Critical Analysis Of The National Bowel Cancer Screening Program In Australia

Overview of the Program

Critical analysis of a National Health Promotion Programme.

The burden of cancer in Australia, as is in the rest of the world has been increasing. Governments through community initiatives have attempted to solve the issue of increasing incidences of bowel cancer and allocating funds towards the related initiative. The National Bowel Cancer Screening Program in Australia was rolled out in 2006 with the aim of having screened all the Australians who are between 50 and 74 years before the year 2020[1]. This program is currently in its third phase has already achieved over 70% of its targeted population.  The program has however experienced some challenges and problems along the over 10n years, which have led to interventions by the federal and territorial governments[2]. This paper is an analysis of the program which aims at exploring the program from the perspective of the political process that led to its inception, the progress made in the last decade the program has been running, changes and impacts of the program to the identified health concern.

Bowel cancer has been regarded as one of the leading causes of death and morbidity in the Australian population. Regardless of the state or territory, all people are at relatively high risk of developing bowel cancer due to the foods being consumed and the lifestyle the people have adopted[3]. According to the cancer statistics worldwide, Australia has the second-highest bowel cancer incidence globally. The local statistics have also indicated that more than 16,000 people in Australia are found to have bowel cancer annually, and over 93% of them are above the age of 50 years[4]. Among the Australian, one in every 19 men and 1 in every 30 women have the possibility to get bowel cancer after they are 50 years. These statistics indicate that Australian levels of government must ensure that the disease is controlled from early stages. Although 90% of the bowel cancer cases can be successfully treated if diagnosed in good time, in 2003, 80 Australians died every week due to bowel cancer-related complications[5]. This is due to the lack of governmental initiative in health promotion[6]. The program was therefore established to focus directly on the healthy population and prevent them from being part of the negative statistics. The tangible target of the program is to screen all Australians above the age of 50 years by the year 2020. This will ensure that cases of bowel cancer are detected early enough to allow speedy treatment and recovery[7]. It is expected that with full implementation, the program can save up to 500 lives each year.

The Background of the Program

According to experts, it is highly possible for a disease like bowel cancer to develop and progress inside the body of a human being without having any physical signs or symptoms.  This means that the disease often is diagnosed during its late stages if the person is to rely on physical symptoms or warning signs[8]. This has justified the need for a screening program for bowel cancer and also other types of cancer. Diagnostic screening for bowel cancer, as is done in this program entails capturing people who are within the vulnerable and susceptible population but have no symptoms of the disease. This follows a comprehensive and extensive health education to enlighten and educate the people on the health promotion program. The intention of the screening is to look for polyps or traces of cancer cells within the person’s fecal material.  The screening process makes use of a test that identifies even the smallest traces of blood in the bowel motion. This test, Fecal Occult Blood Test (FOBT) can be conducted in one’s home. Blood traces are indications of exfoliated bowels and may be an indication of possible bowel cancer. The program, therefore, has an objective to increase the number of people who have bowel cancer detected and treated early.

The Australian report on bowel cancer in the early twenty-first century triggered the public concern for the disease. By the year 2002, stakeholders in public health had already demonstrated their concerns for the increased incidence of the disease as well as the ballooning disease burden related to bowel cancers. This led to the beginning of extensive research on the problem with research evidence from various areas indicating the weight of the problem from the perspective of the community. The research evidence also triggered the public advocacy and activism that led to the preparation of the initial policy document aimed at proposing a nation-wide screening program. This initiative was well received by the policy makers and stakeholders in the healthcare industry and the first program was initiated. This program was pilot-tested in 2003[9].

The program, arranged into three phases brought about an agreement between the Australian Government and the states and territory governments in the implementation and operation of the screening program[10]. The Victorian Department of Health and Human Services was offered the responsibility to implement the program in Victoria as other departments in each of the rest of the states undertook their responsibilities[11]. This enabled a complete roll-over of the program in the whole country and also made it easy to monitor the program from the local levels. However, there was a national program committee that receives reports from all other stakeholders and takes appropriate actions to ensure the program remains on course[12].

The Policy Process for the Initiation of the Program

The national committee has also been tasked with the responsibility to mobilize communities, train the caregivers and screening professionals as well as mobilizing and allocating crucial resources. These resources are collectively provided by the national, state and territorial government through the combined effort initiative. In additional to the governments, the program also welcomes other stakeholders including non-governmental organizations and individual citizens who feel that they can donate to the course. The link to the donation and fundraisers are available on the program’s website. Currently, the budgetary allocation to the program accounts for up to 55% of the annual expenditure of the program while the rest comes from other stakeholders and international donors.

The first phase of the project began in August 2007 and ran until 30^th June 2008. This was the initialization phase which also set the ground for further engagement. The target ages for the project were fifty-five and 65 years. Phase 2 was conducted between 1^st July 2008 and 30^th June 2013 was a bit longer than the first phase and the eligible ages were 50, 55 and 65 years.  It is during this time that the National Bowel Cancer Screening Program funding was commenced as the program started to take roots and bear fruits. The program is currently in its third phase which started in July 2013 and expected to run until 2020. It is expected that by then, over for million Australians will have been invited to the program every year and over 500 lives saved following early detection of the disease and subsequent treatment[13].

The program has been effectively reduced the incidence of bowel cancer in the country. The program offers free bowel cancer screening to all the people who are eligible, based on their age and relative risks. The positive results of this program have been the introduction of home-based testing kits that are availed to all the eligible persons. This has increased the ability and willingness of the people to conduct their tests at home and only go to the doctor if the results of the home test are positive[14]. On such occasions, the doctor refers the person for deeper investigations. This entails colonoscopy where appropriate and comprehensive clinical assessment. The program, therefore, offers timely access to diagnosis and treatment which then increase the likelihood of the full treatment. The other benefit is that all Participants regardless of the outcome of the home-test are provided with opportunities for follow-up[15]. Follow-up allows the experts to evaluate changes in the person’s health and their response to treatment. The participants, therefore, become part of the program from their entry and for the rest of their lives, ensuring contact with healthcare professionals for inquiry about their health concerns even unrelated to bowel cancer[16].

The Impacts of the Program

The program has however suffered several challenges since its inception. First, there has been a deep concern for the availability of funds that are necessary for the program. As earlier noted, the budgetary allocation for the project accounts for just above half the annual expenditure of the project. The implication of this is that the other half has to be donated. Donations depend largely on the global economic environment. Following the 2008-2009 financial crisis, the program suffered a major setback especially in the second part of Phase two. This necessitated an increase in the budgetary allocation into the program but still did not allow the program to fully meet its objectives. The second challenge which has led to barriers to implementation is the public awareness of the existence of the project. According to a review report published after the first phase only about 23% of the people within the target, ages had access to information on the program. This meant that the program could not meet its targeted people unless an awareness creation program was initiated. This also necessitated allocation of more funds to public health education and promotion that was conducted in all the territories and especially in the rural areas. It has also been reported that to date, the usability of the home-testing kits is still not clear to many people[17]. There are cases of failed tests and false positive tests that have been reported which often lead to erroneous statistics that have resulted to false alarms. However, with follow-up, these cases are easily cleared.

Despite these challenges and barriers to effective implementation, the successes of the program are more impacting to the community health[18]. The success of the program offers an opportunity for public health learning. The lessons from this program are to be applied in other health promotion programs focusing on different other health concerns such as other types of cancers and ailments. In addition, the program has also allowed the stakeholders in the public health and health promotion sector to interact closely with the community, and this will form a good foundation for further interaction in programs and research related to different health conditions or health situations[19]. There is, therefore, the opportunity for more extensive and focused research on the issues as well as a deeper understanding of the community health from a perspective of knowledge and experience[20]. To the government, the program has continually provided data on the health status and concerns of the target cohort. This information will be valuable in future policy direction and guiding the decision and policy-making at the state, territory or even the national level.

Health promotion focuses directly on the community initiatives towards the prevention of illness and disability. The primary level of prevention as identified in primary health care entails health education, screening of people and prevention education to help prevent illnesses. The National Bowel Cancer Screening Program was initiated to run for over ten years with a focus on increasing the public awareness of the problem associated with bowel cancer and conducting screening programs on eligible persons. The program was informed by the increased incidence of the disease in Australia and the related deaths from the condition. Further, expert reports indicated that if diagnosed early enough over 90% of the patients with bowel cancer can be fully treated[21].

The program, since its inception, has been able to attract and screen over 10 million Australians and will continue to do so until 2020. With the screening, people have been treated for the condition, and an average of 500 deaths have been prevented each year[22]. The future of the program is therefore based on the follow-up that will be given to those who have been found and treated as well as those with familial or genetic predisposition. The program can also be implemented for other conditions with the aim of replicating the successes.

AIHW&AACR, Cancer in Australia: An Overview, 2012 (2012) vol Cat.  no. C

Australian Institute of Health and Welfare, ‘Cancer in Australia’ [2001] Cancer 141

Christou, Aliki, Judith M Katzenellenbogen and Sandra C Thompson, ‘Australia’s National Bowel Cancer Screening Program: Does It Work for Indigenous Australians?’ (2010) 10(1) BMC public health 373 <https://www.biomedcentral.com/1471-2458/10/373>

Ee, Hooi C and John K Olynyk, ‘Making Sense of Differing Bowel Cancer Screening Guidelines’ (2009) 190(7) Medical Journal of Australia 348

Flitcroft, KL et al, ‘A Comparative Case Study of Bowel Cancer Screening in the UK and Australia: Evidence Lost in Translation?’ (2011) 18(4) Journal of medical screening 193 <https://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3466604&tool=pmcentrez&rendertype=abstract>

Foreman, Linda, ‘Bowel Cancer Screening–a Role for General Practice.’ (2009) 38(4) Australian family physician 200 <https://www.ncbi.nlm.nih.gov/pubmed/19350068>

Jalleh, G et al, ‘Efficacy of Bowel Cancer Appeals for Promoting Physical Activity’ (2005) 16(2) Health Promotion Journal of Australia 107 <https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16130584>

Jalleh, Geoffrey et al, ‘Beliefs about Bowel Cancer among the Target Group for the National Bowel Cancer Screening Program in Australia’ (2010) 34(2) Australian and New Zealand Journal of Public Health 187

Javanparast, Sara et al, ‘Barriers to and Facilitators of Colorectal Cancer Screening in Different Population Subgroups in Adelaide, South Australia’ (2012) 196(8) Medical Journal of Australia 521

Martini, Angelita et al, ‘Colorectal Cancer Screening in Rural and Remote Areas: Analysis of the National Bowel Cancer Screening Program Data for South Australia.’ (2005) 11(2) Rural and Remote Health 1648 <https://www.ncbi.nlm.nih.gov/pubmed/21590571>

Martini, Angelita et al, ‘Colorectal Cancer Screening in Rural and Remote Areas: Analysis of the National Bowel Cancer Screening Program Data for South Australia.’ (2008) 11(2) Rural and remote health 1648 <https://www.ncbi.nlm.nih.gov/pubmed/21592859>

Millard, FB, ‘Bowel Cancer Screening in Australia’ (2006) 35(4) Aust Fam Physician 188

Smith, Sian K et al, ‘A Decision Aid to Support Informed Choices about Bowel Cancer Screening among Adults with Low Education: Randomised Controlled Trial.’ (2010) 341(2) BMJ (Clinical research ed.) c5370 <https://www.ncbi.nlm.nih.gov/pubmed/20978060%5Cnhttps://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC2965151>

Varlow, M et al, ‘Self-Reported Participation and Beliefs about Bowel Cancer Screening in New South Wales, Australia’ (2014) 25(2) Health Promotion Journal of Australia 97 <https://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=medl&AN=25017447%5Cnhttps://gw2jh3xr2c.search.serialssolutions.com?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rfr_id=info:sid/Ovid:medl&rft.genre=article&rft_id=info:doi>

Ward, Paul R, Cushla Coffey and Samantha Meyer, ‘Trust, Choice and Obligation: A Qualitative Study of Enablers of Colorectal Cancer Screening in South Australia’ (2015) 37(7) Sociology of Health and Illness 988

Australian Government Department of Health and Ageing, National Bowel Cancer Screening Project (2011) Author <https://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-about>

Flitcroft, Kathy L et al, ‘Fifteen Years of Bowel Cancer Screening Policy in Australia: Putting Evidence into Practice?’ 37

NHS Cancer Screening Programmes, NHS Bowel Cancer Screening Programme (2013) NHS Cancer screening programmes websi

NHS Cancer Screening Programmes, NHS Bowel Cancer Screening Programme (2013) NHS Cancer screening programmes website.

Angelita Martini et al, ‘Colorectal Cancer Screening in Rural and Remote Areas: Analysis of the National Bowel Cancer Screening Program Data for South Australia.’ (2005) 11(2) Rural and Remote Health 1648 <https://www.ncbi.nlm.nih.gov/pubmed/21590571>.

Hooi C Ee and John K Olynyk, ‘Making Sense of Differing Bowel Cancer Screening Guidelines’ (2009) 190(7) Medical Journal of Australia 348.

Australian Government Department of Health and Ageing, National Bowel Cancer Screening Project (2011) Author <https://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-about>.

Paul R Ward, Cushla Coffey and Samantha Meyer, ‘Trust, Choice and Obligation: A Qualitative Study of Enablers of Colorectal Cancer Screening in South Australia’ (2015) 37(7) Sociology of Health and Illness 988.

Sara Javanparast et al, ‘Barriers to and Facilitators of Colorectal Cancer Screening in Different Population Subgroups in Adelaide, South Australia’ (2012) 196(8) Medical Journal of Australia 521.

Sian K Smith et al, ‘A Decision Aid to Support Informed Choices about Bowel Cancer Screening among Adults with Low Education: Randomised Controlled Trial.’ (2010) 341(2) BMJ (Clinical research ed.) c5370 <https://www.ncbi.nlm.nih.gov/pubmed/20978060%5Cnhttps://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC2965151>.

Linda Foreman, ‘Bowel Cancer Screening–a Role for General Practice.’ (2009) 38(4) Australian family physician 200 <https://www.ncbi.nlm.nih.gov/pubmed/19350068>.

M Varlow et al, ‘Self-Reported Participation and Beliefs about Bowel Cancer Screening in New South Wales, Australia’ (2014) 25(2) Health Promotion Journal of Australia 97 <https://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=medl&AN=25017447%5Cnhttps://gw2jh3xr2c.search.serialssolutions.com?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rfr_id=info:sid/Ovid:medl&rft.genre=article&rft_id=info:doi>. Smith et al.

Australian Institute of Health and Welfare, ‘Cancer in Australia’ [2001] Cancer 141.

G Jalleh et al, ‘Efficacy of Bowel Cancer Appeals for Promoting Physical Activity’ (2005) 16(2) Health Promotion Journal of Australia 107 <https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16130584>.

Kathy L Flitcroft et al, ‘Fifteen Years of Bowel Cancer Screening Policy in Australia: Putting Evidence into Practice?’ 37.

Australian Institute of Health and Welfare.

Aliki Christou, Judith M Katzenellenbogen and Sandra C Thompson, ‘Australia’s National Bowel Cancer Screening Program: Does It Work for Indigenous Australians?’ (2010) 10(1) BMC public health 373 <https://www.biomedcentral.com/1471-2458/10/373>.

FB Millard, ‘Bowel Cancer Screening in Australia’ (2006) 35(4) Aust Fam Physician 188.

KL Flitcroft et al, ‘A Comparative Case Study of Bowel Cancer Screening in the UK and Australia: Evidence Lost in Translation?’ (2011) 18(4) Journal of medical screening 193 <https://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3466604&tool=pmcentrez&rendertype=abstract>.

Jalleh et al, ‘Efficacy of Bowel Cancer Appeals for Promoting Physical Activity’.

AIHW&AACR, Cancer in Australia: An Overview, 2012 (2012) vol Cat.  no. C.

Angelita Martini et al, ‘Colorectal Cancer Screening in Rural and Remote Areas: Analysis of the National Bowel Cancer Screening Program Data for South Australia.’ (2008) 11(2) Rural and remote health 1648 <https://www.ncbi.nlm.nih.gov/pubmed/21592859>.

Geoffrey Jalleh et al, ‘Beliefs about Bowel Cancer among the Target Group for the National Bowel Cancer Screening Program in Australia’ (2010) 34(2) Australian and New Zealand Journal of Public Health 187.

AIHW&AACR.