9.2 Colorectal cancer
Please note that Section 9.2 was updated in August 2018
Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80
Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80
Biennial faecal occult blood test (FOBT) can reduce colorectal cancer (CRC) mortality by 16%.17 The original trials of FOBT screening used the guaiac-based FOBT, but this has been superseded by the more sensitive and specific faecal immunochemical test (ie iFOBT). Organised screening by iFOBT is recommended for the asymptomatic (average risk) population from 50 years of age every two years (A) until 74 years of age with repeated negative findings.18,19
In November 2017, the National Health and Medical Research Council (NHMRC) endorsed a new national guideline on CRC prevention and screening. Screening recommendations, which used to be determined solely on lifetime risk of CRC, now also account for absolute risk of cancer in the short term.109 Risk assessment should include determining the number and type of relatives affected by CRC, and age at diagnosis (refer to Table 9.2.1. Colorectal cancer: Identifying risk). The new guideline also changed the recommendations on CRC screening modality in people at moderate risk of CRC. Of note, iFOBT is now recommended for people in this group from 40 to 49 years of age and colonoscopy five-yearly from 50 to 74 years of age. Digital rectal examination (DRE) is not recommended as a screening tool (D), but is important in evaluating patients who present with symptoms (eg rectal bleeding).
Colonoscopy is not recommended as a screening test for people at average risk of CRC. No randomised controlled trial (RCT) has evaluated the effect of colonoscopy on CRC mortality, although trials are in progress in Spain, Sweden and the US. Colonoscopy has indirect and direct harms, including, rarely, death from the procedure (one in 10,000–14,000 colonoscopies).20, 21 Harm may be caused by the bowel cleanout prior to the procedure (eg dehydration, electrolyte imbalances), sedation used during the procedure (eg cardiovascular events), or the procedure itself (eg infection, colonic perforations, bleeding). There is insufficient evidence about the use of computed tomography (CT) colonography (also refer to Chapter 15. Screening tests of unproven benefit), faecal deoxyribonucleic acid (DNA) or plasma circulating DNA tests to recommend them as alternatives to iFOBT for CRC screening.22
The 2017 NHMRC-endorsed guideline also examined an updated systematic review of trial evidence on the effects of low-dose aspirin on CRC incidence and mortality. The guideline development group considered evidence relating to the additional benefits from reduction in cardiovascular disease risk and potential adverse effects (ie haemorrhagic stroke, gastrointestinal bleeding, peptic ulcer).109 Overall, it was found that the benefits of taking low-dose aspirin outweighed the harms, and the guideline recommends that aspirin should be actively considered in all people aged 50–74 years.
Patients who have adenomatous polyps removed at colonoscopy are then classified as having above-average risk for the development of metachronous adenomatous polyps and CRC. Table 9.2.2 provides advice about colonoscopic surveillance and recommended frequency based on the number and histology of polyps. It is important to try to obtain information about the histology, size and number of polyps removed, as this determines the future risk of adenomas and CRC and, therefore, frequency of recommended surveillance colonoscopy.30
Measures to increase screening in these groups include organised approaches such as employing recall and reminder systems;32,33 recommendations by the GP for the screening;33,34 addressing capacity issues, including convenience;33,35 and minimising barriers such as cost.33,35,36 Refer to the RACGP’s Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting (Green Book).
The National Bowel Cancer Screening Program, using iFOBT, is being expanded, and by 2020 will offer biennial screening for people aged 50–74 years. GPs are critical, not just in maximising participation but in managing participants with a positive iFOBT.34,37
Participation is under-represented by Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse (CALD) peoples.38
- Hewitson P, Glasziou PP, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev 2007;1:CD001216.
- Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J. Evaluating test strategies for colorectal cancer screening-age to begin, age to stop, and timing of screening intervals: A decision analysis of colorectal cancer screening for the US Preventive Services Task Force from the Cancer Intervention and Surveillance Modeling Network (CISNET). Rockville, MD: Agency for Healthcare Research and Quality, 2009. Search PubMed
- Australian Cancer Network Colorectal Cancer Guidelines Revision Committee. Guidelines for the prevention, early detection and management of colorectal cancer. Sydney: Cancer Council Australia and Australian Cancer Network, 2005. Search PubMed
- Viiala CH, Zimmerman M, Cullen DJ, Hoffman NE. Complication rates of colonoscopy in an Australian teaching hospital environment. Intern Med J 2003;33(8):355–59. Search PubMed
- Rabeneck L, Paszat LF, Hilsden RJl. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008;135(6):1899–906, 906 e1. Search PubMed
- US Preventive Services Task Force. Draft Recommendation Statement – Colorectal Cancer: Screening. 2015. Available at uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement38/colorectal-cancer-screening2#citation10[Accessed 15 October 2015].
- Cooper K, Squires H, Carroll C, et al. Chemoprevention of colorectal cancer: Systematic review and economic evaluation. Health Technol Assess 2010;14(32):1–206. Search PubMed
- National Cancer Institute. Colorectal cancer screening (PDQ®) – Health Professional Version. US National Institutes of Health, 2012. Available at cancer.gov/cancertopics/pdq/screening/colorectal/HealthProfessional/page4 [Accessed 2015 October].
- Australian Cancer Network. Familial aspects of bowel cancer: A guide for health professionals. Canberra: National Health and Medical Research Council, 2002. Search PubMed
- National Cancer Institute. Genetics of colorectal cancer (PDQ®) – Health Professional Version. US National Institutes of Health, 2012. Available at cancer.gov/cancertopics/pdq/genetics/colorectal/HealthProfessional/page1 [Accessed 15 October 2015].
- Burn J, Gerdes AM, Macrae F, et al. Long-term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: An analysis from the CAPP2 randomised controlled trial. Lancet 2011;378(9809):2081–87.
- Rothwell PM, Fowkes PG, Belch JP, Ogawa H, Warlow CP, Meade TW. Effect of daily aspirin on long term risk of death due to cancer – Analysis of individual patient data from randomised trials. Lancet 2011;377(9759):31–41. Search PubMed
- Rothwell PM, Wilson M, Elwin CE, et al. Long term effect of aspirin on colorectal cancer incidence and mortality: 20 year follow up of 5 randomized controlled trials. Lancet 2010;376(9754):1741–50.Search PubMed
- Cancer Council Australia Colonoscopy Surveillance Working Party. Clinical practice guidelines for surveillance colonoscopy – In adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Sydney: Cancer Council Australia, 2011.Search PubMed
- van Dam L, Kuipers EJ, van Leerdama ME. Performance improvements of stool-based screening tests. Best Pract Res Clin Gastroenterol 2010;24(4):479–92. Search PubMed
- Holden DJ, Jonas DE, Porterfield DS, Reuland D, Harris R. Systematic review: Enhancing the use and quality of colorectal cancer screening. Ann Intern Med 2010;152(10):668–76.Search PubMed
- Steinwachs D, Allen JD, Barlow WE, et al. National Institutes of Health state-of-the-science conference statement: Enhancing use and quality of colorectal cancer screening. Ann Intern Med 2010;152(10):663–67.Search PubMed
- Pignone MP, Flitcroft KL, Howard K, Trevena LJ, Salkeld GP, St John DJB. Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for bowel cancer in Australia. Med J Aust 2011;194(4):180–85.Search PubMed
- Zapka J, Taplin SH, Anhang Price R, Cranos C, Yabroff R. Factors in quality care – The case of follow-up to abnormal cancer screening tests – Problems in the steps and interfaces of care. J Natl Cancer Inst Monogr 2010;2010(40):58–71.Search PubMed
- Senore C, Malila N, Minozzi S, Armarolia P. How to enhance physician and public acceptance and utilisation of colon cancer screening recommendations. Best Pract Res Clin Gastroenterol 2010;24(4):509–20.Search PubMed
- Department of Health and Ageing. National Bowel Cancer Screening Program: About bowel screening. Canberra: DoHA, 2012. Available at cancerscreening.gov.au/internet/screening/publishing.nsf/Content/about-bowel-screening [Accessed 15 October 2015].
- Weber MF, Banks E, Smith DP, O’Connell D, Sitas F. Cancer screening among migrants in an Australian cohort; cross-sectional analyses from the 45 and Up Study. BMC Public Health 2009;9:144. doi: 10.1186/1471-2458-9-144.Search PubMed
- Hanrahan P, D’Este CA, Menzies SW, Plummer T, Hersey P. A randomised trial of skin photography as an aid to screening skin lesions in older males. J Med Screening 2002;9(3):128–32.Search PubMed
- Cancer Council Australia Colorectal Cancer Guidelines Working Party. Cancer Guidelines Wiki: Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Sydney: Cancer Council Australia, 2017. Available at http://wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer [Accessed 19 June 2018].