National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 15: Prevention and early detection of cancer
Prevention and early detection of colorectal (bowel) cancer
☰ Table of contents

Recommendations: Prevention and early detection of colorectal (bowel) cancer

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Screening

 All adults Ask about family history of colorectal cancer (Box 1) in order to estimate the individual risk of developing colorectal cancer As part of an annual health assessment GPP 94
Category 1: People near average risk age 50–74 years (Box 1) Promote client participation in the National Bowel Cancer Screening Program using the immunochemical faecal occult blood test (iFOBT) kit that is received through the mail for eligible ages

iFOBT tests can be sourced through pathology centres or purchased through other organisations for those people who wish to do two-yearly bowel screening prior to full implementation of the screening program in 2020, or for those aged 45–49 years who have one family member with colorectal cancer

Refer all abnormal results for appropriate diagnostic evaluation, usually with a local colonoscopy provider		 iFOBT screening every two years in age range 50–74 years

For people in this category with one relative with colorectal cancer, consider starting screening from age 45 years		 IA
PP

94, 97-99, 108
People near average risk aged 75–85 years If requested, discuss the risks and benefits of screening using iFOBT, as any benefit is likely to be small due to higher risks of complications and lower benefits if previously screened. These discussions should take into account individual circumstances such as overall health and comorbidities

If positive iFOBT test, refer for appropriate diagnostic evaluation, usually with colonoscopy		 Population screening not recommended. If asked, consider iFOBT every two years depending on individual circumstances and patient choice IC 94,97,98
Category 2: People at moderate risk (Box 1) Recommend iFOBT then colonoscopy screening, starting from age 40 years (Computed tomography [CT] colonography may be considered if colonoscopy is contraindicated) iFOBT screening every two years in age range 40–50 years

Colonoscopy should be performed every five years from ages 50 to 74 years		 III–IIC 94, 108
Category 3: Those at potentially high risk (Box 1) Start iFOBT then colonoscopy screening from age 35 years (CT colonography may be offered if colonoscopy is contraindicated)

Consider referral to a genetic centre for hereditary cancer syndromes, especially for those with three people with colorectal cancer on the same side of the family

(Refer to ‘Resources’ for specific recommendations for screening for those with familial cancer syndromes – these groups require much earlier screening, some from adolescent years)		 iFOBT screening every two years in age range 35–45 years

Colonoscopy should be performed every five years in age range 45–74 years

Consider referral at the time of determining the individual is at high risk, or later if not done initially		 III–IIC 94, 108
Past history of adenoma Undertake surveillance colonoscopy Time frame for surveillance colonoscopy varies depending on risk (refer to ‘Resources’) I, III–IIA 109, 110
History of inflammatory bowel disease (ulcerative colitis or Crohn’s disease) Undertake surveillance colonoscopy Time frame for surveillance colonoscopy varies depending on risk (refer to ‘Resources’) II, III–IIB 109, 110

Behavioural

 All people Provide lifestyle risk factor counselling on the benefits of regular physical activity, maintaining healthy weight, alcohol intake in the low-risk range, restricting energy intake and dietary fat (refer to Chapter 1: Lifestyle)

Also recommend the consumption of vegetables and sources of dietary fibre as these foods may be protective.

Recommend consuming only moderate amounts of red meat, minimising the consumption of charred and processed meats		 As part of an annual health assessment III–IIC 82, 94

Chemo-prophylaxis

 Following complete removal of adenoma at colonoscopy, or nonsyndromic familial cancer patients Assess bleeding risk and, if no contraindications, consider low-dose (100 mg) daily aspirin (in consultation with a specialist)

Benefit may be increased when concurrent elevated cardiovascular disease (CVD) risk is present (refer to Chapter 11: Cardiovascular disease prevention)		 At time of diagnosis IIB 94,106, 107
For those at high risk due to Lynch syndrome Unless contraindicated, recommend daily aspirin (evidence that low-dose 100 mg/day is as effective as high dose) At time of diagnosis, specialist consultation. Usually from age 25 years for those with Lynch syndrome carrier status I, IIA 94, 102, 111,112
For people aged 50–69 years at average risk of colorectal cancer Discuss evidence that low-dose aspirin (100–300 mg per day) commencing at age 50–70 years for at least 2.5 years reduces the risk of colorectal cancer 10 years after commencement, and reduces the risk of cardiovascular events in a shorter time frame (refer to Chapter 11: Cardiovascular disease prevention). Combined reduction of colorectal cancer and cardiovascular risks outweighs the risk from bleeding complications. Benefit for cancer prevention may be longer lasting with longer duration of use

Consider 10-year life expectancy and CVD risk, and avoid in those with high risk of bleeding, renal impairment and uncontrolled hypertension
Less evidence for colorectal cancer prevention for women aged >65 years, but women this age with CVD risk factors are likely to also benefit
Refer to ‘Resources’ for further information		 Consider discussing from age 50 years, taking into account individual preferences and risk– benefit profile, including access to services if complications

Consider breath testing for Helicobacter pylori and treatment if positive before commencing aspirin		 IB
PP		 94, 105
94
For people at moderate (Category 2) or high risk (Category 3) without a familial syndrome Consider 100 mg aspirin daily in those without high risk of bleeding, renal impairment or uncontrolled hypertension

Consider H. pylori testing, and treatment if positive, before commencing aspirin		 Discuss risks and benefits as in above PP 94
*Refer to Box 1 for risk categories.

Box 1. Risk categories for colorectal cancer based on family history94

Category 1

Category 2

Category 3

Those at near average risk based on family history (95–98% of population; risk slightly below to up to two times average risk, 10% lifetime risk)

Those at moderately increased risk based on family history (2–5% of population; risk three-fold to six-fold average risk, 15–30% lifetime risk)

Those at potentially high risk based on family history (<1% of population; risk seven-fold to ten-fold average risk, 30–40% lifetime risk)

No first-degree or second-degree relative with colorectal cancer

One first-degree relative with colorectal cancer diagnosed at age ≥55 years

One first-degree and one second-degree relative with colorectal cancer diagnosed at age ≥55 years

One first-degree relative with colorectal cancer diagnosed at age <55 years

Two first-degree relatives with colorectal cancer diagnosed at age ≥55 years

One first-degree relative and at least two second-degree relatives with colorectal cancer diagnosed at age ≥55 years

At least three first-degree or seconddegree relatives with colorectal cancer, with at least one diagnosed at age <55 years

At least three first-degree relatives with colorectal cancer diagnosed at age ≥55 years


Background

Colorectal cancer is the third most common cancer diagnosed in Aboriginal and Torres Strait Islander peoples. Recent reports show that the incidence rate for Aboriginal and Torres Strait Islander peoples for colorectal cancer is 10% less than for non-Indigenous Australians, with a mortality rate 30% lower.3 The participation rate for Aboriginal and Torres Strait Islander peoples in bowel screening is not routinely reported.89 One review of participation in the National Bowel Cancer Screening Program estimated that the participation rate for nonIndigenous Australians was 2.1 times greater than for Aboriginal and Torres Strait Islander peoples.90
The lower participation of Aboriginal and Torres Strait Islander peoples in the bowel cancer screening program may be due to lack of awareness, inappropriateness of educational material in testing packs, cultural reasons, beliefs about bowel cancer, a higher risk of not having a fixed address, and underidentification of Aboriginal or Torres Strait Islander origin when returning forms. Culturally appropriate and localised health promotion campaigns and information, recommendations for testing by a person’s health service, alternative methods of distributing test kits, and specific strategies to promote screening through Aboriginal and Torres Strait Islander health services may increase participation in screening.91–93

Estimating risk based on family history

Age is the biggest risk factor for developing colorectal cancer. The 2017 National Health and Medical Research Council (NHMRC)-endorsed Clinical practice guidelines for the prevention, early detection and management of colorectal cancer94 are used to determine an asymptomatic person’s risk of colorectal cancer based on family history. Box 1 highlights the risk factors for each risk category. Refer also to ‘Resources’.


Interventions

Screening: It takes approximately 10 years for benign colorectal adenomas to progress to cancer. Screening for colorectal cancer allows cancers to be detected at an earlier stage when treatment is more effective, and allows some cancers to be prevented through removal of benign adenomas. The survival rate is higher for people with colorectal cancer detected through screening.95

Immunochemical faecal occult blood test (iFOBT) screening: Evidence shows that two-yearly screening of asymptomatic average risk people aged 50–75 years using an iFOBT reduces the risk of dying from colorectal cancer. For iFOBT screening, it is estimated that for every 1000 people screened regularly, approximately 20 deaths from colorectal cancer will be prevented, with 10 people having gastrointestinal or cardiovascular complications due to follow-up colonoscopy. Some evidence suggests that screening could be considered for those aged 76–85 years, but that the appropriateness of this depends on patient circumstances. Evidence is lacking for benefit of screening for those aged >85 years.96–99

The National Bowel Cancer Screening Program is being expanded and by 2020 every person eligible for Medicare and aged 50–74 years will be invited to participate in bowel cancer screening using an iFOBT kit sent through the mail.100 For people aged >50 years not eligible for the National Bowel Cancer screening program, iFOBT kits may be bought through Cancer Council state organisations, and some GPs, pathology centres and pharmacies. GPs can also refer patients for iFOBT tests to pathology labs that can use Medicare Benefits Schedule (MBS) pathology items for patients eligible to claim Medicare benefits.101

Other screening methods: Computed tomography (CT) colonography, flexible sigmoidoscopy and colonoscopy may be appropriate screening methods for some people. Colonoscopy is not recommended as first-line screening for those near average risk due to the increased risk of harm compared to iFOBT screening, but may be appropriate for people with a moderate or high risk.94,97–99

Aspirin: There is increasing evidence of the overall benefit of taking aspirin for prevention of adenomas and colorectal cancers.94,102–105 For people with previous adenomas who are at higher risk of colorectal cancer, or for those at high risk due to familial cancer syndromes, in particular Lynch syndrome, benefits of reduction in recurrent adenoma and colorectal cancer may outweigh the risks of harm.94,106,107 For people aged 50–69 years at moderate to high risk of cardiovascular disease (CVD), there is some evidence that low-dose aspirin for at least 2.5 years may decrease the risk of CVD and after 10 years reduce the risk of bowel cancer, and that aspirin could be considered in those at lower risk of bleeding with at least 10 years’ life expectancy, with much greater benefit versus harms for those aged 50–59 years compared to 60–69 years. Approximately 9–14 cases of colorectal cancer may be prevented (depending on age and CVD risk) for 1000 men aged 50–69 years taking low-dose aspirin for several years.94,105 Aspirin is not currently recommended in Australian guidelines for the prevention of CVD (refer to Chapter 11: Cardiovascular disease prevention). For people at moderate or high risk of colorectal cancer without a familial syndrome, the benefits generally outweigh the risk for those without risk factors for bleeding.94 It is unknown whether the same risk–benefit ratios would apply to Aboriginal people in Australia in the same age ranges, and consideration should be given regarding access to services should bleeding complications arise. Refer to ‘Resources’ for updated Australian clinical guidelines for colorectal cancer94 and more details on recommendations for prophylactic aspirin to prevent colorectal cancer.
 

Resources
 
National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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