Dr Guy Hingston ( left ) Specialist breast reduction surgeon ( breastreduction . com . au ) and colonoscopist ( drguyhingston . com ) with a special interest in colorectal cancer prevention , Mackay Specialist Day Hospital , Mackay , Queensland .

Dr John Goldston ( right ) GP , North Mackay ; adjunct senior clinical lecturer , James Cook University Medical School , Queensland .

First published online on 28 February 2025

INTRODUCTION

LIKE many GP and non-GP specialist

colleagues , when the primary author turned 50 , he requested a screening colonoscopy ( that turned out to include a polypectomy ). Therefore , should we not as a medical profession follow the ‘ do unto others ’ rule and recommend screening colonoscopy to our patients ? And if so , why ?

To avoid ( rightly ) being called hypocrites for recommending one form of colorectal cancer screening to our patients ( national FOBT screening ), but adopting another form of colorectal cancer screening for ourselves ( screening colonoscopy ), we need to review the science , culture and logistics of colorectal cancer screening using colonoscopy as a primary modality , while still supporting the National Bowel Cancer ( FOBT ) Screening Program ( see figure 1 ), and ask ourselves the important question : When is a screening colonoscopy indicated ?

Asymptomatic patients developing colorectal cancer present a

unique challenge in general practice , as their condition may not be detected until it has reached an advanced stage . In addition , routine screening for colorectal cancer is often not emphasised for asymptomatic individuals , leading to missed opportunities for early detection . Further , many Australians consider that because they don ’ t have any symptoms , they are therefore healthy — adopting a mistaken ‘ She ’ ll be right , mate ’ attitude .

Unfortunately , many people find the thought of colorectal cancer screening offensive , or worse , they simply prefer not to know . Thus , colorectal cancer is often diagnosed at an advanced stage because of its truly occult ( hidden ) nature , its lack of symptoms ( and / or subtle symptoms ) in the early stages , and the unwillingness of far too many Australians to undergo screening for the disease .

Compounding the issue of colorectal cancer screening is the concern in the medical community regarding

both the increasing incidence of asymptomatic colorectal cancer and the growing incidence of colorectal cancer in patients younger than 45 . 1 When it occurs in younger patients , it is often more aggressive and has a poorer prognosis . 2 The lack of wider community awareness about colorectal cancer occurring in younger individuals , and the misconception that the condition only affects older patients , also contributes to the delayed diagnosis and treatment in this population .

This How to Treat discusses screening colonoscopy . It aims to ensure GPs are up to date with the latest international research , as well as with the recommendations of leading Australian national stakeholders , funding and availability of screening colonoscopy .

COLORECTAL CANCER MORTALITY

IN 2021 , colorectal cancer ( see figure 2 )

was the second most common cause of cancer death in Australia ( see

figure 3 ). In 2021 , there were 5350 deaths from colorectal cancer in Australia ( 2838 males and 2512 females ). When 2023 figures are released , it is estimated there will be 5307 deaths ( 2810 males and 2497 females ). 3 Around 80 % of these patients have no family history of colorectal cancer .

The large Nordic-European Initiative on Colorectal Cancer trial ( NordICC trial ; see later ) reported 10 years of follow-up in 2022 . This important study found a 50 % reduction in colorectal cancer mortality in the screening colonoscopy group at 10 years . 4 , 5

The large UK Flexible Sigmoidoscopy Screening Trial ( UKFSST ; see later ) reported 17 years of follow-up in 2017 . This study revealed a 66 % reduction in left-sided colorectal cancer mortality in the screening flexible sigmoidoscopy group . 6

The authors argue that this Level 1A evidence should now be changing the advice we give patients on which primary colorectal cancer