Following a comprehensive review of the evidence and the publication of the Clinical Practice Guidelines for the prevention, early detection and management of Colorectal Cancer, immunochemical faecal occult blood testing (iFOBT) every 2 years from age 50-74 was recommended for population screening in Australia. Modelling has shown that with current levels of participation, the National Bowel Cancer Screening Program (NBCSP) is expected to prevent 59,000 deaths over the period 2015-2040; an additional 16,800 and 24,800 deaths would be prevented if participation was increased to 50% and 60%, respectively. Given the effectiveness of the NBCSP, Cancer Council supports the strategies to improve participation.
Increase participation in the National Bowel Cancer Screening Program
Investment in mass media campaigns and communications strategy over three years to increase NBCSP participation
The cost-effectiveness of mass-media social marketing campaigns to promote health and reduce health system expenditure is well-documented. Mass media (particularly free-to-air TV) are the most cost-effective communication channels for influencing healthy behaviour among the NBCSP age cohort, and thereby reducing health system expenditure. Research has shown that mass media campaigns increase participation within the National Cervical Screening Program and these results are applicable to bowel cancer screening. Campaign returns increase exponentially in relation to the level of investment and the duration and reach of campaigns. Digital platforms, particularly through search, is also a rapidly growing medium for seniors. Sustained communication campaigns are necessary to improve participation in the NBCSP. Long-term investment is required to extend the positive effects of targeted communication campaigns. Sustained campaigns are likely to be more successful than shorter campaigns as absence of information exposure or marketing for competing products or opposing messages may undo positive health-related behaviour changes. Adequately funded, long-term campaigns are needed to boost participation rates in the NBCSP.
Tailored communication strategies are necessary to maximise program participation in population groups that have lower screening rates. Data show that people in socially disadvantaged groups, current smokers and people from culturally and linguistically diverse backgrounds tend to screen at lower rates than the general population.
Primary care engagement strategy
General practitioners (GPs) can play a crucial role in maximising NBCSP participation rates as GP endorsement has been shown to significantly increase participation. One of the major reasons associated with not participating in screening was the absence of GPs’ recommendation. Although the screening test is completed in the home, participants are asked to nominate a GP for referral, follow-up and management, in the event that they receive a positive FOBT result. GPs also have a role in providing data for the program registry and for continuous program improvement. Multiple studies have shown that Australians eligible for the NBCSP are more likely to participate if advised by their GP and if their GP supports the program.
In view of the evidence, the current Practice Incentive Payment scheme for GPs should be expanded beyond cervical cancer screening to include the bowel cancer screening, with clearer reporting and increased remuneration for tasks such as contributing to the program register. GPs should also receive additional professional support through a communications and engagement strategy developed and delivered in partnership with the Primary Care Collaborative Clinical Trials Group (PC4 – a national group funded by Cancer Australia), the Royal Australian College of General Practitioners and Cancer Council.
Promotion of clinical practice guidelines to health professionals
The National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines for the prevention, early detection and management of Colorectal Cancer were updated in 2017 and provide recommendations to guide best practice across the continuum of care for bowel cancer. More than 900,000 colonoscopies are performed in Australia annually with only relatively small proportion (4.7% in 2015) performed on people who have received a positive iFOBT through the NBCSP. The promotion of the clinical practice guidelines would increase the use of iFOBT for people at average risk and improve the prioritisation of colonoscopy services. The MBS Review Taskforce Gastroenterology Committee report expressed concern that average risk patients were undergoing low-value colonoscopies and noted that low-value testing may be compromising access to services for those who need it most. As a result the Australian Government has committed to the introduction of a new suite of MBS items to better describe the indications for initial colonoscopy including following a positive iFOBT result. A dissemination strategy for the clinical practice guidelines is required to ensure wide promotion to health professionals so that best practice can be achieved.
Explore opportunities for policy reform to improve the efficiencies in the health system
There are opportunities to improve the referral and follow-up care for participants in the NBSCP with a positive iFOBT result. Many health systems incorporate a specialist consultation prior to colonoscopy, which increases waiting times for NBCSP participants. In contrast, direct (or open) access colonoscopy enables GPs to directly refer for the procedure without requiring prior specialist consultation. This is common practice in many parts of Australia and internationally. A trial in NSW has shown that fast-track (or open access) colonoscopy decreases the interval between GP referral to colonoscopy. Policy reform recommending routine open access colonoscopy has to be weighed against the potential for inappropriate overuse of colonoscopy for low yield indications.
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