National Bowel Screening Programme: Frequently asked questions

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Why is New Zealand introducing a National Bowel Screening Programme?

Every year, more than 3000 New Zealanders are diagnosed with bowel cancer and more than 1200 die from it. 

There may be no warning signs that bowel cancer is developing.

The free National Bowel Screening Programme aims to save lives by detecting bowel cancer at an early stage, when it can often be successfully treated.

How many people will be screened through the NBSP?

Once fully implemented the NBSP will invite more than 700,000 people for screening every two years.

What are the benefits of a bowel screening programme?

International evidence shows that bowel screening programmes can save lives through early diagnosis and treatment of bowel cancer.

International findings indicate that a bowel screening programme has the potential to reduce deaths from bowel cancer by at least 16 to 22% (after 8 to 10 years) in the population offered screening.

Bowel screening has health, social and economic benefits. Early identification and treatment results in better outcomes for those with bowel cancer and lower treatment costs when compared to the cost of treating more advanced cancers.

A bowel screening programme that has equal screening and follow-up rates for Māori and non-Māori could reduce inequities through early diagnosis and treatment.

The NBSP will focus on initiatives that drive equitable participation for all population groups.

How can bowel screening save lives?

Bowel screening saves lives by detecting cancer at an early stage, when it can often be successfully treated. Bowel screening is for people who have no obvious symptoms of bowel cancer.

Around two thirds of the cancers diagnosed through the Bowel Screening Pilot at Waitemata DHB are early stage (Stage 1 or 2). Go to the Bowel Screening Pilot Monitoring Indicators to find out more.

Where cancers are diagnosed through services that treat people who already have symptoms of bowel cancer, only about 40% are found at an early stage.

How many polyps and cancers will be detected?

About seven in 10 people who have a colonoscopy as part of the National Bowel Screening Programme will have polyps (growths) detected, which if removed may prevent cancer developing.

About seven in 100 people who have a colonoscopy as part of the National Bowel Screening Programme will be found to have cancer, and most will require treatment.

More than 700,000 people aged between 60 and 74 will be invited for screening every two years once the programme is fully implemented.

It is anticipated that in the early rounds of screening, 500 to 700 cancers will be detected each year.

How is the National Bowel Screening Programme (NBSP) being funded?

Budget 2016 has provided $39.3 million over four years to begin implementation of the NBSP. This will cover the cost of the design, planning and set-up phases. Additional funding has been set aside for work on the national IT system and infrastructure needed for a national programme.

Ongoing funding will be subject to Budget 2017 decisions. It would cover the ongoing operational costs of the programme, including screening colonoscopies. Surveillance colonoscopy procedures that follow a colonoscopy in the NBSP would also be funded.

DHBs will be responsible as usual for funding treatment costs and the cost of routine diagnostic and surveillance colonoscopies covered by the colonoscopy Wait Time Indicators.

How will the programme be rolled out?

The programme will be progressively rolled out across the country beginning in the 2017/18 financial year (1 July 2017 to 30 June 2018).

Hutt Valley and Wairarapa DHBs will be the first DHBs to begin screening the eligible 60 to 74 year age group, with all other DHBs following in stages.

Bowel screening will continue to be offered at Waitemata DHB, where the BSP has been operating since late 2011. The BSP will transition to the National Bowel Screening Programme in January 2018.

When will other DHBs begin offering bowel screening?

Confirmed roll-outs for throughout 2017/18 financial year (1 July 2017 to 30 June 2018):

  • Waitemata DHB
  • Hutt Valley DHB
  • Wairarapa DHB
  • Counties Manukau DHB
  • Southern DHB

Indicative times for other DHBs

Throughout 2018/19 financial year (1 July 2018 to 30 June 2019):

  • Northland DHB
  • Auckland DHB
  • Waikato DHB
  • Hawkes Bay DHB
  • Whanganui DHB
  • MidCentral DHB
  • Capital & Coast DHB
  • Nelson Marlborough DHB
  • Canterbury DHB
  • South Canterbury DHB

Throughout 2019/20 financial year (1 July 2019 to 30 June 2020):

  • Bay of Plenty DHB
  • Tairawhiti DHB
  • Lakes DHB
  • Taranaki DHB
  • West Coast DHB

Could the proposed order change?

Provisional start dates are for planning purposes only and are subject to confirmation. A final readiness assessment will be carried out before DHBs can begin screening.

DHBs must be able to demonstrate their ability to deliver a safe and effective bowel screening service. The Ministry will work closely with DHBs as they prepare to begin screening and will assist them to meet the requirements of the readiness assessment.

How was the roll-out order decided?

Following the Budget 2016 announcement of a national bowel screening programme, DHBs were given a provisional start date range to assist with early planning. This was based on a Ministry assessment of information that had been provided by DHBs in 2015.

A questionnaire seeking more detailed information to inform the roll-out was sent to DHBs in late May 2016. The questionnaire responses have been carefully analysed and considered alongside other factors at each DHB that could impact the safe and effective roll-out of the programme.

DHBs have been assessed against set criteria including financial performance, how well they are meeting the colonoscopy wait time indicators and Faster Cancer Treatment health target, their bowel screening IT capability, cancer incidence, equity and their eligible population.

As a result, a new roll-out order was determined. The new order is intended to place DHBs in the best possible position to achieve a successful start to bowel screening in their area and is expected to allow adequate time for recruitment.

Why have Hutt Valley and Wairarapa DHBs been selected for the first stage of the roll-out?

A number of factors contributed to the decision, including their small size, their history of working together, their willingness to build a closer working relationship and their strong primary care links.

The DHBs were able to begin screening in the 2017/18 financial year.

Their small size will enable them to adapt more easily to the complex requirements of an evolving programme, including managing changing IT requirements as they link to an enhanced pilot IT system and then move to a new national bowel screening IT system that will be built.  The new national screening IT system will safely support the larger volumes involved when larger and increased numbers of DHBs begin screening. Increased automation will also facilitate quality monitoring.

This will also mean they can trial new systems and processes for the wider roll-out. The DHBs have a unique population mix that includes a rural component.

How well are Hutt Valley and Wairarapa DHBs meeting demand for symptomatic and surveillance colonoscopies?

Both Hutt Valley and Wairarapa DHBs have made good gains in recent times but like many DHBs there are fluctuations in how well they meet the wait time indicators each month.

The number of DHBs meeting the wait time indicators in each category has significantly improved in recent years however a continued focus on colonoscopy service provision is required to ensure the gains made are not lost.

How will bowel screening services be delivered?

During the first stage of the roll-out, the Bowel Screening Pilot (BSP) Coordination Centre will manage and send screening invitations, coordinate the processing, analysis and management of completed faecal immunochemical tests and results for the Pilot and also for bowel screening at Hutt Valley and Wairarapa DHBs.

A National Coordination Centre (NCC) will be established in 2018 to take over this role. The NCC will host the 0800 number (0800 924 432), send letters to participants following a negative result and notify GPs electronically of all results.

The NCC will also advise the local DHB endoscopy service of all positive results.

The Ministry will contract directly with a single laboratory to provide the services associated with the faecal immunochemical test (FIT) kit.

DHBs will be responsible for delivering colonoscopies, overseen by four bowel screening regional centres that will support clinical leadership, and manage quality and equity in their area.

DHBs will continue to be responsible for surgical and cancer treatment.

How will general practice be involved in the programme?

GPs have a key role to play in the success of the NBSP.

GPs will advise their patients of positive test results, refer them for a screening colonoscopy and support them through the process.

They will be able to provide their patients with information about the NBSP, reassure them about the screening pathway and prompt their eligible patients to participate when they are invited every two years.

GPs can help raise awareness of bowel cancer among their patients, and refer those with a strong family history bowel cancer to the New Zealand Familial Gastrointestinal Cancer Service for assessment and support. GPs can also help identify and refer for surveillance colonoscopy their patients who on the basis of their family history meet the moderate risk criteria – see the brochure for primary health practitioners at Guidance on Surveillance for People at Increased Risk of Colorectal Cancer.

International experience shows that screening programmes with direct GP involvement have higher participation rates.

What will the screening test and pathway be?

The screening pathway will mirror the successful model used in the Waitemata DHB Bowel Screening Pilot, which began in late 2011. Eligible people will be identified through a population register and will be invited to complete a bowel screening test every two years.

They will be sent a pre-invitation letter and information about the programme, followed by an invitation letter and faecal immunochemical test (FIT) kit to complete at home and send by Freepost to the laboratory for testing.

The test can detect tiny traces of blood in bowel motions that may be an early sign of pre-cancerous polyps or bowel cancer. International studies have indicated that FIT is effective in detecting bowel cancer at an earlier stage and reducing deaths from bowel cancer, and is cost-effective.

Most European countries with an organised screening programme use as their screening test a non-invasive faecal test. European countries that have started organised screening more recently (including Ireland and the Netherlands) are, like New Zealand, using the newer immunochemical faecal occult blood test known as FIT or iFOBT.

In line with other international bowel screening programmes, the amount of blood needed to trigger a positive result (positivity threshold) has been set at a level where there is a greater likelihood of a cancer being found in participants undergoing colonoscopy. Details on the positivity threshold chosen for the programme are available in the Age Range and Positivity Threshold document.

Has flexible sigmoidoscopy (FS) been considered for screening here?

At this stage the Ministry and its professional advisory groups believe there is no indication to change the screening test to FS. The Ministry will regularly review any new evidence in relation to this or the addition of FS to other screening modalities.

In England a one-off FS is gradually being introduced for people aged 55 years, in addition to their regular two yearly FOBT screening from the age of 60 to 74 years. In the United Kingdom, participation in FS at the age of 55 years was recently reported to be 43.1%.

In contrast, the Waitemata DHB bowel screening pilot has been successful in detecting early stage cancer using a FIT and has shown that 56% of people aged 50 to 74 will participate in such a programme.

Both Ireland and the Netherlands, after rigorous evaluation, have recently introduced population based bowel screening with an immunochemical faecal occult blood test.

Even if not performed by specialists, FS still requires endoscopic resource, including staff and theatre space.

Modelling has shown that in New Zealand, pressure on endoscopy resources from FS would be greater than that generated by a screening programme using FIT and would require extensive workforce training to ensure participants received quality procedures. It would delay implementation of a national bowel screening programme by several years.

Will DHBs be able to cope with the extra demands of a bowel screening programme?

DHBs were surveyed in October 2015 to establish:

  • the approach each DHB would take to manage the anticipated increase in colonoscopy volumes
  • the estimated additional capital requirements (noting that non-capital approaches should be identified where possible as the Ministry  would prefer to invest in services)
  • the year their DHB would be ready to begin screening, if a roll-out begins in 2017.

DHBs provided assurance that they could manage the increase in colonoscopy volumes if they received:

  • a definitive start date that gave adequate time to plan and implement the programme
  • adequate funding to set up and deliver the programme.

Is there sufficient workforce to do the colonoscopies?

Information from the Waitemata DHB Bowel Screening Pilot and discussions with the sector confirm there is the capability and clinical workforce in New Zealand to deliver the additional colonoscopies required for a progressive roll-out of a national bowel screening programme for people aged 60 to 74 years. Initiatives are underway to strengthen the endoscopy workforce, including:

  • increasing the number of trainees for specialities that are involved in delivering colonoscopy
  • discussions with the relevant professional bodies to determine if some specialists performing colonoscopy could potentially devote a greater proportion of their time delivering colonoscopy
  • close monitoring of the endoscopy workforce and the impact for other specialties if endoscopy workforce practices change
  • delivering an endoscopy training programme for nurses with the first cohort able to perform procedures from 2018. Within DHBs this could release more experienced clinicians to perform the more complex colonoscopies associated with screening
  • investigate the increased use of CT colonography (CTC) where clinically appropriate.

How will the programme drive equitable outcomes?

There are differences in bowel cancer survival in New Zealand by ethnicity, age and place of residence (urban or rural).

Māori are 30% less likely than non-Māori to get bowel cancer, but once diagnosed, are 30% more likely to die from it.

This is partly because Māori are more likely to be diagnosed with bowel cancer at an advanced stage when it is more difficult to treat. Many factors contribute to poorer survival for Māori.

Standardising care along the diagnostic and treatment pathway can reduce inequities by enabling fair access to quality services.

The NBSP will focus on initiatives that drive equitable participation for all population groups.

What initiatives will be introduced to enable equal participation?

The programme includes actions to enable equal participation such as:

  • targeted actions to increase participation in bowel screening for Māori, Pacific and high deprivation population groups (active follow-up on invitations, targeted health promotion, engagement with community groups, churches and marae)
  • each DHB will have an equity plan, to implement locally appropriate actions to increase equity
  • national monitoring of participation and outcomes by ethnicity through the bowel screening IT system to inform and drive actions to improve equity
  • primary care involvement in promoting participation and managing positive results
  • national governance to have a strong focus on equity.

What happens to people currently eligible for screening as part of the Waitemata DHB pilot?

Bowel screening will continue to be offered at Waitemata DHB, which will transition to the National Bowel Screening Programme in January 2018.

Eligible people aged 50 to 74 years who are living in the Waitemata DHB area will continue to be invited for screening until the Pilot ends in December 2017. People who have been invited to take part in the Pilot will continue to be invited to complete a bowel screening test every two years, while they are still eligible.

People living in the Waitemata DHB area who have not turned 50 by the end of the Pilot and have not been invited to participate in the Pilot, will become eligible for screening as part of the National Bowel Screening Programme once they turn 60.

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