42 HOW TO TREAT : SCREENING COLONOSCOPY HALVES COLORECTAL CANCER MORTALITY
42 HOW TO TREAT : SCREENING COLONOSCOPY HALVES COLORECTAL CANCER MORTALITY
14 MARCH 2025 ausdoc . com . au
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reducing her risk of dying from
colorectal cancer .
Case study four
Gavin , 35 , presents to the GP complaining
of left upper quadrant pain . He has had a few similar episodes earlier in the year . He is a married man , with twins , and his wife is expecting their third baby .
On examination , he is tender in the left upper quadrant and he looks a little pale . Blood tests show a mild elevation of his inflammatory markers and negative Helicobacter pylori serology . Abdominal ultrasound does not demonstrate any pathology , but there appears to be some free fluid in the left iliac fossa . Gavin ’ s discomfort does not settle , so a CT is ordered . This shows enlargement of the abdominal lymph nodes but no other evidence of pathology . The GP refers Gavin for specialist investigation , and a colonoscopy reveals the presence of a transverse colon colorectal cancer primary ( see figure 12 ).
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Box 6 . Those eligible for MBS-funded screening colonoscopy
1 . Anyone at any age where the doctor considers there is a clinical need for a colonoscopy ( MBS 32228 ) and this is not provided for via MBS item numbers 32222 to 32226 . This once per patient lifetime funded procedure is ideal for normal ( or low ) risk populations .
2 . Anyone with a positive FOBT ( MBS 32222 ), again in normal ( or low ) risk populations .
3 . Anyone with a moderate risk due to their family history ( MBS 32223 ) defined as : a . One first-degree relative younger than 55 at diagnosis ; OR b . Two first-degree relatives with a history of colorectal cancer ; OR c . One first-degree relative and two second-degree relatives with a history of colorectal cancer .
4 . 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 .
Australians who do not fulfill the above four criteria can still request referral for a screening colonoscopy , but their screening colonoscopy will currently have to be self-funded outside of the MBS .
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Figure 12 . Transverse colon colorectal cancer primary . |
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Case study five
Genevieve , 43 , presents to the GP
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refers her for a gastroscopy and colonoscopy , which reveals the presence of a 16mm splenic flexure colonic polyp . Excision of this polyp reveals |
that “ Sections show a pedunculated tubulovillous adenoma exhibiting low grade ( moderate ) epithelial dysplasia and focal high grade dysplasia . |
There is no evidence of malignancy ”. This unexpected polypectomy is performed and effectively stops this polyp turning cancerous over the coming months . |
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complaining of intermittent abdominal bloating for a few years . The GP |
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How to Treat Quiz .
GO ONLINE TO COMPLETE THE QUIZ ausdoc . com . au / how-to-treat
1 . Which THREE statements regarding colorectal cancer are correct ? a It may be asymptomatic in the early stages . b The incidence is rising in younger people . c It is usually diagnosed in the early stages . d Routine screening is not typically recommended for the asymptomatic and / or those younger than 45 .
2 . Which TWO statements are correct ? a Fewer than 2000 Australians die each year from colorectal cancer . b Colorectal cancer was the second most common cause of cancer death in Australia in 2022 . c Slightly more men than women died from colorectal cancer in Australia in 2022 . d Around 80 % of patients with colorectal cancer have a family history of colorectal cancer .
3 . Which THREE statements regarding the National Bowel Cancer Screening Program are correct ? a The program recommends screening start at a younger age in Indigenous Australians . b This is the current mainstay of colorectal cancer screening across Australia . c Those aged 45-74 are eligible . d Screening involves a FOBT every two years after the patient ’ s 45th birthday .
4 . Which TWO statements regarding current GP referrals of patients are correct ? a A patient who previously had a normal colonoscopy and has one first-degree relative with a diagnosis of colorectal cancer at age 56 is eligible for a Medicare-funded colonoscopy . b A patient who has not had a colonoscopy and has one first-degree relative with a diagnosis of colorectal cancer at age 56 is eligible for a Medicare-funded colonoscopy . c A patient who had a normal colonoscopy five years earlier and has two first-degree relatives with a diagnosis of colorectal cancer at any age is eligible for a Medicare-funded colonoscopy . d A 60-year-old asymptomatic patient with no family history of colorectal cancer who had a normal colonoscopy five years earlier is eligible for a Medicare-funded colonoscopy .
5 . Which THREE statements regarding the major colonoscopy colorectal cancer screening trials are correct ? a The NordICC trial reported that screening colonoscopy achieved a 50 % reduction in colorectal cancer mortality . b Colorectal cancer screening using FOBT reduces colorectal cancer by 10 %. c After 17 years of follow up , the UKFSST reported that screening flexible sigmoido scopy reduced left-sided colorectal cancer mortality by 66 %. d A single colonoscopy performed in every Australian aged 55-64 would likely halve the death rate from colorectal cancer .
6 . Which THREE statements regarding colonoscopy and polypectomy are correct ? a Removal of precancerous adenomatous polyps during a colonoscopy can prevent their
SCREENING COLONOSCOPY HALVES COLORECTAL
CANCER MORTALITY
change to invasive colorectal cancer . b Colonoscopic polypectomies do not reduce the risk of succumbing to colorectal cancer . c The occult nature of the development of bowel cancer is a major contributor to the lethal nature of the condition d Colonoscopists in Australia should all now be audited on a three-yearly cycle .
7 . Which THREE are MBS funding criteria for five-yearly colonoscopy defining moderate risk of colorectal cancer from family history ( MBS number 32223 )? a A patient with one firstdegree relative less than 55 years of age at diagnosis . b A patient with two firstdegree relatives with a history of colorectal cancer . c A patient with one first-degree relative older than 55 years of age at diagnosis . d A patient with one firstdegree relative and two second-degree relatives with a history of colorectal cancer .
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8 . Which THREE are current Cancer Council Australia recommendations regarding screening ? a Offer colorectal cancer screening colonoscopy in category 1 patients . b Offer patients with category 2 ( moderate ) and category 3 ( high ) risk five-yearly colonoscopy . c People with category 1 ( low ) risk should undergo iFOBT screening in line with population screening every two years from age 45 to 74 . d Refer those in category 3 ( high ) to a culturally safe family cancer clinic .
9 . Which THREE statements accurately indicate how Australia could move forward with colonoscopy colorectal cancer screening ? a By increasing the number of nurse practitioner colonoscopists . b By decreasing the enrolment in FOBT screening . c By providing federally funded colonoscopy cancer screening clinics like BreastScreen . d By providing an MBS criterion specifically for a screening colonoscopy once between 45 and 65 .
10 . Which THREE statements regarding the ethical dilemmas associated with colonoscopy colorectal cancer screening are correct ? a We do not need to inform patients regarding the very low risks of colonic perforation and bleeding following colonoscopy because of the very strong benefit of the 50 % reduction in colorectal cancer-specific mortality . b All Australians should have the same screening options made available to them , irrespective of social class or geographical location . c All colonoscopists should be enrolled in a rotating three-yearly quality assurance audit program to measure adenoma detection rates and colonoscopy completion rates . d Current colonoscopists have an ethical obligation to train the next generation of doctors and nurses to safely perform colonoscopy .
CONCLUSION
SO , is it time for GPs to recommend screening colonoscopy as a primary modality for colorectal cancer in patients considered low risk by their family history ?
The authors consider that the answer to this question is yes , and that it is now time for GPs to advise patients that screening colonoscopy is a legitimate option for them to consider . The Level 1A evidence is strong and robust , and the ethical obligation on referring practitioners to follow this scientific evidence is equally compelling . GPs thinking about referring their patients for screening colonoscopy should consider the important new information confirming the 50-66 % colorectal mortality reduction as shown in the NordICC and UKFSST trials .
It is accepted that there are still major national colonoscopy logistics , equity issues , training , funding and other problems yet to be worked through . However , the authors argue that the process of colorectal cancer screening should start with the GP making Level 1A evidence-based medicine recommendations to their patients . Patients can then make an independent decision based on their own perceived benefits , risks and costs . The public and private health marketplace will then have to work through the logistics and solutions required to meet this increased need .
The authors suggest that significant grassroots uptake as a result of GPs increasing referrals for screening colonoscopy ( on both Level 1A evidence-based scientific and ethical grounds ) is an important step to take before further national progress can be made to reduce the high rate of colorectal cancer mortality .
RESOURCES
• The Australian Commission on Safety and Quality in Health Care ’ s Colonoscopy Clinical Care Standard bit . ly / 3VJi0Sa
• Royal Australian College of General Practitioners ’ Guidelines for Preventive Activities in General Practice ( the Red Book ) bit . ly / 4iERKlE
References Available on request from howtotreat @ adg . com . au