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Clinical guidelines

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

Prevention and early detection of colorectal (bowel) cancer

Author Dr Nadia Lusis
Expert reviewers Professor Bruce Armstrong

Background

Colorectal cancer is the third most common cancer diagnosed in both Aboriginal men and women.3 The aged standardised incidence of colorectal cancer from available data showed a 41% lower relative risk in Aboriginal and Torres Strait Islander people compared to non-Indigenous people.4 Despite the lower incidence of bowel cancer, due to later stage at diagnosis,2 the burden of disease (measured in disability adjusted life years [DALYs]) for colorectal cancer in Aboriginal people was 1.1 times higher than that of the total Australian population.1 One review of participation in the National Bowel Cancer Screening Program estimated that the participation rate for non-Indigenous Australians was 2.1 times greater than that for Aboriginal and Torres Strait Islander people.72 

The lower participation of Aboriginal and Torres Strait Islander people 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 population 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.73-75

Estimating risk based on family history

The 2005 National Health and Medical Research Council endorsed Guidelines for the prevention, early detection and management of colorectal cancer76 are used to determine an asymptomatic person’s risk of colorectal cancer based on family history. Table 15.3 highlights the risk factors for each risk category. Also see Resources.

Table 15.3. Risk categories for colorectal cancer based on family history
Category 1
Those at or slightly above average risk based on family history
Category 2
Those at moderately increased risk based on family history
Category 3
Those at potentially high risk based on family history
No personal history of colorectal cancer, colorectal adenomas or chronic inflammatory bowel disease and no confirmed close family history of colorectal cancer
OR
One first degree (parent, sibling, child) or second degree (aunt, uncle, niece, nephew, grandparent, grandchild) relative with colorectal cancer diagnosed at age 55 years or older
OR
Two relatives diagnosed with colorectal cancer at age 55 or older but on different sides of the family
One first degree relative with colorectal cancer diagnosed before the age of 55 years (without potentially high risk features as in category 3)
OR
Two first or one first and one second degree relative/s on the same side of the family with colorectal cancer diagnosed at any age (without potentially high risk features as in category 3)
Three or more first degree relatives or a combination of first and second degree relatives on the same side of the family diagnosed with colorectal cancer
OR
Two or more first or second degree relatives on the same side of the family diagnosed with colorectal cancer plus any of the following high risk features:
  • multiple colorectal cancers in a family member
  • colorectal cancer before the age of 50 years
  • a hereditary non-polyposis colorectal cancer (HNPCC) related cancer (endometrial, ovarian, stomach, small bowel, renal pelvis or ureter, biliary tract, brain cancer)
OR
  • at least one first degree or second degree relative with a large number of adenomas throughout the large bowel (suspected familial adenomatous polyposis (FAP)
OR
  • member of a family in which a gene mutation that confers a high risk of colorectal cancer has been identified

Interventions

The evidence for faecal occult blood testing (FOBT) screening is that it is most appropriate for those aged 50-75 years. Screening could be considered for those aged 76-85 years depending on patient circumstances. Evidence is lacking for benefit of screening for those aged >85 years.76-79 A limited National Bowel Cancer Screening Program concluded in 2010, and plans for further government funding remain uncertain. FOBT kits (for a fee) may be obtained through The Cancer Council and some GPs and pharmacies.80,81 Sigmoidoscopy (preferably flexible) every 5 years from the age of 50 years76 or colonoscopy every 10 years79 may be alternatives to second yearly FOBT. GPs can also refer patients for examination of faecal specimens for occult blood under Medicare Benefits Schedule (Items 66764, 66767 and 66770).

There is ongoing debate about the benefits of using aspirin for prevention of adenomas and colorectal cancers.76,82-87 For people with previous adenomas who are at higher risk of colorectal cancer, benefits of reduction in recurrent adenoma and colorectal cancer may outweigh the risks of harm.76,84,88

Recommendations: Colorectal cancer prevention and detection
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All people Ask about family history of colorectal cancer (see Table 15.3) in order to estimate the individual risk of developing colorectal cancer As part of an annual health assessment GPP76
People at or slightly above average risk age 50+ years (category 1: Table 15.3) Consider faecal occult blood test (FOBT)* and refer all abnormal results for appropriate diagnostic evaluation Every 2 years from age 50-75 years, and could be continued beyond 75 years depending on individual circumstances* IA76-79
People at moderate risk (category 2: Table 15.3) Consider referral for colonoscopy
(Flexible sigmoidoscopy and double contrast barium enema or CT colonography may be offered if colonoscopy is contraindicated)
Every 5 years starting at age 50 years, or at an age 10 years younger than the age of first diagnosis of bowel cancer in the family, whichever comes first IIIC76
Those at potentially high risk (category 3: Table 15.3) Consider referral to a specialist service for further risk assessment and possible genetic testing, and to a bowel cancer specialist to plan appropriate surveillance
(See Resources for specific recommendations for screening for those with FAP or HNPCC)**
At the time of determining the individual is at high risk
Offer referral later if not done at initial assessment
IIIC
Past history of adenoma Undertake surveillance colonoscopy Timeframe for surveillance colonoscopy varies
(see Resources)
IA76
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, avoidance of tobacco smoking, restricting energy intake and dietary fat (see Chapter 1: Lifestyle)
Also recommend consuming only moderate amounts of red meat, minimising consumption of charred and processed meats, and consuming vegetables and dietary fibre as these foods may be protective
As part of an annual health assessment IIIC1,38,65,66,76
Chemoprophylaxis Following complete removal of adenoma at colonoscopy Consider prophylactic aspirin use (in consultation with a specialist) At time of diagnosis with colorectal adenoma IIC76,84,88
*  Free, one-off FOBTs are offered to people turning 50, 55 or 65 years between January 2011 and December 2014. GPs can also refer patients for examination of faecal specimens for occult blood under Medicare Benefits Schedule (Items 66764, 66767 and 66770)
** Familial adenomatous polyosis (FAP); hereditary non-polyosis colorectal cancer (HNPCC)

Resources

Guidelines for the prevention, early detection and management of colorectal cancer used to determine a person’s risk of colorectal cancer based on family history
www.nhmrc.gov.au/ publications/synopses/cp106/ cp106syn.htm or summary at www.cancer.org.au/ file/HealthProfessionals/Clinicalpracticeguidelines July2008.pdf

Familial aspects of bowel cancer: a guide for health professionals
www.health.gov.au/ internet/screening/publishing.nsf/Content/1F35A75DC194E 59CCA2574EB007F7532/$File/familial-guide.pdf.

References

  1. Vos T, Barker B, Stanley L, Lopez AD. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, The University of Queensland, 2007.
  2. Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. Lancet Oncology 2008;9(6):585-95.
  3. Australian Bureau of Statistics & Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2008, ABS cat no. 4704.0. Canberra: ABS, 2008. Cited October 2011. Available at www.aihw.gov.au/publications/index.cfm/title/10583.
  4. Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview,2010. Cat. no. CAN 56. Canberra: AIHW,2010 cited 2011 October 10. Available at www.aihw.gov.au/publications/can/ca08/ca08.pdf.
  5. Australian Institute of Health and Welfare & Department of Health and Ageing. National Bowel Cancer Screening Program: Annual monitoring report 2009, cat. no. CAN 45. Canberra: AIHW, 2009. Cited October 2011. Available at www.aihw.gov.au/publications/can/can-45-10752/can-45-10752.pdf.
  6. Bowel Cancer Screening Pilot Monitoring and Evaluation Steering Committee. The Australian Bowel Cancer Screening Pilot Program and beyond: final evaluation report. Canberra: Department of Health and Ageing, 2005. Cited October 2011. Available at www.health.gov.au/internet/screening/publishing.nsf/Content/2DDFA95B20302107CA2574EB007F7408/$File/final-eval.pdf.
  7. Christou A, Katzenellenbogen JM, Thompson SC. Australia’s national bowel cancer screening program: does it work for indigenous Australians? BMC Public Health 2010;10:373.
  8. Christou A, Thompson SC. How could the National Bowel Cancer Screening Program for Aboriginal people in Western Australia be improved? Report to the WA Bowel Cancer Screening Implementation Committee, Department of Health, Western Australia, 2010. Cited October 2011. Available at www.healthnetworks.health.wa.gov.au/cancer/docs/Aboriginal_Bowel_Cancer_Final_Report.pdf.
  9. Australian Cancer Network Colorectal Cancer Guidelines Revision Committee. Guidelines for the prevention, early detection and management of colorectal cancer, 2005. Cited October 2011. Available at www.nhmrc.gov.au/publications/synopses/cp106/cp106syn.htm.
  10. Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev 2007;Jan 24;(1):CD001216.
  11. Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, Ballegooijen Mv, Kuntz KM. Evaluating test strategies for colorectal cancer screening: a decision analysis for the US preventive services task force. Ann Intern Med 2008;149:659-69.
  12. US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149(9):627-37.
  13. Department of Health and Ageing. National Bowel Cancer Screening Program: about the program. Canberra: Commonwealth of Australia, 2009. Cited October 2011. Available at www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-about.
  14. Cancer Council Victoria. Faecal occult blood tests. Melbourne: Cancer Council Victoria, 2010. Cited October 2011. Available at www.cancervic.org.au/preventing-cancer/attend-screening/bowel_cancer_screening/faecal_occult_blood_tests.
  15. US Preventive Services Task Force. Routine aspirin or nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2007;146:361-4.
  16. Rostom A, Dubé C, Lewin G, et al. Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors for primary prevention of colorectal cancer: a systematic review prepared for the US Preventive Services Task Force. Ann Intern Med 2007;146(5):376-89.
  17. Dubé C, Rostom A, Lewin G, et al. The use of aspirin for primary prevention of colorectal cancer: a systematic review prepared for the US Preventive Services Task Force. Ann Intern Med 2007;146(5):365-75.
  18. Asano TK, McLeod RS. Non steroidal anti-inflammatory drugs (NSAID) and aspirin for preventing colorectal adenomas and carcinomas. Cochrane Database Syst Rev 2004(2):CD004079.
  19. Rothwell PM, Wilson M, Elwin C-E, et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Lancet 2010;376(9754):1741-50.
  20. Cuzick J, Otto F, Baron JA, et al. Aspirin and non-steroidal anti-inflammatory drugs for cancer prevention: an international consensus statement. Lancet Oncology 2009;10(5):501-7.
  21. Cole BF, Logan RF, Halabi S, Benamouzig R, Sandler RS, Grainge MJ, et al. Aspirin for the chemoprevention of colorectal adenomas: meta-analysis of the randomized trials. J Natl Cancer Inst 2009 February 18,2009;101(4):256-66.
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