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Consumer Fact Sheet ______________________________________________ Bowel Cancer Screening and Testing - Making Individual Choices This fact sheet provides information on currently available bowel cancer screening and testing methods. Each procedure has advantages and disadvantages that may differ for individuals. Bowel (colorectal) cancer screening and testing decisions should ideally be made after discussions with a doctor, so an assessment can be made on the type of screening method that will suit you best. Your family medical history and other health conditions may mean some bowel cancer screening methods will not be right for you. Screening and Testing For Bowel Cancer Many cancers, including bowel cancer, are curable if found early. Most cancers do not cause any warning signs in their beginning stage, which makes finding cancer early, very important. Regular bowel cancer screening is used to detect cancers at an early stage when they are curable and to identify non-cancerous growths known as adenomas or polyps. Although polyps are not cancers, they may turn into cancer if they aren't removed. Testing for bowel cancer is normally carried out after a screening test has given a positive result; or when signs and symptoms such as passing blood in the stool (poo), changes in bowel habits (constipation and/or diarrhoea) or abdominal pain are experienced. The cure rate for patients who have surgery before bowel cancer has spread is about 90%. However, once bowel cancer has spread to nearby areas only about half of patients are cured and, if it spreads to any other organs or tissues, cures are much less likely. Bowel cancer may occur at any age but the likelihood increases progressively after age 40 and sharply after age 50. It is generally accepted that screening and testing procedures should be quite safe, and that the benefits should considerably outweigh the harms. Bowel Cancer Risk Some people are more at risk of developing bowel cancer than others. Anything that increases a person's chance of getting bowel cancer is called a risk factor. Individuals with one or more of the known risk factors are classified as above average or high risk, while those without any of the known risk factors are classified as average risk. Some risk factors for bowel cancer have not been fully identified or are not yet known. Bowel Cancer Screening and Testing - Making Individual Choices Known risk factors for bowel cancer include: Being older than 50 years of age. Having a parent, brother, sister, or child with bowel cancer or polyps. Having certain hereditary conditions, such as familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC also known as Lynch Syndrome). Having a personal history of any of the following: Bowel cancer or non cancerous polyps Other types of cancer that may spread to the bowel Inflammatory bowel diseases such as Ulcerative colitis or Crohn's disease. If you have one or more of these factors you should discuss the risk with your doctor. Around 4% of bowel cancers are passed on in families. In some cases where there is a family history of bowel cancer, a doctor may suggest commencing screening earlier and/or more often. Your doctor will discuss your family history with you and may recommend particular kinds of bowel cancer screening that would best suit you. In some cases a doctor may suggest genetic testing which will provide an assessment of your risk for developing bowel cancer. The limitations of genetic testing will be discussed with you before and after genetic testing. Bowel Cancer Screening and Testing Options There is a range of bowel cancer screening tests currently available. The tests differ in cost and potential risk to the patient. The effectiveness and potential harms of the most commonly used tests are provided below. Costs and availability are given in the tables on the last two pages. Faecal Occult Blood Test (FOBT) Polyps and bowel cancer often (but not always) produce a tiny amount of blood that you usually cannot see. You can use a FOBT at home to check for this blood. The instructions will explain how to take some samples of your stools (poo) on separate days. Types of FOBT Two main types of FOBT are available - guaiac and immunochemical tests. Immunochemical tests (eg. Detect, also known as Magstream (produced by Bayer) and Insure produced by Enterix, do not require special dietary or medication restrictions. This type has been found to be best at detecting bowel cancer Guaiac tests (eg. Haemoccult, Haemoccult II, Haemoccult Sensa) require that you don’t eat red meat, raw fruit and vegetables and iron supplements for three days prior to stool sample collection. Availability of FOBT Currently, FOBT kits are available through General Practitioners (cost approx $32, including pathology testing costs) or by participating in small community based initiatives (such as Rotary Bowelscan). Test kits are also available directly from The Cancer Council NSW – Consumer Fact Sheet 2 Bowel Cancer Screening and Testing - Making Individual Choices manufacturers for approximately $15 (this does not include cost of pathology testing). It appears likely that a national bowel cancer screening program using immunochemical tests will be introduced gradually over the next few years, which may mean the cost of the tests will be free or reduced. The manufacturers of the two types of immunochemical tests recommended for use in the national pilot project are: Bayer Australia Ltd PO Box 903 875 Pacific Highway Pymble NSW 2073 Australia Ph: +61 (0) 2 9391 6000 Fax: +61 (0) 2 9988 3311 Enterix Australia 15/2 Eden Park Drive Email: [email protected]. Phone: 9889 5200. Fax: 9889 5211 How often? The risk of death from bowel cancer is reduced more with yearly screening than with 2nd yearly screening. It has been found that the risk of death is reduced by around a third (30%) with yearly screening compared to around a 7th (15%) in people who are screened every two years. When introduced, the national bowel cancer screening program will more than likely be based on 2nd yearly screening for both men and women 50 years or older of average risk (without a personal or family history of bowel cancer and without symptoms). Advantages • Once you and your doctor have agreed that FOBT is a suitable test for you, FOBT can be performed at home, making it more convenient and cheaper than other tests (The FOBT is sent to a lab for processing once the specimen has been collected). • It has been found that people over the age of 50 who are of average risk (those without a family history or a previous history of bowel cancer or other bowel diseases and who have no signs or symptoms of bowel cancer) will have a much lower chance of dying from bowel cancer if they have a second yearly FOBT. • Most people find the FOBT easy and convenient. Disadvantages • Not all polyps or cancers will bleed, thus a FOBT may produce normal results even when cancer is present. Therefore if there are other symptoms or risk factors such as a family history of bowel cancer, you should see your doctor. • Conditions other than cancer (such as stomach ulcers and haemorrhoids) may cause bleeding. Therefore, a FOBT may detect blood that is not associated with bowel cancer and you may have to undergo more tests, which may not have been necessary. The main harm identified with use of FOBT is anxiety after a false positive test (when the FOBT detects blood from causes other than cancer) • Some patients fail to report a positive FOBT test to their doctor. The Cancer Council NSW – Consumer Fact Sheet 3 Bowel Cancer Screening and Testing - Making Individual Choices Flexible sigmoidoscopy A flexible sigmoidoscopy involves the use of a lighted tube to examine the lower part of the bowel. The bowel is inflated with air to make viewing the walls of the bowel easier. Unlike a colonoscopy that examines the entire bowel, a flexible sigmoidoscopy only explores the lower third to half of the colon. Around half of all bowel cancers occur in the lower third of the colon. Several leading medical groups recommend routine screening with sigmoidoscopy every 4-5 years, along with second yearly FOBT, for both men and women 50 years or older of average risk (without a personal or family history of bowel cancer and without symptoms). Advantages • A flexible sigmoidoscopy can be more quickly and easily performed and is generally less expensive than full colonoscopy. • Potential cancers can be seen and biopsied and/or removed at the time. Disadvantages • Patients are usually not sedated for this test so may experience pain or discomfort — mostly gas-like pains from the air used to inflate the bowel • As is the case with colonoscopy, the procedure carries with it the small risk of bowel perforation and infection, though this is less common with sigmoidoscopy than it is with colonoscopy. • A flexible sigmoidoscopy cannot detect polyps or cancers that are located deep within the colon beyond the reach of the sigmoidoscope. UBarium Enema A barium enema involves filling the bowel through a thin tube inserted into the anus with liquid called barium. The barium causes some polyps or cancers to show up in an xray. Like the sigmoidoscopy and colonoscopy, this procedure requires the bowel to be properly emptied before the test. Patients are normally required to have a liquid diet before the test and a drink containing a special bowel cleansing solution prior to the test. The cleansing solution helps patients pass all the contents of the colon, which makes it easier for the doctor to view the walls via an xray of the colon and detect any abnormalities. Advantages • Barium enema is good at detecting large cancers and large polyps. • Most of the bowel can be inspected with a barium enema Disadvantages • A barium enema doesn't allow the doctor to remove or perform a biopsy on any detected polyps or masses during the procedure. Instead, it requires a follow-up colonoscopy. • A barium enema may miss a substantial proportion of small and medium-size polyps. • A barium enema does not always show the lowest part of the bowel, which may mean that other procedures could also be required. • Certain people such as those with existing bowel conditions (eg. Crohns disease) are at greater risk for complications with this procedure such as perforation of The Cancer Council NSW – Consumer Fact Sheet 4 Bowel Cancer Screening and Testing - Making Individual Choices the bowel, infection or the bowel may narrow and become blocked by the barium. Colonoscopy A colonoscopy is a procedure that examines the entire length of the bowel using a long, thin, flexible tube that is inserted in the anus. The tube has a light at the end and is connected to a video monitor to assist the doctor in detecting and removing polyps and cancers. While colonoscopy can be used as a screening test (it is often recommended for people of above average risk), it is more often used to provide a more complete assessment of the bowel after other tests that screen for bowel cancer (FOBT, sigmoidoscopy, barium enema) have come back positive. This procedure requires the bowel to be properly emptied before the test. Patients are normally required to have a liquid diet before the test and a drink containing a special bowel cleansing solution prior to the test. The cleansing solution helps patients pass all the contents of the colon, which makes it easier for the doctor to view the walls of the colon and detect any abnormalities. The doctor also inflates the bowel slightly (by pumping air into it via the anus) to make viewing the walls of the colon even easier. Patients are usually sedated but awake during the procedure, and typically experience little pain. Your doctor will usually provide you with a referral to a specialist to have a colonoscopy. A colonoscopy is most often performed in a hospital or day clinic and requires you to be away from home or work for around 4 hours. Patients are normally advised not to drive for 24 hours after a colonoscopy. Waiting times for a colonoscopy in a public hospital differ depending on where you live. Information on waiting times and waiting lists for surgical and medical procedures in NSW public hospitals can be obtained from www.health.nsw.gov.au/waitingtimes/ Advantages • By providing a more complete bowel examination, colonoscopy is the most effective test for detecting bowel cancer and large polyps. • The test allows doctors to see the bowel directly and to remove or take a sample of any suspicious growths. Disadvantages • Colonoscopy may miss up to 15 per cent of growths that are less than 1cm • Patients may find a colonoscopy inconvenient, uncomfortable or embarrassing. • A colonoscopy carries a small risk of puncturing the colon, which can lead to internal bleeding and infection. There is also a very small risk of death with a colonoscopy. • A specialist gastroenterologist usually carries out this test. Patients are able to claim the cost of this procedure under Medicare (covers high risk patients every two years and those needing follow up tests). Additional costs may include the The Cancer Council NSW – Consumer Fact Sheet 5 Bowel Cancer Screening and Testing - Making Individual Choices • cost of the specialist appointment, cost of the bowel preparation, pathology costs for testing any polyps or biopsies if they are taken and transport costs. After sedation patients are unfit to drive, so transport will need to be organised. Virtual Colonoscopy Virtual colonoscopy has some similarities to a colonoscopy. The day before the procedure, a preparation is taken orally to help patients completely empty their bowel. Prior to the procedure, the bowel is inflated with air via a tube inserted in the anus to make viewing the bowel easier. A computed tomographic (CT) scanner is then used to take hundreds of pictures of the bowel (from the outside). Using a computer to put the images together, a radiologist can view the bowel from many different angles. Virtual Colonoscopy is not commonly used as a routine screening procedure at present Advantages • Virtual colonoscopy presents less risk of puncturing the colon than colonoscopy does. • Virtual colonoscopy takes around five minutes (excluding preparation time), and since sedation is usually unnecessary, the patient can leave immediately after the scanning is completed. • Virtual colonoscopy doesn’t normally require sedation or painkillers and may be more acceptable to the elderly, the immobile or for those whom colonoscopy is not recommended such as persons with heart or lung problems. Disadvantages • Virtual colonoscopy detects 60 to 90 percent of medium to large polyps or cancers but may not detect small polyps or cancers. • Follow-up colonoscopy is required to confirm findings, perform biopsies or removal of any detected polyps or masses. • Currently patients are unable to claim the cost of this procedure under Medicare. The cost to patients is approximately $350. • This procedure is currently limited to centres, usually in major metropolitan areas, with established CT scanners, relevant computer software and specialists trained in the interpretation of processed images. Questions for you and your doctor to consider: • • • • Am I at risk of bowel cancer? What bowel screening/testing options are best for me? Do I have other illnesses that may have an influence on the screening/testing procedure I have? What is the cost of the screening/testing procedure? The Cancer Council NSW – Consumer Fact Sheet 6 Bowel Cancer Screening and Testing - Making Individual Choices Bowel Cancer Screening and Testing Options Procedure Faecal Occult Blood Testing (FOBT) Flexible sigmoidoscopy Frequency Risk Cost Advantages Disadvantages FOBT detects between 79% and 37% of bowel cancers. Detection Routine screening at least every two years for both men and women 50 years or older of average risk (without a personal or family history of bowel cancer and without symptoms). The main harm identified with use of FOBT is anxiety after a false positive test (when the FOBT detects blood from causes other than cancer) FOBT kits can be purchased from chemists (for between $15 and $32). Additional costs may include any follow up tests should the FOBT be positive for blood. FOBT can be done at home, making it more convenient and cheaper than other tests. Not all polyps or cancers will bleed. Therefore, a FOBT may produce normal results even when cancer is present. Cannot detect polyps or cancers that are located deep within the bowel beyond the reach of the sigmoidosco pe and may miss small cancers or polyps Routine screening with sigmoidoscopy every 4-5 years, along with a second yearly FOBT, for both men and women 50 years or older of average risk (without a personal or family history of bowel cancer and without symptoms). The procedure carries with it the small risk of bowel perforation and infection, though it is less common with sigmoidoscopy than it is with colonoscopy. Patients are able to claim the cost of this procedure under Medicare. Additional costs may include the cost of the specialist appointment, cost of the bowel preparation, pathology costs for testing any polyps or biopsies if they are taken. The Cancer Council NSW – Consumer Fact Sheet Most people find the FOBT easy and convenient. A flexible sigmoidoscopy can be more quickly and easily performed than full colonoscopy. Potential cancers can be directly visualized and can be biopsied (take a sample for testing) and/or removed Conditions other than cancer (such as stomach ulcers and haemorrhoids) may cause bleeding. Therefore, a FOBT may detect blood that is not associated with bowel cancer. Since they are rarely given an intravenous sedation for the procedure, patients are more likely to experience pain or discomfort — mostly gas like pains from the air used to inflate the bowel 7 Bowel Cancer Screening and Testing - Making Individual Choices Procedure Detection Frequency Risk Cost Advantages Disadvantages Barium Enema A barium enema detects most large cancers and polyps but may miss a substantial proportion of small and medium-size polyps. Routine screening every 4-5 years for both men and women 50 years or older of average risk (without a personal or family history of bowel cancer and without symptoms). Certain people such as those with existing bowel conditions (eg. Chrohns disease) are at greater risk of the following complications with this procedure: the barium may perforate the colon and cause infection. The bowel may also narrow and become blocked. Patients are able to claim the cost of this procedure under Medicare. Additional costs may include cost of the bowel preparation and travel costs if required. Barium enema is good at detecting large cancers and large polyps in particular areas of the bowel. A barium enema doesn't allow the doctor to remove or perform a biopsy on any detected polyps or masses directly. Instead, it requires a follow-up colonoscopy. Colonoscopy detects most cancers and polyps greater than 1 cm but may miss up to 15 per cent of growths that are less than 1 cm. Colonoscopy is usually recommended as a follow-up test if any of the other screening tests are abnormal. Colonoscopy is not normally used as a routine screening procedure for people of average risk for bowel cancer. However it is the screening method of choice for people at above average risk. Screening intervals from 2 – 10 years may be required. A colonoscopy carries a small risk of puncturing the colon, which can lead to internal bleeding and infection. There is also a very small risk of death with a colonoscopy. Patients are able to claim the cost of this procedure under Medicare (covers high risk patients every two years and those needing follow up tests). Additional costs may include the cost of the specialist appointment, cost of the bowel preparation, pathology costs for testing any polyps or biopsies if they are taken and transport costs. Potential cancers can be directly visualised and can be biopsied (take a sample for testing) and/or removed Colonoscopy The Cancer Council NSW – Consumer Fact Sheet A barium enema does not always allow an evaluation of the lowest part of the bowel, which may mean that a sigmoidoscopy may also be required. Patients may find a colonoscopy inconvenient, uncomfortable and embarrassing. A colonoscopy is most often performed in a hospital or day clinic and requires you to be away from home or work for around 4 hours. Patients are normally advised not to drive for 24 hours after a colonoscopy. 8 Bowel Cancer Screening and Testing - Making Individual Choices Virtual Colonsocopy Virtual colonoscopy detects 60 to 90 percent of cancers and polyps that are medium to large in size, may miss small polyps and cancers. Virtual Colonoscopy is not commonly used as a routine screening procedure at present. Because it is well tolerated without sedation or analgesia and may be more acceptable to the elderly, the immobile, those with contraindications for conventional colonoscopy and those with heart or lung problems. Virtual colonoscopy presents less risk of puncturing the colon than colonoscopy does. The dose of radiation from a virtual colonoscopy has been estimated to be about equal to that of a barium enema Patients are currently unable to claim the cost of this procedure under Medicare (or private funds in Australia) at this stage. The cost to patients is approximately $350. Additional costs may include any follow up tests should the virtual colonoscopy find any abnormalities. Virtual colonoscopy takes less than five minutes, and since sedation is usually unnecessary, the patient can leave immediately. Follow-up colonoscopy is required to confirm findings, perform biopsies or removal of any detected polyps or masses directly. This procedure is currently limited to centres, usually in major metropolitan areas, with established CT scanners, relevant computer software and specialists trained in the interpretation of processed images. This resource is intended for use by the general public and is based on the best available information at the time of publication. Additional information and advice on bowel cancer can be obtained by phoning the Cancer Helpline on: 13 11 20 or by visiting the Cancer Council NSW web site www.cancercouncil.com.au The Cancer Council NSW – Consumer Fact Sheet 9