Australia commenced an organised population screening program for colorectal (bowel) cancer in 2006, the National Bowel Cancer Screening Program (NBCSP). Indicators of the performance of NBSCP include the elapsed time between a positive screening test and a follow-up diagnostic assessment.1 Following a positive screen, further diagnostic evaluation should occur in a timely fashion, thus minimising potential for harm from delayed diagnosis and treatment.1 This indicator should not be considered a hospital wait time indicator, as there are various steps, decisions and wait times in the pathway between a positive screen and a diagnostic assessment.
It should be noted that this indicator relies on information being reported to the Program Register; however, this is not mandatory.1 Additionally, not all participants with a positive screening result will necessarily undergo diagnostic assessment.
About this measure
Australia has one of the highest rates of colorectal cancer in the world, and it is projected that this cancer will be the third most commonly diagnosed cancer recorded in Australia in 2019 (after breast cancer and prostate cancer).1, 2 It is anticipated that in 2019, 16,398 persons will be diagnosed with colorectal cancer and that this cancer will cause 5,597 deaths.3 It is also estimated that colorectal cancer will remain the second leading cause of cancer death in Australia (after lung cancer).3
Colorectal cancer may be present for many years before showing clear symptoms, but non-visible bleeding of the colon and rectum can occur in the precancerous stage.1 The faecal occult blood test (FOBT) is a non-invasive test that detects microscopic amounts of blood in a faecal sample. Regular screening using the FOBT and treatment of FOBT-positive cases can reduce mortality due to colorectal cancer by up to one-third.4
A positive FOBT result requires follow-up procedures to determine an accurate diagnosis. Colonoscopy is currently considered to be the most appropriate investigation, because it enables a biopsy to be taken for histopathological diagnosis. Colonoscopy also allows identification and endoscopic removal of precancerous polyps and adenomas.1
In 2002, a pilot program was undertaken in Australia to test the feasibility, acceptability, and cost-effectiveness of national colorectal cancer screening. The success of this pilot program led to the Australian Government implementing:
- Phase 1 of the NBCSP, which commenced in August 2006 to screen Australians of the target ages of 55 and 65 years.
- Phase 2 commenced in July 2008 and screened Australians of the target ages of 50, 55 and 65 years.
- Phase 3 commenced in July 2013 and screened Australians of the target ages of 50, 55, 60 and 65 years.
- Phase 4 of the NBCSP commenced on 1 January 2015; in this phase the program is being gradually rolled-out over 5 years to achieve biennial screening for Australians aged 50–74 years.2
Current status
In 2017, of the eligible invited population who returned a positive (abnormal) result from a correctly completed FOBT screening kit and who had a follow-up colonoscopy, the median time between a positive screening result and a diagnostic assessment was 52 days (53 days for males, 51 days for females).1 A slightly longer median time to assessment was observed for persons in their 50s (53 and 54 days for persons aged 50–54 and 55–59 years, respectively) than for older Australians ( to 52 days, 51 days, and 52 days for persons aged 60–64, 65–69, and 70–74 years respectively).1
Aboriginal and Torres Strait Islander peoples
In 2017, there was a longer median time between a positive screen for colorectal cancer and diagnostic assessment for Indigenous Australians (70 days) than for non-Indigenous Australians (52 days).1
Remoteness and socioeconomic status (SES)
In 2017, the median time between a positive screen for colorectal cancer and diagnostic assessment was highest for people living in Remote areas (66 days) and Very Remote areas (65 days) and lowest for those living in Major Cities (51 days).1 Analysis by socioeconomic status showed that median times to assessment were highest for people living in the lowest socioeconomic areas (SES 1, 61 days) and lowest for people living in the highest socioeconomic areas (SES 5, 46 days).1 As reporting of follow-up assessments is not mandatory, there is an unknown level of under-reporting and levels of under-reporting may differ across population groups.1
Trends
Over the period 2007 to 2017, the median time between a positive screen for colorectal cancer and diagnostic assessment varied between 52 and 57 days. Since 2010, the median time to assessment has generally decreased, from 57 days to 52 days in 2017.1 In each reporting year, females were observed to have a lower median time to diagnostic assessment compared to males (approximately 2 to 3 days shorter). Within each age group, the median time to diagnostic assessment generally fluctuated over time. Observed decreases mostly occurred among males and females aged 50–54 years.
Aboriginal and Torres Strait Islander peoples
From 2014 to 2017, the median time between a positive screen for colorectal cancer and diagnostic assessment for Indigenous Australians has fluctuated between 64 days (2015) and 83 days (2014). Nonetheless, a generally decreasing trend is indicated with the median time to assessment being to 70 days in 2017. For non-Indigenous Australians, the median time to assessment decreased from 2014 to 2017 has fluctuated between 52 and 54 days. 1, 5-7
Remoteness and socioeconomic status (SES)
Data are available for the median time between a positive screen for colorectal cancer and diagnostic assessment, by remoteness area for the years 2015 to 2017 and by SES area for the years 2014 to 2017.
Across these periods, the median time between a positive screen for colorectal cancer and diagnostic assessment in each remoteness areas and SES area has fluctuated and shown no apparent trend.1, 5-7
Colorectal cancer control in Australia
Since the initial trial of national cancer control screening through the pilot program and, subsequent implementation of the NBCSP, improvements have been observed in mortality and survival rates. 1, 3 The age-standardised colorectal cancer mortality rate has decreased from 24.7 deaths per 100,000 in 2002 to 18.7 deaths per 100,000 in 2016, and the 5-year survival rate has increased from 62.9% in 2001–2005 to 69.9% in 2011–2015. The AIHW has analysed outcomes for persons who, in the period 2006−2010, were: aged 50-74 years; and diagnosed with colorectal cancer. During this time, in Phases 1 and 2 of the NBSCP, invitations to screen were sent to persons turning 50, 55 or 65 years old. For persons who did not receive an invitation to screen, the risk of colorectal cancer death was 13% higher than for those that did receive an invitation to screen.4
The NCCI measures Capture of stage data and Distribution of cancer stage present national data for Registry-Derived stage (RD-Stage) at diagnosis for the top 5 cancers by incidence in 2011. These data show that people aged 50 years and over had a higher proportion of early stage colorectal cancers at diagnosis (stage 1 and stage 2) than those aged less than 50 years. RD-stage data collection in subsequent years will provide us with more detailed evidence regarding the impact of the NBSCP on early detection of colorectal cancer in the target age range.
About the data
This measure shows the median time between a positive NBCSP screening test and a follow-up diagnostic assessment. For 2017 data, the positive screening test occurred between 1 January 2017 and 31 December 2017, and the follow-up diagnostic assessment was up to 31 December 2018.
Median time to follow-up assessment data was first reported in 2016, following publication of NBCSP performance indicators in 2014.1 Thus, to allow a trend comparison over time, these new indicator specifications were applied retrospectively to earlier years of program data.
Methodology
Remoteness
Participants were allocated to a remoteness area using the postcode supplied at the time of screening, using the Australian Statistical Geography Standard (ASGS) 2011.
Socioeconomic status
Participants were allocated to a socioeconomic group using their residential postcode according to the Socio-Economic Indexes for Areas (SEIFA) Index of Relative Socio-Economic Disadvantage (IRSD). For 2017 data the 2016 IRSD was used; for 2016, 2015, and 2014 data the 2011 IRSD was used.
Data sources
Australian Institute of Health and Welfare. AIHW Bowel cancer screening publications: Accessed December 2019; https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/cancer/reports
Australian Institute of Health and Welfare 2019.National Bowel Cancer Screening Program: monitoring report 2019.Cat. no. CAN 125. Canberra: AIHW.
Australian Institute of Health and Welfare 2018.National Bowel Cancer Screening Program: monitoring report 2018.Cat. no. CAN 112. Canberra: AIHW.
Australian Institute of Health and Welfare 2017.National Bowel Cancer Screening Program: monitoring report 2017.Cat. no. CAN 103. Canberra: AIHW
Australian Institute of Health and Welfare 2016.National Bowel Cancer Screening Program: monitoring report 2016.Cat. no. CAN 97. Canberra: AIHW
Data caveats
The National Bowel Cancer Screening Program is being implemented in a phased approach. National screening of Australians aged 60–64 years did not commence until Phase 3 was implemented in 2013, and screening of 70–74 years old commenced with the roll-out of Phase 4 in 2015 which incorporates biennial screening.
This indicator relies on information being reported, but this reporting is not mandatory. Thus, the data may be incomplete, with an unknown level of under-reporting which may differ across groups and in different years.
References
Activity in this area
Data:
Australian Institute of Health and Welfare. AIHW cancer screening publications: Accessed December 2019; https://www.aihw.gov.au/reports-statistics/health-welfare-services/cancer-screening/reports
Policy:
Australian Government Department of Health. National Bowel Cancer Screening Program Phase Four (2015 – 2020) Policy Framework. Accessed December 2019; http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/program-frameworks-and strategies
References
1. Australian Institute of Health and Welfare 2019. National Bowel Cancer Screening Program: monitoring report 2019. Cat. no. CAN 125. Canberra: AIHW.
2. Australian Government Department of Health 2019. National Bowel Cancer Screening Program. Canberra: Australian Government Department of Health. Accessed: 06 December 2019; http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/about-the-program-1.
3. Australian Institute of Health and Welfare 2019. Cancer data in Australia. Cat. no. CAN 122. Canberra: AIHW. Accessed: 6 December 2019; https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia.
4. Australian Institute of Health and Welfare 2018. Analysis of bowel cancer outcomes for the National Bowel Cancer Screening Program 2018. Cat. no. CAN 113. Canberra: AIHW.
5. Australian Institute of Health and Welfare 2018. National Bowel Cancer Screening Program: monitoring report 2018. Cat. no. CAN 112. Canberra: AIHW.
6. Australian Institute of Health and Welfare 2017. National Bowel Cancer Screening Program: monitoring report 2017. Cat. no. CAN 103. Canberra: AIHW.
7. Australian Institute of Health and Welfare 2016. National Bowel Cancer Screening Program: monitoring report 2016. Cat. no. CAN 97. Canberra: AIHW.