HOW TO TREAT 41 public outpatient consultation , allowing direct booking to colonoscopy . This frees up clinic time for patients with more complex issues , allowing minimal delays for those requiring a screening colonoscopy . Open access colonoscopy clinics also provide a team of focused , dedicated individuals tasked to provide efficient and effective colonoscopy services . For example , patients can undergo a more thorough informed consent process as they interact with the administration , pre-op nursing and colonoscopists each step of the way .
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HOW TO TREAT 41 public outpatient consultation , allowing direct booking to colonoscopy . This frees up clinic time for patients with more complex issues , allowing minimal delays for those requiring a screening colonoscopy . Open access colonoscopy clinics also provide a team of focused , dedicated individuals tasked to provide efficient and effective colonoscopy services . For example , patients can undergo a more thorough informed consent process as they interact with the administration , pre-op nursing and colonoscopists each step of the way .
The authors reasonably consider that many more of these clinics should be set up , and that these should be directly federally funded , using BreastScreen infrastructure and clinics as a model , using appropriately trained and audited nurse and doctor colonoscopists . These envisaged federal screening colonoscopy clinics should be rolled out across Australia using doctor and nurse colonoscopists to provide the required level of service .
As stated above , the Level 1A evidence ( which confirms a greater than 50 % colorectal cancer mortality reduction ) now dictates that we head towards an extended delivery of screening colonoscopy far more widely across our Australian population . Hence , the GP has a key role in educating patients so that , in turn , the required political willpower will follow with further funding in this important preventive health area of colorectal cancer prevention .
SUMMARY
THE list of those now eligible for MBS-funded screening colonoscopy appears in box 6 .
CASE STUDIES
Case study one
GRACE , aged 50 and asymptomatic , seeks her GP ’ s advice on preventive health screening . She has never had a colonoscopy before , but because of the GP ’ s experience of seeing several asymptomatic patients present with bowel cancer , and together with the GP ’ s new knowledge regarding the international studies showing a 50 % reduction in colorectal cancer mortality with screening colonoscopy , her GP refers Grace for a screening colonoscopy , hoping that the colonoscopist will use the 32228 item number , as in the GP ’ s opinion there is a clinical need for a colonoscopy .
A significant tubular adenoma with low grade dysplasia is subsequently found and removed from Grace ’ s caecum , and she is placed on a five-year recall for a repeat colonoscopy .
Normal
Repeat colonoscopy every five years until 74
• Screening colonoscopy should be offered to family history moderate-risk patients every five years 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 , to age 74 , using MBS item number 32223 :
— A patient with one first-degree relative diagnosed with colorectal cancer younger than 55 . — Two first-degree relatives of any age diagnosed with colorectal cancer . — One first-degree relative and two second-degree relatives of any age diagnosed with colorectal cancer .
Figure 9 . MBS 32223 Moderate Risk Five Yearly Screening Colonoscopy Pathway .
Normal
Repeat colonoscopy every year until 74
MBS 32223 Moderate Risk Five Yearly Screening Colonoscopy Pathway
Age 10 years younger than earliest age of diagnosis of colorectal cancer in a first-degree relative or age 50 ( whichever is earlier )
Screening colonoscopy
Polyp ( s )
Polypectomy then repeat colonoscopy in time interval ( 1 , 3 or 5 years ) depending on number and type of polyps
MBS 32226 High Risk Yearly Screening Colonoscopy Pathway
Age 10 years younger than earliest age of diagnosis of colorectal cancer in a first-degree relative or age 40 ( whichever is earlier )
Screening colonoscopy
Polyp ( s )
Polypectomy
Abnormal
Colorectal cancer
Treatment
Abnormal
Colorectal cancer
Treatment
• Screening colonoscopy should be offered to family history high-risk patients every year 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 , to age 74 , using MBS item number 32226 :
— Anyone with a high risk because of their family history ( MBS 32226 ), who has a known or suspected familial condition , such as familial adenomatous polyposis , Lynch syndrome or serrated polyposis syndrome ; or a genetic mutation associated with hereditary colorectal cancer .
Figure 10 . MBS 32226 High Risk Yearly Screening Colonoscopy Pathway .
Box 5 . Cancer Council Australia colorectal cancer screening recommendations based on individual risk category
• For people assessed as having category 1 risk of colorectal cancer [ Practice Point 15 ]: — iFOBT screening should be performed in line with population screening every two years from age 45 to age 74 .
— Low-dose ( 100mg ) aspirin daily should be considered from age 45 to 70 in consultation with a healthcare professional .
• For people assessed as having category 2 risk of colorectal cancer [ Practice Point 16 ]: — Colonoscopy should be offered every five years 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 , to age 74 .
— CT colonography may be offered if clinically indicated .
— Low-dose ( 100mg ) aspirin daily should be considered from age 45 to 70 in consultation with a healthcare professional .
• For people assessed as having category 3 risk of colorectal cancer [ Practice Point 17 ]: — Colonoscopy should be offered every five years 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 , to age 74 .
— CT colonography may be offered if clinically indicated .
— Low-dose ( 100mg ) aspirin daily should be considered from age 45 to 70 in consultation with a healthcare professional .
— Referral to a culturally safe family cancer clinic should be considered . Those carrying their family-specific mutation or having uncertain genetic status require careful cancer screening .
Source : Cancer Council Australia 2023 19
Case study two
Greg , aged 40 , presents to his GP requesting a screening colonoscopy . His grandfather was diagnosed with colorectal cancer in his 60s and Greg is concerned that he might develop bowel cancer one day . Greg is only eligible for a colonoscopy under MBS item number 32228 , but his GP reasonably considers that there is a clinical need for colonoscopy and so makes the referral .
On colonoscopy , several premalignant polyps are found ( four sessile serrated lesions and one tubular adenoma ), and all are completely removed ( see figure 11 ).
Case study three
Gretel , aged 60 , presents to her GP requesting a repeat screening colonoscopy after a normal colonoscopy five years earlier . Her father had developed colorectal cancer at age 60 . Gretel is currently completely asymptomatic and has no other indications for colonoscopy that fit any of the MBS item number criteria .
However , the MBS no longer has an item number for this indication ( as the sole first-degree relative has to be 55 or younger ). Gretel is thus required to either cover the entire cost without any Medicare or private health fund contribution , or not have a colonoscopy . Gretel elects to proceed with colonoscopy , and four precancerous polyps are found . These are removed , thus significantly
DIAGNOSTIC SUMMARY : 1 . HEPATIC FLEXURE POLYP - SESSILE SERRATED LESION .
2 . DISTAL TRANSVERSE POLYP - FEATURES SUGGEST SESSILE SERRATED LESION WITH DYSPLASIA ( SEE REPORT ).
3 . SPLENIC FLEXURE POLYP - SESSILE SERRATED LESION . 4 . DISTAL DESCENDING COLON POLYP - SESSILE SERRATED LESION . 5 . SIGMOID COLON POLYPS - TUBULAR ADENOMA . HYPERPLASTIC POLYP .
Figure 11 . Greg ’ s pathology summary .