Bowel and cervical screening effective, but participation rates need to improve

Amanda Lyons

8/05/2018 3:38:21 PM

New research shows that the national bowel cancer and cervical cancer screening programs are proving effective, but participation rates are not as high as they could be.

GPs can help to boost cervical and bowel screening rates by identifying and encouraging people to participate in general practice.
GPs can help to boost cervical and bowel screening rates by identifying and encouraging people to participate in general practice.

The Australian Institute of Health and Wellbeing (AIHW) released two reports earlier this week investigating the outcomes and effectiveness of the national cervical cancer and bowel cancer screening programs.
Both programs have proven effective.
Since the National Cervical Screening Program (cervical screening) began in 1991, incidence of cervical cancer has fallen from 17 to 10 new cases per 100,000 women aged 20–69, while mortality has fallen from four to two deaths per 100,000 women aged 20–69.
The National Bowel Cancer Screening Program (bowel screening), active since 2006, has helped to raise the rates of early detection and prevention, thereby reduced morbidity and mortality from bowel cancer in Australia.
However, both programs have issues regarding participation rates.

The cervical screening rate has been slowly declining over time – two-yearly participation has decreased from 60% in 2006–07 to 56% in 2015–16; while the bowel screening participation rate stood at a low 41% in 2015–16, although this number actually represents a slight increase over time.
According to public health physician Associate Professor Julia Brotherton, GPs can help boost the declining participation rate for cervical screening by identifying women in their practice who may need encouragement to participate.
‘The biggest current risk factor for cervical cancer in Australia is never having been screened or being under-screened, so there is a big opportunity here to prevent cancer by engaging more women in screening,’ she told newsGP.
However, Associate Professor Brotherton also believes the introduction of the human papillomavirus (HPV) vaccination program and, subsequently, the new five-yearly cervical screening program presents good news in the face of declining Pap smear rates.
‘Fortunately, our new program only requires women to screen five years if they have a negative test, as the HPV-based cervical screening test has a greater negative predictive value than the Pap test. That means your risk of underlying high-grade disease is lower five years after a negative HPV test than it was two years after a negative Pap test,’ she said.
The new program also offers a way to engage women who have been traditionally hard to reach.
‘GPs can now offer eligible women the option of taking their own vaginal HPV test as part of the organised screening program,’ GP and cervical screening expert Dr Lara Roeske told newsGP.
‘For GPs and for women this is a welcome strategy that aims to improve screening participation and assist with overcoming the barriers some women experience to having a clinician-collected cervical sample.
‘For example, Aboriginal and Torres Strait Islander women, women from culturally and linguistically diverse backgrounds, rural or remote regions and experiencing socioeconomic disadvantage are over-represented among the under-screened.
‘High rates of adherence to follow-up have been reported in women with a positive HPV test result from a self-collected sample.’
The bowel screening program relies entirely on self-sampling, with faecal occult blood testing (FOBT) kits sent to potential screening participants in the mail. Despite this, participation remains relatively low, which can seem frustrating, as the screening program has been shown to be very effective.
‘There’s evidence of this not only from previous trials, but also from monitoring of the national program,’ Professor Jon Emery, GP and Herman Professor of Primary Care Cancer Research at the University of Melbourne and Western Health, told newsGP.
‘Patients that have screened are more likely to have bowel cancers detected early, and research is already beginning to show evidence that there are improvements in survival through that earlier detection.’
Professor Emery believes there are many reasons bowel cancer screening rates remain relatively low, from the test being difficult to schedule into busy lives to the ‘yuck factor’ people feel about sampling their own waste. However, he believes that GPs are vital in helping to boost the numbers and can use a variety of strategies to do so.
‘We know that if a GP endorses the FOBT kit, patients are more likely to undertake screening,’ Professor Emery said. ‘There are various ways that practices can potentially support the program.
‘Because the invitation is linked to birthdate, practices can systematically identify patients who are about to receive an invitation, particularly those who are going to be invited new into the program. If the practice sends a letter saying, “You’re going to be receiving a bowel cancer kit in a few weeks, this is something we recommend,” patients are actually more likely to do the kit. There are letters available for that purpose through the national program.
‘And then just opportunistically mentioning it to patients if they are in the right age group when they come in, checking they’re up to date with their bowel screening.’
Although overall bowel screening uptake rates are currently low, the AIHW report contained very encouraging figures on rates of re-participation.
‘If you can get patients to do the first test, their participation rate is 77% when they get invited again,’ Professor Emery said. ‘So once they’re over the hurdle of the first test, they’re more likely to stay in the program.’
While measures such as sending letters and reminding patients in consultation require some systematic effort, Professor Emery believes it is worth it.
‘At the moment, nearly half of all bowel cancers are diagnosed at a later stage when the prognosis is much worse, and the bowel screening program could dramatically shift that,’ he said.

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