Bowel Cancer Screening Program

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 7/8

Abstract

We previously reported on the establishment of a bowel cancer screening pilot program. Since then the Federal Government has announced that it will phase in a national program with the ultimate aim that by 2008 every Australian will be screened for bowel cancer every two years. The final report of the Bowel Cancer Screening Pilot Program was published in October 2005. It showed favourable outcomes in terms of each of the key research objectives: feasibility, acceptability and cost-effectiveness.

Recent developments

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

The results of the pilot show that a national bowel cancer screening program is feasible, acceptable and cost-effective.  There will be a significant challenge in raising participation rates and delivering the program in the immediate future. This is why it is sensible for the program to be phased in over a number of years.  Another key challenge, and one that has been given some media attention- is the issue around ensuring equitable access to high quality colonoscopy. 

It is highly likely that there will be a considerable increase in the demand for colonoscopy services following the implementation of a national bowel cancer screening program.  Currently, there is only limited capacity in the public sector for further colonoscopy services - and the cost of private colonoscopy can be high, especially for 55% of the population who are not privately insured.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Civil Society

Stakeholder positions

The final report of the Bowel Cancer Screening Pilot Program was published in October 2005.  It showed favourable outcomes in terms of each of the key research objectives: feasibility, acceptability and cost-effectiveness (a summary of the results will be reported later in this survey). During the 2004 election campaign (and 12 months prior to the publication of the pilot program report), the federal government announced that it would invest AUD 25.5 million over four years on a national bowel cancer screening program.  This election announcement became, in effect, the policy paper.

The government's announcement was publicly welcomed by the Australian Cancer Council and the Clinical Oncological Society of Australia.  The Cancer Council of Australia is a national non-government cancer control organisation.  The Council acts nationally to advise government and other bodies on appropriate practice and policies for the prevention, detection and treatment of cancer and is an advocate for the rights of cancer patients to best treatment and supportive care.

Actors and positions

Government
Prime minister and cabinet	very supportive		strongly opposed
Civil Society
Cancer council of Australia	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

Thus far this policy has required little legislative change, and therefore the input from the legislature has been limited. The implementation of a national bowel screening program was announced one year prior to the publication of the final pilot evaluation report.  Therefore it is difficult to make definitive conclusions about whether the evaluation had any significant influences on the design of the policy - noting that large aspects of the policy still need to be developed.  There are however two main policy differences between the Government's election announcement and the final evaluation report.  These were:

• The Government has stated that it wants to phase-in a program covering everybody over the age of 55.  The evaluation report recommends an upper age limit of 75 in the first instance.  It further recommends an evaluation of this policy to see whether there should be an upper age limit.
• The Government announced that for people from an Aboriginal and Torres Strait Islander background, the policy would be phased in for everybody over the age of 45.  The evaluation report makes a number of statements about providing greater access and information to people from an ATSI background but does not refer to a lower age range.

Legislative outcome

n/a

Actors and influence

Government
Prime minister and cabinet	very strong		none
Civil Society
Cancer council of Australia	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

The Government committed itself to a national roll-out of a bowel cancer screening program in 2004 but many aspects of the implementation phase are yet to be fully developed.  It has allocated AUD 43.4 million over three years for the program The program will be phased in over three years, commencing in mid 2006. Initially screening utilising Faecal Occult Blood Tests (FOBTs) will be offered to Australians turning 55 or 65 years of age.  People participating in the program will be invited to complete a simple test in the privacy of their own home and mail it in for analysis.  Participants with a positive result will be referred by their GP for further tests, usually a colonoscopy.

The program has received overall support. General practitioners involved in the pilot study have been supportive, as have important advocacy groups such as the Cancer Council of Australia.  However, the pilot study achieved a participation rate of 45.4%.  This results was lower amongst certain population groups, in particular people with an Aboriginal and Torres Strait Islander background.

Issues around participation and follow-up have been identified as key issue for the program.

Monitoring and evaluation

The Australian Department of Health and Ageing reports that "an evaluation of the national bowel cancer screening program will be completed prior to the 2008 Budget with the aim of extending bowel cancer screening, if successful on clinical grounds, to all Australians over 55 and Indigenous Australians over 45 years of age".

It is interesting to note that the decision to expand the program will be based solely on clinical grounds - excluding economic considerations.

Expected outcome

The final report of the pilot bowel cancer screening program showed:

• 45% of eligible people returned an Faecal Occult Blood Tests (FOBT);
• Of those, 8% returned a positive result;
• Of those, 55% had a colonoscopy;
• Of those, 19% had advanced adenomas or suspected cancer; and 
• The cost-effectiveness analysis showed that for a target population of 55-74 years the estimated cost per life year saved was AUD 24,000. The incremental CEA ratio for a target population of 50 to 74 was AUD 20,000.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

This policy will have a significant impact on the early detection of bowel cancer; one of Australia's biggest cancer killers.  The roll out of a national program will ensure greater equity of access but the key challenge will be to ensure higher participation rates than those achieved in the pilot programs, and ensuring that down-stream issues such as the availability of high quality colonoscopy do not impose high barriers of access in the program's follow-up procedures.

References

Sources of Information

For information about the National Bowel Cancer screening program visit:

www.cancerscreening.gov.au/bowel/bcaust/program.htm

For the final evaluation report visit:

www.cancerscreening.gov.au/bowel/pdfs/eval_oct05.pdf

For the Government's election announcement visit:

www.liberal.org.au/2004_policy/ACF3C25.pdf

For the Cancer Council of Australia and Clinical Oncological Society of Australia media notice visit:

www.cancer.org.au/documents/4OCT04_Coalition_cancer_plan_CC_response.pdf

Reform formerly reported in

Bowel Cancer Screening Pilot Process Stages: Evaluation, Idea, Pilot

Author/s and/or contributors to this survey

Kees van Gool

Suggested citation for this online article

Kees van Gool. "Bowel Cancer Screening Program". Health Policy Monitor, April 2006. Available at http://www.hpm.org/survey/au/a7/2