38 HOW TO TREAT : SCREENING COLONOSCOPY HALVES COLORECTAL CANCER MORTALITY
38 HOW TO TREAT : SCREENING COLONOSCOPY HALVES COLORECTAL CANCER MORTALITY
14 MARCH 2025 ausdoc . com . au
Box 2 . The Medical Board of Australia 2020 Good Medical Practice
• 3.2.6 Providing treatment options based on the best available information .
• 3.2.7 Only recommending treatments when there is an identified therapeutic need and / or a clinically recognised treatment , and a reasonable expectation of clinical efficacy and benefit for the patient .
Source : The Medical Board of Australia
2020 14
Box 3 . Australian stakeholders involved in colonoscopic polypectomy
• Australian College of Rural and Remote Medicine ( ACRRMaccredited colonoscopists ).
• Australian College of Nurse Practitioners .
• Australian Commission on Safety and Quality in Health Care .
• Australian Federal Department of Health & Ageing .
• Bowel Cancer Australia .
• Cancer Council Australia — with endorsement from the National Health & Medical Research Council ( NHMRC ).
• Conjoint Committee of GESA and RACS .
• Gastroenterological Society of Australia ( GESA ).
• Medicare Benefits Schedule ( MBS ).
• National Health and Medical Research Council ( NHMRC ).
• RACGP ( particularly the RACGP Red Book ).
• Royal Australasian College of Surgeons ( RACS ).
• Safer Care Victoria ( SCV ).
• State government departments of health .
PAGE 36 we as a profession now have an ethical responsibility , per clause 3.2.6 of the code , to provide patients with the risks and benefits of various individual colorectal cancer screening programs . This should allow patients to decide whether or not they should proceed with screening colonoscopy .
It is important to note that a oneoff colonoscopy with polyp ectomy for a person aged 50 could result in an addition of 20-40 years of life for that individual patient by preventing the development of colorectal cancer . Thus , the ethical “ reasonable expectation of clinical efficacy and benefit for the patient ” ( clause 3.2.7 of the code ) is another reason why GPs could consider recommending colorectal cancer screening with colonoscopy .
THE AUSTRALIAN STAKEHOLDERS
THERE are multiple Australian stakeholders involved , in some way or other , with providing colonoscopy and colonoscopic polyp ectomy . Together , these stakeholders all aim to provide , promote and enhance the quality and safety of colonoscopy across Australia ( see box 3 ). Most colonoscopies in Australia ( see figure 6 ) are currently performed by general surgeons and gastroenterologists , but it is noted that nurse endoscopists represent the largest potential numerical growth entity in Australian colonoscopists over coming years . 15-17
National Health and Medical Research Council and Cancer Council Australia
The Clinical Practice Guidelines for Surveillance ( not screening ) Colonoscopy recommendations were approved by the chief executive officer of the National Health and Medical Research Council ( NHMRC ) in October 2017 . 18 Further , clinical practice guidelines for population screening of colorectal cancer were published by Cancer Council Australia in November 2023 . 19 These updated guidelines provide the latest Australian Government-endorsed evidence-based advice on population screening and risk , and screening based on family history .
Appendix E of this November 2023 publication looks specifically at the various colorectal cancer screening tests and assesses their effectiveness in reducing colorectal cancer mortality rates , feasibility , acceptability and cost-effectiveness . They state that “ The studies reviewed concluded no clear preference for a specific CRC screening test . However , there was evidence of a slight preference for colonoscopy because of the high accuracy and reliability , followed by iFOBT [ immunochemical faecal occult blood test ], because of the ease , convenience , and lower cost and lastly flexible sigmoidoscopy because of the accuracy .” 19
In March 2024 , Cancer Council Australia published three colorectal cancer risk categories in its Clinical Practice Guidelines for the Prevention , Early Detection and Management of Colorectal Cancer : Risk and Screening Based on Family History . 19 These categories appear in box 4 .
In the same document , Cancer Council Australia also made recommendations regarding colorectal cancer screening for these individuals ( see box 5 ). 19
Thus , Cancer Council Australia currently recommends that patients with Category 2 risk should be offered five-yearly screening colonoscopy starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first-degree relative , or age 50 ( whichever is earlier ) up to age 74 . And for patients with Category 3 risk , Cancer Council Australia again recommends five-yearly screening colonoscopy starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first-degree relative , or age 40 ( whichever is earlier ) up to age 74 . However , Cancer Council Australia stopped short of recommending screening colonoscopy as a primary modality in Category 1 patients .
The authors disagree with this stance taken by Cancer Council Australia , as the international prospective Level 1A data discussed earlier now points to the 50-66 % colorectal cancer mortality reduction in large randomised controlled populations versus only 16 % colorectal cancer mortality reduction in FOBT . 4-6 Thus , the authors ’ view is that Category 1 patients should also be given the opportunity of undergoing a potentially PAGE 40
Figure 3 . Estimated cancer mortality in Australia in 2022 .
A
Source : Australian Government Cancer Australia 3
Figure 4 . CT colonography of a rectal mass to differentiate between stool and colonic neoplasia by dual-energy CT in an 88-year-old male .
A . Volume rendering . B . Thin slice . It also shows the rectal tube used for insufflation of gas to distend the colon .
Dual-energy contrast-enhanced CT ( axial plane ) revealed no enhancement of mass , iodine value = −1.4 mg / mL ( white arrow ), suggesting no blood supply to the mass , which was validated as stool by colonography .
Figure 5 . Polypectomy and scar .
Figure 6 . Colonoscopy being performed .
B
File : CT colonography of a rectal mass . jpg CC - Wikimedia BY-SA / bit . ly Commons / 41l5mKL