Lower screening age calls for more tailored bowel cancer surveillance

Australia’s recent move to lower the starting age for bowel (colorectal) cancer screening from 50 down to 45 years old will mean better outcomes – but it will also increase the burden on an already struggling healthcare system, warn Flinders University researchers.

They predict that the expanded screening program will likely lead to an influx of younger adults who will require ongoing surveillance with regular colonoscopies, prompting the team to review current clinical guidelines for at risk individuals.

Led by Flinders University, the new research reveals a shift in how surveillance might be approached in the future using a faecal test and how it could provide extra peace of mind for those at risk of bowel cancer.

Early-onset bowel cancer (diagnoses under 50 years old) is rising worldwide and currently 1 in 9 (11%) Australians diagnosed with bowel cancer are under the age of 50.

“Whilst lowering the starting age for bowel cancer screening is great, it means that more people may need to undergo regular colonoscopies over their lifetime, leading to longer waiting times for already stretched colonoscopy services,” says lead author Maddison Dix.

Colonoscopies - a medical procedure to look inside the bowel - are the gold standard for detecting bowel cancer, however they are not without risk and typically require several days of preparation and going under sedation while in hospital.

“To reduce the number of colonoscopies those at risk will need to have over their lifetime, we surveyed how they would feel about doing faecal tests in addition to, or instead of, colonoscopies,” says Ms Dix a PhD student from the FHMRI Bowel Health Service.

Conducted by a team of researchers from Flinders University, Flinders Medical Centre and the University of Melbourne, the study surveyed almost 300 people who are at risk for bowel cancer, comprising younger adults (under 50 years) and older adults (50 years and above).

Participants were asked about their preferences for colonoscopy frequency and the role of the faecal tests that are used in the National Bowel Cancer Screening Program to determine the need for a colonoscopy based on the presence of blood.

“Our key finding was that most people, regardless of their age, wanted more frequent bowel cancer surveillance than what is currently recommended in clinical guidelines,” she says.

“And that a faecal test may provide additional reassurance for those with a higher fear of bowel cancer - particularly those who were under the age of 50.”

The study revealed that a significant percentage of participants —54.1% of younger adults and 58.1% of older adults—preferred more frequent colonoscopies than current guidelines suggest indicating a clear demand for increased monitoring among those at risk.

Both groups also overwhelmingly supported incorporating faecal tests between surveillance colonoscopies, with 91.2% of younger participants and 93% of older adults in agreement.

Although comfort levels with a faecal test-only approach were low, people appreciated it as a valuable addition to traditional colonoscopy surveillance.

One of the study's notable findings is the role of fear in influencing surveillance preferences.

“Younger adults reported significantly higher levels of fear regarding bowel cancer despite bowel cancer traditionally being viewed as ‘an older person’s disease’, and this correlated with a preference for more frequent surveillance,” says Ms Dix.

“This suggests a psychological aspect that healthcare providers might want to consider when providing care for younger adults with an increased risk of bowel cancer.”

The researchers proposed that the addition of faecal tests into existing colonoscopy-based surveillance protocols could allow for personalised strategies that extend the time between colonoscopies for those with negative results.

Such an approach could meet the needs of patients wanting closer monitoring while also optimising the use of resources – such as nurses, equipment and funding - in healthcare systems.

Senior researcher Associate Professor Erin Symonds says that as early-onset bowel cancer continues to increase, this study reinforces the urgent need to adapt and update surveillance strategies to suit younger adults.

“Traditional guidelines often do not address the specific concerns and preferences of this demographic, which is becoming increasingly significant as screening eligibility ages are lowered,” says Associate Professor Symonds.

The paper, The Impact of Age on Preferences for Colorectal Cancer Surveillance Strategies: Are Fecal Immunochemical Tests FIT for Surveillance? was published in Cancer Medicine by Maddison Dix, Sarah Cohen-Woods, Molla M. Wassie, Jean M. Winter, Carlene J. Wilson, Graeme P. Young, Charles Cock and Erin L. Symonds.

Acknowledgements: This study was financially supported by an Australian National Health and Medical Research Council project grant (APP1160443).