroft: That’s righty. So the federal government funds up to the point where you get a positive faecal occult blood test, and then it’s up to the states to follow that up.

Norman Swan: and I hear lots of muttering at State level about the bowel cancer screening program, they don’t like it.

Kathy Flitcroft: I don’t think they’re happy at all.

Norman Swan: and some people say that we still don’t have enough capacity to do the colonoscopies that you would generate if you actually did do a national bowel screening program, even though that feasibility study was done.

Kathy Flitcroft: Yes. Some people have that view, and that’s still the justification that the government is using for a very limited roll-out. but there’s over 500,000 colonoscopies performed in Australia each year.

Norman Swan: many of which are unnecessary.

Kathy Flitcroft: well yes, and that figure is increasing by 10% each year. So to say we don’t have colonoscopy capacity, you can no longer say that.

Norman Swan: and there was a study I think it was done in Adelaide, which showed that if you actually had colonoscopies done for the right reasons, we’ve got plenty of capacity.

Kathy Flitcroft: Absolutely. The issue there though is the need to ensure equity, because a lot of those colonoscopies are being done in the private system. What a colleague from the University of North Carolina suggested was that the government could use a voucher system. So once you have a positive faecal occult blood test, you could be sent a voucher which entitles you to have a colonoscopy in either the private or the public sector with the cost covered.

Norman Swan: What’s your take on all this? This just the usual stuff up in the fragmented Australian health system?

Kathy Flitcroft: Yes, look bowel cancer screening is just such a missed opportunity to do a public good. The Rudd government came into power preaching three things: firstly, it was very big on evidence, secondly, prevention was really important, and the third thing is that cancer is such a burden on Australian society. So bowel cancer screening ticks all those boxes.

Norman Swan: So what are the lessons from this?

Kathy Flitcroft: It seems to be the budget process controlled by the Expenditure Review Committee, so that involves people from Finance, Treasury, and the Department of the Prime Minister and Cabinet, and perhaps they’re having a little bit too much influence in selecting what health policies get funded. and my concern is that unless they’re a little bit more flexible in their approach, it won’t be funded in the future.

Norman Swan: Kathy Flitcroft is a Research Fellow in Health Policy in the School of Public Health at the University of Sydney.

I asked the offices of the Health Minister, Nicola Roxon and the Opposition spokesman on Health, Peter Dutton, what their policies were on introducing an evidence-based national bowel cancer screening program, and stepping up to the mark like they do with breast and cervical cancer.

The Minister eventually got back to us and basically acknowledged that bowel cancer was an important cause of death and screening was important, but that as Kathy Flitcroft implied, they’re hanging off, she says (I’m paraphrasing) because they don’t want to overwhelm the colonoscopy supply, if you like. So they’re phasing it in.

Peter Dutton’s office, despite several emails and phone calls, never came back to us with a response what their policy is going into this election, in terms of national bowel cancer screening programs.

I’d be interested to know what you think the issues are from your point of view, going into this election. I might follow up on some of those. We’ve got a couple up our sleeves ourselves, and if you want to go the ‘Comments’ page attached to this particular story on bowel cancer screening on our website and you’ll find this story on national bowel cancer screening. Send us your comments about what you think the single biggest issue is for you going into the election, in terms of health and whether it would sway your vote. We might follow up on some of those.

Flitcroft KL et al. fifteen years of bowel cancer screening policy in Australia: putting evidence into practice? Medical Journal of Australia 2010;193:37-42

After this program has gone to air we received the following response from the Opposition spokesman on health Peter Dutton:

“As a government the Coalition placed a high priority on the fight against cancer establishing Cancer Australia and providing significant funding for a wide range of measures including the Strengthening Cancer Care Initiative. The Coalition introduced Australia’s bowel screening program. I am aware of concerns regarding bowel cancer screening and commit to reviewing the program in Government.”

Tagged as: cancers, university of sydney