Beating Bowel Cancer - Prevention, detection, treatment

Hello, I'm Norman Swan. Welcome to this program on beating bowel cancer - prevention, detection, treatment. We're coming to you on Rural Health Channel 600. Nearly 300 people a week are diagnosed with bowel cancer and tragically for a disease that can be detected when it's curable, bowel cancer still has a very high mortality rate, especially for people living in rural and remote Australia. This program will help you to reduce delay in diagnosis in your patients and reverse the appalling statistics in rural and remote communities. We'll also clarify additions to the National Bowel Cancer Screening Program from the new 2012 budget. This is a professionally accredited program from the Rural Health Education Foundation. As usual, there are a number of useful resources available on the Rural Education Health Foundation's website - rhef.com.au. Let's meet our panel. Cameron Bell is a consultant gastroenterologist at Royal North Shore Hospital in Sydney. - Welcome, Cameron. - Good evening. Cameron is also Director of Bowel Cancer Australia, a member of the Program Advisory Group of the National Bowel Cancer Screening Program and Chair of the working party on Clinical Practice Guidelines for Surveillance Colonoscopy for Cancer Council Australia. John Bronger is a community pharmacist with over 30 years' experience. - Welcome, John. - Thank you, Norman. John was the national president of the Pharmacy Guild for 11 years, and is currently president of the Pharmaceutical Society of Australia, NSW Branch Committee. Sally Cockburn is a GP and health advocate with many years' experience, currently working in suburban Melbourne. - Welcome, Sally. - Thank you. Sally is involved in community health issues, health policy and education at many levels. She is a presenter on Melbourne radio 3AW with Talking Health, and is an ambassador on bowel cancer, aren't you? We'll see an example of that later on. Tammy Farrell is an experienced registered nurse and nurse adviser for Bowel Cancer Australia. - Welcome, Tammy. - Thank you, Norman. Tammy has qualifications in nutrition and is Managing Director of Core Health Consulting and author of The Real Man's Tool Box. What's inside the real man's toolbox? The Real Man's Tool Box is a DIY health manual for men. Right. And the main tip is? The main tip is to look after yourself, and to see your GP. Right. And - ignore man flu but not anything else. Tammy works with rural and remote mining communities and blue-collar industries as a health consultant for employees. James St John is a gastroenterologist interested in population screening for bowel cancer and familial cancer. - Welcome, Jim. - Good evening, Norman. Jim was Director of Gastroenterology at the Royal Melbourne Hospital, a senior clinical consultant in the National Cancer Control Initiative and has been based at Cancer Council Victoria since then. Jim is a pioneer of national bowel cancer screening from its inception, has been pushing hard all the way through. Welcome, Jim, in particular. Welcome to you all. Where does bowel cancer sit, Jim, in terms of mortality? It's just ridiculous. It's up second or third. It's second. Lung cancer causes most deaths followed by bowel cancer. - It's outrageous. - Over 4,000 deaths each year. What should it be? If we were actually doing our job getting early detection going according to current technology, what could we get it down to? I'm an optimist. I believe we could reduce the mortality down to 2,000 or 1,000. It's going to depend on participation. Whatever the program is - the population screening, the special programs for people with increased risk, families with very special risk. But this is a cancer that lends itself to screening. We can detect these cancers at a curable stage with screening tests well before they cause symptoms. And Cameron, why the rural disparity? Is it late diagnosis? I don't think that's clear, Norman. I'm sure that access to resources is an issue. I'm not sure, James, about participation in the bowel cancer screening program, whether that's substantially different in rural... Participation in the outer and inner regional area is higher than in the major cities. The difference is... But the survival rates are very different. There's a gradation from rural to city. It may well be ready access to specialised services at least as one factor. And Indigenous communities, Cameron? The incidence of bowel cancer is lower than in non-Indigenous communities. There are a couple of confounding things. There's a higher rate of cancer of unknown primary in Indigenous Australians. I suspect that a goodly proportion of that is bowel cancer that goes undetected and unlabelled. NORMAN: And uninvestigated, presumably. Potentially uninvestigated, yes. Sally, the risk factors? The risk factors are being over 50, having a family history, conditions like ulcerative colitis and Crohn's disease, and being Australian, living in Australia. I thought Crohn's disease didn't raise the risk? No, it does. Crohn's disease and ulcerative colitis are two determining factors that we want to watch for. It's not as much of a risk factor as ulcerative colitis, but in the segments that are affected, so anybody with more than about a third of their colon affected by Crohn's disease and patients with severe anorectal Crohn's disease are at an increased risk. What about lifestyle factors, Tammy? Lifestyle factors - physical inactivity, high alcohol consumption and standard dietary guidelines that people follow can put a person at risk by around 70%. I thought the vegetable story, the roughage story, had been disproven? No, fibre is important. But we're finding that high red-meat intakes... So it's more that vegetables mean a reduction in red meat? That's right. That's what goes with the red meat as well. We'd be looking at trying to limit to around 500g of red meat per week. Sorry, Jim? - Smoking, Tammy? - Yes. Smoking is one of the big factors that we're trying to reduce in terms of bowel cancer. And obesity and type-2 diabetes as well? Exactly right. And that's a growth-factor phenomenon, Jim? Yes. It's a little bit unknown. Teasing out what's obesity, what's insulin resistance and what's a consequence of the metabolic syndrome itself is difficult. NORMAN: And gender split? It's a common misconception that it's a male disease. It is slightly more common in men, but by age 75, 1 in 17 Australian men will have developed bowel cancer. It's 1 in 27 Australian women. But by age 85, it's 1 in 12 Australians will develop bowel cancer. 1 in 10 for men, and it's now I think 1 in 15 for women. It used to be 1 in 14. The figures changed a little bit. It's the second commonest internal female cancer, the second commonest male cancer, the second commonest cancer killer and it certainly kills more Australians than die on our roads. Tell me about the genetics, Jim, associated genetic problems. The genetics are critically important in a small group. When you look at all bowel cancer, about 3% or 4% of cases turn out to be members of families with either Lynch syndrome, what we refer to as HNPCC - hereditary nonpolyposis colorectal cancer - or families with familial polyposis. This is a situation where we can now do genetic testing in many families. Once the family-specific mutation has been found, you can offer predictive testing to other members of the family to see whether they inherited the faulty gene or not. It's a major problem in a small number of people. And if you have the gene? If you have the gene, with Lynch syndrome, because they get cancer at an early age, we recommend colonoscopy starting at the age of 25 or even earlier in some families. They get fast-track cancers, and they need a colonoscopy every year. It's a critical situation for them. They get multiple cancers. Some people opt for prophylactic colectomy simply because of the disastrous history within their families. Familial polyposis - total colectomy? Normally total colectomy, yes. Tell me about Lynch syndrome. Lynch syndrome is a very complex diagnosis. It's based on family history. It's based on several generations being involved. It centres around at least one of the people in the family affected by bowel cancer being young, either 45 or 50 depending on which set of guidelines you're trying to stick to. Bowel cancer is a very important component of it but it also involves other gastrointestinal cancers like small-bowel cancer, stomach cancer, hepatobiliary cancer. Also gynaecological cancers, endometrial and ovarian. And then transitional cell cancer of the renal tract. It's a complex diagnosis. It's something where familial cancer services are often crucially important in terms of sorting out whether someone's family history is consistent with it being Lynch syndrome. What's your practice in general practice, Sally, in terms of detecting these families, or is it just opportunistic? In general practice, it's important to have that conversation with the patient, but sometimes they don't know what their family history is - Granny died of something. You didn't talk about it then. It is a detective game. We do need to utilise our births, deaths and marriages. A few of my patients have discovered that their father died of bowel cancer and no-one told them. A question has come in from Micheline, who asks, 'Is there a biochemical marker that could be used for early detection?' Well, they're being worked on. Faecal biomarkers are being developed. Was it carcinoembryonic antigen at one point or have I got that wrong? That's a test for more advanced cancer. It's used to look for recurrence of cancer rather than early diagnosis. This is a real problem. Patients read about those in the glossies, and think, I want one of those blood tests. To explain to them, no, we're using these as markers of progression, is really hard. Let's go to our first case history. 52-year-old Brenda has just celebrated five years of post-breast cancer survival. She reckons she's neglected the rest of her health. She read an article that there may be a risk of other cancers, and she wants to know if she's at increased risk of bowel cancer. She comes to you, Sally, 'cause you're the ambassador. I'd congratulate her for thinking about the rest of her body. You can understand, she's been staring down the barrel of breast cancer, and that's scary. She's 52, she would have received something in the mail at 50, but she ignored it. This is something we have to take into account. Some of these people throw away their screening tests. To talk to her about what's her risk... There are misconceptions about the BRCA gene, and I'd like to throw to my esteemed colleague on the BRCA gene situation 'cause a lot of people worry about that. Is there an association with bowel cancer with BRCA? Short answer - no. NORMAN: Long answer is? - Well, it's complicated, like everything in medicine. Only 5% to 10% of breast cancers are BRCA-positive. In those families, the studies are divided between whether there's any increased risk or not of bowel cancer. Ashkenazi Jews have got the terrible Jewish diet to deal with. - That complicates it. - Hard to tease that out. Before we get off the genetics, it's important to remember the non-FAP, non-Lynch people. In sporadic bowel cancer, it's been estimated that 30% of it has a genetic basis, but it's a very complicated genetics. It's not simple autosomal-recessive or autosomal-dominant. - And multigene? - Yeah. We know more about risk in those families than what the genetic basis is. Coming back to Brenda, she's a 52-year-old woman who has survived breast cancer and she should slot into recommendations for people over 50. Take a history, examine her, if she's got no symptoms, I'd get her having a faecal occult blood. It is one of the misconceptions that breast cancer is a risk factor for bowel cancer and a risk factor for the family. What are the current recommendations, Jim? Where are we at with screening? Our national guidelines are that all Australians who are in good health should be in a population-screening program based on faecal occult blood testing, unless they have special risk factors. We've discussed ulcerative colitis and Crohn's, Lynch syndrome and familial polyposis. Clearly, with a strong family history, where there's no definite genetic basis, we base screening on colonoscopy. For 98% of the population, we'd say they should be having a faecal occult blood testing every two years. If the test is positive, they should have that investigated. That's normally done by colonoscopy. That's the evidence base, based on randomised controlled trials which show a 30% reduction in mortality. Level-1 evidence, randomised controlled trials, many other studies. But we don't have an evidence-based - national screening program, do we? - We're moving towards it. It's a huge task to set up a national program for five million people, to make sure you have high quality, that you're gathering all the data to show what the outcomes are, how efficient the program is. So the decision was made to start with people turning 55 and 65, then to roll out the program from there. In 2008, it was decided to include 50-year-olds. You mentioned the budget in May. It was announced that 60-year-olds would be introduced into the program next year. People turning 60 from 1st January will receive invitations from 1st July. NORMAN: That's at five-yearly intervals? JIM: Yes. In 2015, people turning 70 will join the program. Then in 2017, there will be a start of a two-yearly rollout. The first thing is, we'll have screening every 5 years from 50 to 70. These things are so obvious you forget - why FOB testing? There's a good reason. Back in the mid-1960s, a surgeon in the United States was doing screening for *** cancer using sigmoidoscopy. He said he wasn't finding enough. It wasn't productive. He suggested that we should use a test for blood in the bowel action. Cancers tend to have low-grade bleeding. Because of that, there was this interest in faecal occult blood testing for population screening, a simple test to see who should be having colonoscopy. Randomised trials were started in the 1970s, early 1980s. By 1996, we had this level-1 evidence. Australia moved very quickly. We adopted this as our national guideline by the NHMRC in 1998. It was recommended that there should be a pilot to look at the practicality, the feasibility and the acceptability of this in the Australian population. We ran a pilot from 2002 to 2004. Then we had the start of the national program in 2006. One thing we found in the pilot was that there were 1,270 people who had a positive faecal occult blood test and 67 of them turned out to have cancer. 5.3% it was when they had their colonoscopy. In the pilot, it was decided that people who had a strong family history or who had symptoms suggestive of bowel cancer as assessed by their doctors should also have a colonoscopy even though their test was negative. In that group, there were 530. Only 2 had cancer. So the likelihood of finding cancer when the test was positive was 14 times greater than when it was negative, even though those people had what we would regard as strong risk factors. It depends on the age, but it was between a 10 and 20, almost 30-fold increase in likelihood of finding cancer if your test is positive compared to having a negative test. It's a remarkable screening test. We've gone beyond - you don't brush your teeth and you don't eat red meat? The test we use is an immunochemical test. NORMAN: Do a show-and-tell for us. It's an immunochemical test for human globin. It only detects bleeding from the large bowel. If you brush your teeth, as you say, that globin is digested. It isn't recognisable. NORMAN: Show us what happens. People receive this kit in the mail. This is the package. It includes a letter of invitation. They receive a pre-invitation letter several weeks before to alert them that this is about to arrive. And to encourage them and enhance participation. To encourage them to talk to their doctors if they're not sure it's appropriate for them. Say they've had bowel cancer years before, they're already having colonoscopy. They should see their doctors and discuss it, and almost certainly phone the information line and opt out. They receive an information booklet. They receive a registration form and a consent form. In addition, they receive the test kit. This is the kit currently being used in the national program. People worry about stool tests. We keep saying, once you've done it once, it's easy. When they do it, they say, no problem. They worry about smell, they worry about the faecal aspect of it. This is where, in general practice, we can be useful. We can tell them in advance, you won't have to handle it, you won't have to touch it. It's up to us to do that. NORMAN: Show us what happens. How do they collect the bowel action? This is a collection sheet, which is placed above the water in the toilet bowl. It's methylcellulose. It's waterproof for two or three minutes. It's biodegradable. - They have to collect samples... NORMAN: Two samples? - Two samples. NORMAN: From separate stools? JIM: Yes. There's no diet needed, no need to change medication. All they have to do is collect the samples. They have a probe. You will see there's a red line there. They have the tube, which contains a buffer, a liquid. Having passed the bowel action onto the collection sheet, they insert the probe down to that depth, swipe two or three times and then simply insert. When that's inserted, that locks. There's a transport tube to protect it. Then it's put in a zip-locked bag. NORMAN: Then you put that somewhere cool until the next time. JIM: Yes. Next bowel action, the same. They collect the sample and in it goes, into its tube. That is returned in a reply-paid envelope. With the forms. SALLY: Who do the results go to? - To the participant, and they normally nominate a general practitioner, so to the general practitioner, and a copy to the central register. - They'll know to come to us? JIM: Yes. It's terribly important that people are aware that it is so simple. Currently less than 40% of people who receive those kits do anything about it. 60% of them end up in the bin, and that's a tragedy - it's a lost opportunity. What are the numbers coming to pharmacies for the kits, John? It depends on whether Rotary has got a promotional period or it's a bowel-screening week, but they do come in. Or whether a local person has had bowel cancer. These are all the triggers. That's when we field large numbers of inquiries. You have an immunochemical test as well? Yes. The one we currently use is this one. NORMAN: Tammy, show us how this one works. Basically, they will purchase this kit from a pharmacy. Inside the envelope, there will be two blue plastic bags, two brushes. These plastic bags have a different function from the plastic we saw Jim showing us? TAMMY: Yes. There's quite a good, in-depth instruction manual, full of pictures, so it's easy to use. Going to the toilet, you would put your used toilet paper in the blue plastic bag. Then get the paintbrush and swirl that around in the toilet water. You don't have to swirl it into the stool itself. The occult blood will attach from the toilet water onto the bristles of this brush. Then you take the sample card in here, and still number one, you would wipe that on this test strip, put this in the blue plastic bag, put it in the bin, seal that over. Then the second time you go for your next stool, you would take out the second brush with the second square, wipe this on here, seal that over, place this in the bin also. Then you would put this in the envelope that is returned to the pathology unit. The results will come back two weeks later to the GP which the patient has requested and to the patient themselves, in order to follow up whether the test was positive or negative. The bowel screen is something that Bowel Cancer Australia set up in collaboration with the Pharmacy Guild and the supplier of the test kit as a simple alternate pathway for people who weren't receiving kits from the government. We haven't found many customers, patients, having difficulty with the process. It's very easy to follow. We haven't had people saying, 'I messed it up, can I have another kit?' We also find that 83% of those who have done the test would do it again because they realise how simple it is. The majority of my patients, when I press them, say, 'I didn't do it 'cause I didn't want to know whether I had to touch it.' May I ask a question? We've got the five-yearly screening. But isn't the NHMRC practice that we do it every two years over 50? Do we do it in between? The national program is moving to two-yearly. But meanwhile, we in general practice should do it two-yearly? Yes, they're advised to have that done every two years. Is the colonoscopy that follows a positive faecal occult blood test free? No. In the national program, the test is free, but then it's usual care. They can be referred to a public hospital or privately. It's up to the general practitioner to decide. Sally, access to colonoscopy? It's hard enough in the city but in rural areas it must be very difficult, especially in the public system. Many of my patients can't afford to go private and can't afford to wait to go public. It's a problem. At Bowel Cancer Australia, we get a lot of inquiries from patients who have been on the screening program. Their concern is that if they are remote, they're on a three- or four-month waiting list when they've had a positive test. A question from Robert - 'How long does it take for colon cancer to develop from a harmless polyp to the first stage?' Give us a sense of the natural history. People are focused on polyps. Not all polyps are worrying. No, not all polyps are worrying. There's a histological type of polyp which can almost be dismissed. Small, distal hyperplastic polyps can almost be ignored. And are not an indication for a colonoscopy? Not for a repeat colonoscopy. If that's all that's found at a colonoscopy, that patient goes back to being the risk they were before that polyp was removed and analysed. An adenoma, that type of polyp, adenomatous polyps, generally take at least something in the order of eight to ten years if they're going to become a cancer. We've got to remember that not all polyps will. A rough estimate would be that in good hands, a colonoscopy will detect adenomatous polyps in probably as high as 50% or 60% of people. But over their lifetime, only 5% to 8% of Australians will get bowel cancer. So we just have to take polyps off without knowing whether that was the polyp that was going to become a cancer. Another question from Craig from Broome asks, 'Is there any connection between diverticulitis and colon cancer?' And Janet, a nurse from Newcastle asks, 'Can the symptoms of diverticulitis confound the diagnosis of bowel cancer?' There's no link between diverticulitis and bowel cancer. And yes, like a lot of other gastrointestinal conditions, including irritable bowel syndrome and haemorrhoids, there's huge symptomatic overlap. JIM: I mentioned before that the tests are colon-specific. Many people who have a normal colonoscopy as part of their investigation are then advised to have a gastroscopy. It is entirely inappropriate. Like the colonoscopy hasn't gone that far? If the bleeding is only arising from the large bowel, it's quite inappropriate with an immunochemical test for them to have a gastroscopy. It's an unnecessary burden for them obviously unless they've got symptoms. You've found bleeding, you don't find anything in the colonoscopy, and they say, maybe there's something in the tummy which there won't be because it would be degraded. JIM: We assume it's bleeding from haemorrhoids or diverticular disease or some other innocuous cause. NORMAN: Damien is 47. He's the only lawyer in a small rural town. He comes to you, Sally, wanting a check-up. He's got no symptoms. A family history of ischaemic heart disease but no family history of cancer. He wants bowel cancer screening. SALLY: Bowel cancer screening? NORMAN: Yes, Doctor, and now. By the way, he's a litigation lawyer. He used to work for an ambulance chaser so I'm told. I'm not going to play defensive medicine, I'm going to treat him properly. He's 47, and the national guidelines say I should start my screening at 50 if he's got no family history. But I treat people, not national guidelines. I see no skin off his or my nose to prescribe a faecal occult blood test. I would not advise him to have a colonoscopy, but I would advise a faecal occult blood despite the fact that he's not 50. What if he says, Sally, that it's an inaccurate test. It's got false positives and false negatives? He wants the real thing. I want to do the faecal occult blood first. Let's discuss it after that. You would say also that colonoscopy has false positives and false negatives. Not by the good Dr Bell's hand. But it's a good point, Norman. James is right to bring it up. People presume that colonoscopy is perfect, and it's not. We've known for at least 15 years that there is a thing called missed lesion. It should be discussed with every patient having a colonoscopy as one of the potential complications of the procedure. Damien then says to you, Sally, 'But I get some itching on my bottom and there's blood on the toilet paper and sometimes a spattering in the pan.' I would examine him. I would get on the gloves and do as the good Sir Edward Hughes taught me - put my finger in before I put my foot in, as long as he didn't have pain. With the spattering, the itch, he's probably got abrasions. I would treat clinical signs that I saw. NORMAN: But you might not see anything. That's true, isn't it, Sally? There's nothing to feel, you can't see anything, there might be some haemorrhoids there. There's no fissure. And he's a litigation lawyer. He'll have a bit of excoriation from scratching. What's the commonest cause of perianal itch? Pruritus ani - Latin for itchy bum. NORMAN: That's a nice fancy description. It's usually due to overvigorous use of toilet paper and irritation of perianal skin from paper particles. We'd treat that first, then get him to do his faecal occult. But get rid of the possible causes. NORMAN: Buy a bidet, then move on. - That's it. At the same time, you'd want him to understand that his risk for bowel cancer is rising progressively as he gets older. If he starts screening now, he should continue on a regular basis. Do you want to look at the absolute risks at this age? We've got a graphic of absolute risk. At 45, 50, it's about 1 in 300. MAN 1: He's almost at 50. MAN 2: In the next five years. MAN 1: His likelihood of getting bowel cancer in the next 5 years is 1 in 300. In the next 10 years, 1 in 100. SALLY: Are you saying he'll pressure us for a colonoscopy? I'm trying to get to the point where, my understanding is that if you've got symptoms, you don't proceed to FOB testing, you proceed to colonoscopy or sigmoidoscopy. Not in the case where we've got symptoms we can treat. If he's got something we can treat and get rid of the symptoms, then check faecal occult blood. Give him anti-itch and anti-haemorrhoid cream, then test his FOB. I'd also see if he was iron-deficient. Some people who have symptoms do need to have investigation for the symptoms, right through to colonoscopy. But once that's been sorted out, he would then need to have ongoing screening. In his case, it would be based on faecal occult blood testing, unless you found an advanced adenoma at the colonoscopy or some special risk factor. It's important to differentiate investigation of his symptoms - history and physical examination to begin with and whatever else - and the issue of screening. They're two separate discussions. I'd also call on Tammy to look at his primary-prevention program. What are you going to do for him, having been reminded, thank you very much? Considering he's a solicitor and possibly sitting for the majority of his day, I'd want to be looking at... Well, he's fidgeting 'cause he's got an itchy bum. True. Moving on the seat. Looking at what his average day looks like. What's his dietary intake like? How sedentary is his lifestyle? Is he a big drinker? Does he smoke? Looking at the parameters we could change to minimise his risk. If it is haemorrhoids, are you drinking enough water? Are you having too much fibre? If you're not hydrated well enough, causing potential haemorrhoids. Speaking of his risk factors, we did know he has a family history of ischaemic heart disease. We could suggest helping both his risk factors with aspirin. I believe there's work done in aspirin. There's mounting evidence that low-dose aspirin - 75mg or 100mg per day - reduces the likelihood of the development of adenoma, of cancer itself and of death from bowel cancer and also other cancers, interestingly. But bowel cancer seems to be the one where there's the greatest effect. Won't that cause problems with the faecal occult blood test? No, not with an immunochemical one. If bleeding is gastric, that blood will be broken down and won't be recognised. Do you get people asking for low-dose aspirin for cancer, John? Not really. But we find a lot of people over 45 now are taking low-dose aspirin as a prophylactic, certainly to prevent stroke and other areas associated with their health. It's a common feature now. Angela, a general practitioner registrar from Mount Beauty in Victoria asks, 'If we screen biannually between government tests, is this covered by the general rebate with Medicare or is the patient out of pocket? Or can the GP order the test like a normal pathology test?' I order it like a normal pathology test and I haven't had complaints from patients so I presume they get a Medicare rebate. You send them to the pathologist and they give you an FOB kit? No, I have it in my cupboard. Can I make a point? They have a use-by date on them. Sometimes it's short. If the patient doesn't do it for six to eight months, they can pass its use-by date. You've got it in your cupboard, it's sent to the pathologist - and they bulk bill? SALLY: Yeah. Leo from Mount Beauty - I presume the GP supervisor of Angela - asks, 'What's the false-negative rate for bowel cancer screening?' For faecal occult? With the immunochemical test we're using, the sensitivity for cancer is of the order of 85% to 90%. It's far more sensitive than the guaiac tests we used in the randomised control trials. They missed about 50% of the cancers. - Sensitivity or specificity? JIM: Sensitivity. And the specificity? I always get this wrong. Specificity is false negative, isn't it? Clinical epidemiology question. You shouldn't have asked it. It's for performance in people who don't have disease. So, how often does someone who's healthy get a positive test? It's in the order of 2% or 3% with the test we're using. This is a test for blood and we're talking about detection of neoplasm. I think Leo's asking how many cancers are missed. What proportion of cancers are missed? In the national program, we'll have to wait to see what happens over the next few years. But it's of the order of 10%, we believe. The next case study is Joe, who goes to see you, John, at his pharmacy to buy an FOB kit. He's heard he should get tested. He's worried because his grandmother had bowel cancer when she was 45. I'd say there's no disadvantage in selling him a test kit. Of course, at 45, he doesn't meet the criteria, but there's still about a 1 in 600 chance. They're better odds than lotto, and a better prize if he's found he's got a problem. He's got a family history of it. Maybe Cameron would have a better idea of it. How do you make sense of this family history, Cameron? You'd want to look into it. His grandmother was only in her mid-40s when she got bowel cancer and that's regarded as - no bowel cancer is good - but in terms of the significance for other family members, 55 is the cut-off. NORMAN: If indeed she had bowel cancer. If she had bowel cancer. That would need to be verified. Then it would be very interesting to know what Joe's parent, the grandmother's child, had - whether there had been premature death from cardiovascular disease, or whether they might have had colonoscopies and had large polyps removed, which would change the whole thing. That's then somebody who potentially has two bowel cancers in his family history. NORMAN: If they'd had screening, they would have had it. Yeah. We just don't know. We can never say to somebody who's had a polyp removed, 'Well, that was a cancer prevented.' There are some times we think that's pretty likely. But if you went into the family history a little bit more, his family history might become more significant. Would you take the family history in the pharmacy, John? You don't take the family history because we're involved in the screening. The advice I would give him if he was concerned about buying it, which he isn't, but if he was, I'd tell him to have a discussion with his GP. I'd let the GP take the history. If someone comes in at 45 years of age, I'd say, 'Well, what's the downside of him buying a bowel-screening kit anyhow?' The odds still increase of bowel cancer over 40 years of age, even though it's not the guidelines. - Sally? - I was going to say, if he has a negative result but you've just found his mother was screened and had polyps, he goes on to have a colonoscopy. We don't know about the mother. The grandmother died at 45. He's negative, and he's 45. What do we do with him then? We don't know what his family history is. You would probably at the very least bring him back when he's 50 and do faecal occult blood testing every one or two years. NORMAN: Make sure he's not missed. That he doesn't fall through the cracks. What's the story with flexible sigmoidoscopy? I noticed a randomised trial in the New England Journal a couple of weeks ago suggesting it was more effective than FOB testing. There are huge logistical and infrastructure ramifications. It's different. There's been a lot of interest in using flexible sigmoidoscopy perhaps at the age of 55, or even every 5 or 10 years as a screening method. It's not competing with faecal occult blood testing. You can combine the two together. In the English screening program, they're suggesting they should have flexible sigmoidoscopy performed at 55, then occult blood testing from 60 through to 74. What proportion of cancers occur in the left side of the colon? About 60%. The percentages are changing slightly. They've shown in three trials, in England, the PLCO trial in the United States and the SCORE trial in Italy have all shown in volunteers that flexible sigmoidoscopy will reduce the incidence and the mortality from bowel cancer in general, but very much so in left-sided bowel cancer. - But these are volunteers. - Not randomised. How would our population react to this? Would they accept the test? James is saying, you've got to multiply that success rate in detecting advanced adenomas or cancers by the participation rate if it's offered to a population. NORMAN: It becomes diluted. - It's of great interest. Watch this space. I meant to ask you earlier about information sources, places people can go for information, Jim. One obvious site is the Cancer Screening website: There are a number of things which can be downloaded. All the letters and all the instructions for the national program. A summary of the NHMRC national guidelines. Information on family history, again, NHMRC-endorsed and developed by Cancer Council Australia. And I think I showed you before, the booklet used in the program. There's a lot of information there. So it's cancerscreening.gov.au There's a couple of other cancer sites - Bowel Cancer Australia and Cabrini, Melbourne. I also say, Norman, that general practitioners are asked to send information back to the national program when they see patients with positive faecal occult blood tests. It's a very simple form, and it can be completed online or you can ring the information line in Hobart, the Medicare information line, to get hard copies or you can print copies of the report and complete them manually from the website. All you have to put in is... check two or three boxes, essentially, then return it to the program. We touched on family history several times, but I think we should make the point that the NHMRC guidelines stratify the risk of your family history. For example, if you have a single first-degree relative whose cancer developed over the age of 55, they regard that as a low increase in risk. The guidelines suggest that those people be treated as average-risk individuals and start screening at age 50. The intermediate-risk category is somebody whose first-degree relative was younger than 55 or who has two family members on the same side of the family, whatever their age was, affected by bowel cancer. For those people, the recommendation is colonoscopy at ten years younger than the youngest affected relative. Then there are the FAP people and the Lynch syndrome people, whose... Starts at an earlier age. ..colonoscopy is more intense and rigorous. You're watching a Rural Health Education Foundation program on preventing and early detection of bowel cancer. We'll be back after this. A home FOB test could save your life. I wish I'd done it earlier. FOB testing is so important. All of these people have had a long battle with bowel cancer. It's a condition that kills around one Australian every two hours. Yet a simple home FOB test kit can help prevent it. Please purchase a home FOB test kit. It could save your life too. - I recognised her. - It was me, indeed. Those were people who volunteered their time. And having someone as high-profile as Cocksie was magnificent. People have seen that in movie theatres. It's scary to think. It would put you off your choc bomb. 25-year-old Glen is a fitter and turner in a factory. One of his mates was diagnosed with bowel cancer, and they were talking about how it's different if caught early. He saw this ad on TV and is looking for advice, but he's scared because he's had bleeding and pain around his *** and has been constipated. No family history of bowel cancer. What will you do for him, Ambassador? I need to take his concern seriously and to fob him off, if you'll excuse the pun. But he's got symptoms, and I need to investigate these, examine him and see if I can see evidence for his bleeding. At 25, his risks are very low. If he's got pain, and it sounds like an *** fissure, I'm not going to stick my finger in because it's too painful. He's another example where I would treat his symptoms and get him back and talk about it again. I'd also give him information on bowel cancer. Cameron, take me through the history-taking of bleeding - what's worrying, what's not. When you can relax, when you can't. - Well, it's a minefield, basically. NORMAN: A red one! At the lower end of the concern spectrum is small amounts of fresh, bright-red blood on the toilet paper only, not mixed in with the stool, particularly if a patient tells you it's been happening on and off for years and years, unchanged. At the other end of the spectrum is heavier bleeding, particularly if it's dark maroon-coloured blood, suggesting that it's not from low down in the anorectum, particularly if the blood is mixed in with the stool and particularly if it's a recent development. It's a minefield, though. But a low cancer will give you fresh bleeding that looks like a haemorrhoid. Absolutely. As Sally said, no-one should be fobbed off. Unless her symptomatic patient Joe responds immediately to treatment for his *** fissure, I'd have a low threshold to investigating someone like that with sigmoidoscopy. He doesn't deserve a colonoscopy? I wouldn't colonoscope him because he's got symptoms that all sound as if they're within reach of a sigmoidoscope. If he was a litigation lawyer? Exactly the same. I'd treat him like he were my brother. I'm just getting a little nervous that you're all a bit relaxed about bleeding. No, I'm not relaxed. But I think in somebody like him, where there is no issue about bowel cancer screening, we're talking now about a symptomatic patient and flexible sigmoidoscopy is adequate investigation of this guy's symptoms. FOB is not an option in him. He's got bleeding. He's 25. If I'm in downtown, suburban Sydney or Melbourne, I can send him for a sigmoidoscopy. But if I'm in a rural area, he's 25, a fitter and turner... It looks like an *** fissure, it smells like an *** fissure, it cracks like an *** fissure, I'd treat that, then get him back and review him, and say, 'Any more *** bleeding without the *** fissure and off you go.' To what extent do you only get bleeding once and that's the only sign you've ever got? And have bowel cancer? That can occur. Many bowel cancers are silent until you've reached an incurable stage. Once you've got bleeding, are you likely to only have one episode? I know what you're getting at. - It's possible. - Thanks for that. Investigating symptomatic people, I'm talking about. Notwithstanding the low risk of finding something. I fully agree we do have to take this seriously. SALLY: Yeah, but logistically... - Most early-stage cancer causes no bleeding, no symptoms. It's silent. But a 25-year-old guy, I mean, where do you draw the line? What are we saying to people in remote areas? I'm talking about a 65-year-old guy. This is another misconception from both the general public and as health professionals - we are seeing young people with bowel cancer. A lot of young people coming to Bowel Cancer Australia are telling us, 'We have visible bleeding. We thought it was haemorrhoids, so we didn't worry about it.' They were pumping weights, taking a lot of protein. We really need to get the message out there that young people can have bowel cancer. We've got to put it in perspective. If every year, 14,000 Australians get bowel cancer, of that 14,000, 1,000 are younger than age 50 and less than 80 are younger than age 35. At 25, you just don't lose them to follow-up. You presume it's an *** fissure unless there's bleeding - I'll be clear - but you get them back. You don't lose them to follow-up. Make sure your receptionist reminds you in a month's time to phone him up and find out how he's going. He's young. He might have inflammatory bowel disease. If he's 55, even though you think it's an *** fissure? I'd think about his symptoms, and if they were still distal, to investigate his symptoms, I'd do a sigmoidoscopy. But if he's an average-risk guy, if it's going to make faecal occult blood testing impossible, and I'm not sure you can rely on the fact that the visible blood disappears. It's possible, after a fissure heals or if someone has haemorrhoids, it's possible to have bleeding-related anorectal pathology to make the FOBT unreliable. Do you mean flexible sigmoidoscopy? So examination of the ***, the sigmoid colon and into the descending colon. My point was, if this was a 55-year-old guy where you can't assume the disappearance of visible blood means he can have an FOBT, then probably he needs a colonoscopy. Very quickly, colonoscopy, current bowel preps and so on. Give us a flavour, so to speak. NORMAN: What they do now. - They've improved, but they're still not ideal. Generally, there's several days of avoiding high-roughage things, particularly things with seeds. While they're good for the bowel normally - muesli, multigrain breads, et cetera - avoid those for three or four days beforehand. Clear fluids the day before, then a bowel preparation that's two or three sachets. It depends on age and absence of comorbidities like heart and renal disease, but for most people under the age of 70, two small-volume doses and a large-volume dose, is my standard preparation. We've got some graphics of polyps so you can see what happens. What are we looking at there? On the left of the screen is a sessile polyp that's not particularly big. On the right is a pedunculated polyp. Both of those would be easily removed. At the colonoscopy they were detected at, they could be removed with a snare. That's a straightforward procedure. They should always be collected and they should all be sent for histopathology. A couple of case studies - a 52-year-old woman comes to see you, Sally. She's back from looking after her sister, who's a year or two older, who's just had surgery for bowel cancer. That's easy. She's got a family history. Her sister is young. I'd send her for a colonoscopy and bypass FOB. Another case is a 65-year-old woman who's living in Queensland who comes to see you feeling very unwell. She's overweight, a smoker, drinks alcohol on a regular basis. She's been suffering from diarrhoea, bloating and cramps, feeling fatigued and vomiting for a week. SALLY: There's so many things she could have. I'll have bowel cancer on my list of differential diagnoses, but I'd need a full work-up with her. You'd probably include iron studies. If she's iron deficient, in premenopausal women, there's a bit of room for manoeuvre. But in a postmenopausal woman or in a male, iron deficiency is a red flag. If she has cancer, it's not good news in her. If her symptoms are due to bowel cancer, her prognosis is worse than if she's found to have an asymptomatic cancer, say, as a result of screening. Are we still into Dukes' classification? No, we've moved on. There's a tumour node metastasis classification that yields stage 1 to 4 that roughly correspond to the A, B, C and D of the old Dukes' classification. The A and the B are variably involving bowel wall only. C, or Stage 3, involving nodes. Stage D or 4 involving metastasis to distant organs. NORMAN: And the outcome of surgery? CAMERON: In the first stage is very good, as is illustrated on the graphic. In Stage 1 disease, 5-year survival rates are around 90%. They progressively fall as the tumour involves deeper into the wall, then the lymph nodes. By Stage 4, with metastases present, the 5-year survival is 5% to 8% only. NORMAN: GPs need to know this because they're pleased she's going to come back - adjuvant chemo is routine now? Its clearest role is in Stage 3 disease, so when lymph nodes are present. It's unnecessary in Stage-1 disease, and it's more controversial in Stage-2 disease. So where the cancer is further through the bowel wall but not yet involving lymph nodes. That's a complex decision. I know we're running out of time. Two or three quick questions. Carol from Tamworth asks, 'Is chronic constipation a risk factor - for bowel cancer?' - No. April from Toowoomba asks, 'Does a vegetarian diet protect you from bowel cancer?' No, not necessarily. You're not eating red meat. That's right. It's a limiting... I thought Seventh-day Adventists had a lower incidence of bowel cancer? I can't tell you on that one. CAMERON: I think they do. I know vegetarians who have had bowel cancer, so it's something you can't rule out. NORMAN: Sure. We were saying exercise, but many people who exercise get bowel cancer. Right. But it is reducing the risk by minimising your red-meat intake. Andrew from Alice Springs asks, 'Is there any evidence that an infective agent can contribute to the development of bowel cancer?' Not a silly question. I'm not aware that there is an infection that increases the risk of bowel cancer. SALLY: Are we starting to get into epigenetics? Not necessarily. We said there's no chance of it in stomach cancer and we know that H-pylori is related. It's not a silly question. But common bowel infections, things like salmonella, campylobacter, shigella don't predispose to subsequent... Thank you all very much. It's been fascinating. Sorry it's been rushed towards the end. We don't want to get to the stage of that lady at the end, where she's got spread, and you're struggling to get to a good result at all. What are your take-home messages? Jim? With the national bowel cancer screening program, we know from the BioGrid study, which has been run with the Colorectal Surgical Society of Australia, that people diagnosed through the program are far more likely to have Stage-1 disease - 40% if not more with Stage-1 - compared to those who present with symptoms, where it's 14%. With distance spread, very few, 3% had metastatic disease compared to about 15% in those who presented with symptoms. We're getting early-stage cancers... NORMAN: It's a powerful story. - ..which should translate into better survival. NORMAN: Tammy? - Two points. For those listening, don't underestimate modifiable lifestyle factors. Taking the time to talk to people in terms of what they're doing and changes they could possibly make to improve their health is important. Also - talk, test and tell. Talk about bowel cancer. Test for it if you're within the age groups or if there are symptoms. And tell your family if it is in the family. NORMAN: Sally? - As general practitioners, it's up to us to sell the message that this is an insurance policy, the only cancer we can prevent other than cervical cancer, with the vaccination. And work in partnership with our pharmacy colleagues. Together, we should be able to make sure people live. In rural areas, it's often hard to see a GP, so they can pick the test up at the pharmacy, and if they're positive, they're referred back to their GP. That's the arrangement. In that age group, you don't have to have the symptoms to have the start of a cancer, so get tested often. NORMAN: Cameron? - Everyone over the age of 50 should do something to reduce their risk of bowel cancer. If they're asymptomatic and have no family history, a faecal occult blood test every two years. If they've got symptoms, get them investigated. If they've got a strong family history, have a colonoscopy. Thank you all very much. I hope you've got a lot from this program on bowel cancer. Let's get those mortality rates down. If you're interested in obtaining more information about the issues raised, there are a number of resources on the Rural Health Education Foundation's website: You can go to the Beating Cancer - Prevention, Detection, Treatment program web page and click the Resources link. If you're a health professional, don't forget to complete and send in your evaluation forms, which can be found on the website. You will receive a certificate of attendance and if eligible, CPD points. Thanks to the Australian Government's Department of Health and Ageing for making the program possible and thanks to you for taking time to attend and contribute. For more information about the Rural Health Channel on 600, you can find that on the Foundation's website: I'm Norman Swan. I'll see you next time. Captions by Captioning & Subtitling International Funded by the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs�