weo crc sc meeting...invitation letter, test kit , consent form structure of the screening programs...

WEO CRC SC Meeting

Taipei, Taiwan

December 3, 2015

Success stories from the Asia-Pacific: Australia & NZ

Erin Symonds, Bowel Health Service, Repatriation General Hospital

Flinders Centre for Innovation in CancerAUSTRALIA

CRC screening in Australia and New Zealand

Erin Symonds

Pilot program commenced in 2002.Full program started in 2006

Pilot program commenced in

2012 and will run until Dec 2017

The structure of the programs

The findings so far

The research that has come

from the programs

Program performance

Why are CRC screening programs needed in Australia and New Zealand?

Erin Symonds

New ZealandAustralia

In 2012:15,840 Australians diagnosed with bowel cancer (population 23 mil)

In 2011:3030 of the New Zealand population diagnosed with bowel cancer (population 4.5 mil)

Pilot screening programs

Erin Symonds

AUSTRALIA: 2002-2004

• Single screening round

• People aged 55-74y

– Mackay (rural) = 11,045

– Adelaide (urban) = 18,431

– Melbourne (urban) = 27,431

– Total Pilot = 56,907

NEW ZEALAND: 2012-2017

• Three screening rounds

• People aged 50-74y

– Waitemata district health board area

– Round 1 = 121,798

– Round 2 = 79,851

Invitation letter, test kit , consent form

Structure of the screening programs

Erin Symonds

Pre invitation letter

Sample returned to laboratory via post

Result to patient, screening register and GP

2 sample FIT 1 sample FIT

Reminder letter - 8 weeks Reminder letter - 4 weeks

Positive results: GP should organise colonoscopy

Copy of pathology requested by screening program

Repeat screening every 5 years**(soon to be every 2 years)

Repeat screening every 2 years(5 years after a positive FIT)

Centralised program

No centralised colonoscopy recall program

Results from the pilot programs

Erin Symonds

45,456,8

0

20

40

60

80

100

Australia New Zealand

%

9586

0

20

40

60

80

100


%9

7,5

0

2

4

6

8

10


%

Participation Correct completion of test

Positivity rate

Results from the pilot programs

Erin Symonds

97,5

0

2

4

6

8

10


%

Positivity rate

55

86,1

0

20

40

60

80

100


%

5,3

13,9

4,3

23,8

0

5

10

15

20

25

cancer advanced adenoma

%


Follow-up of positive FIT with colonoscopy

Positive predictive value

Further results from Australia…(2006-2014)

National Bowel Cancer Screening Program

Ages that get FIT kits

2002-2004 (pilot) 55-74y

2006-2008 55y and 65y

2008-2013 50y, 55y and 65y

2014 50y, 55y, 60y and 65y

2015 50y, 55y, 60y, 65y, 70y and 74y

2016-2020 roll-out to every 2 years (50-74y)

• In 2006 the Australian government commenced the full screening program for bowel cancer using immunochemical FOBTs

Further results from Australia…

Erin Symonds

0

10

20

30

40

50

Pilot (2002-2004)

2006-2008 2008-2011 2011-2012 2012-2013 2013-2014

% p

arti

cip

atio

n

0

5

10

15

20

25

30

35

40

45

50y 55y 60y 65y

% p

arti

cip

atio

n

0

5

10

15

20

25

30

35

40

male female

% p

arti

cip

atio

n

FIT participation rates

Age and FIT participation rate 2013 Gender and FIT participation rate 2013

36.0%

Further results from Australia…

Erin Symonds

0

10

20

30

40

50

Pilot (2002-2004)

2006-2008 2008-2011 2011-2012 2012-2013 2013-2014

% p

arti

cip

atio

n

FIT participation rates

Socioeconomic status and FIT participation rate 2013

36.0%

34,1 36 35,7 36,7 37,4

05

10152025303540

1 (lowest) 2 3 4 5(highest)

par

tici

pat

ion

(%

)

Socioeconomic status

Screening allows early detection and prevention

Personal reasons:

dislike of sampling mode, procrastination, lack of knowledge,

anxiety

Medical reasons:

bleeding conditions- haemorrhoids, IBD, radiation proctitis

Why are less than 40% of people screening for bowel cancer in Australia?

Personal reasons

bleeding condition

colostomy

Dr decision

needs carer

Need another type of screening

test for people who will not or

should not complete FIT

- Blood test for CRC screening?

1. Advanced notification letter

Information sent 2 weeks prior to FOBT kit increased participation

0

10

20

30

40

50

60

no letter letter before FOBT

par

tici

pat

ion

(%

)

*Cost effectiveness studies show that

for the cost of one additional letter

in the program, 54/100,000

additional cancer deaths are avoided (Cronin, Int J Tech Assess Health Care 2013)

How to improve participation rates in bowel cancer screening programs

How to improve participation rates in bowel cancer screening programs

2. Reminder letters

60,0

65,0

70,0

75,0

80,0

85,0

90,0

95,0

100,0

6wk 12wk 18wk 24wk 30wk

Par

tici

pat

ion

rat

e (

%)

50-59y

60-69y

70-75y

Effect of multiple reminder letters on different age groups

0

5

10

15

20

25

30

35

40

45

50y 55y 60y 65y

% p

arti

cip

atio

n

**Advanced notification

letters and reminder letter are

used within the National

Screening programs**

7,5

6,67

7,5 7,5

0

1

2

3

4

5

6

7

8

2006-2008 2008-2011 2011-2012 2012-2013 2013-2014

Po

siti

vity

(%

)FIT positivity rates- Australian program

Effect of running the program in summer?

Netherlands (south west): summer = 8.0%winter = 9.7%2

Florence: 17% lower probability in summer of FOBT positivity1

Veneto: summer = 4.53%winter = 4.97%3

1- Grazzini et al, Gut (2010) 59: 1511-5.

2- van Roon et al Am J Gastroenterol (2012) 107: 99-107.

3- Zorzi et al Gut (2012) 61: 162.

Temperature (C) Positivity rate OR (95% CI)

17°C 6.8% 1.00

17.1 - 26°C 6.3% 0.93 (0.81 – 1.06)

26.1 - 35°C 5.6% 0.80 (0.68 – 0.94)

≥35°C 4.5% 0.65 (0.46 – 0.90)

0

5

10

15

20

25

30

35

0,0

2,0

4,0

6,0

8,0

10,0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

me

dia

n t

em

pe

ratu

re (

°C)

% p

osi

tive

FO

BT

Month that FOBT was returned

n = 21,688 completed FOBTs

FIT positivity rates in Australia

Netherlands (south west): summer = 8.0%winter = 9.7%2

Florence: 17% lower probability in summer of FOBT positivity1

Veneto: summer = 4.53%winter = 4.97%3

The National Bowel Cancer Screening Program avoids

sending FOBT kits in summer

Findings after a positive FIT in the Australian program (2013-2014):colonoscopy reports

Erin Symonds

5,2

16,6

35.0

22,520,3

0

5

10

15

20

25

30

35

40

cancer polyp ≥ 10mm polyp < 10mm other normal

% o

f fi

nd

ings

Findings after a positive FIT in the Australian program (2013-2014): pathology reports

Erin Symonds

4

9,1 8,4

47,3

31,2

0

5

10

15

20

25

30

35

40

45

50

cancer advancedadenoma

non-advancedadenoma

no neoplasia polyps (histologynot provided)

% o

f fi

nd

ings

Good:- Cancers and adenomas are being detectedBad:- There are still many false positives- Not all pathology is reported to the register which limits program evaluation

Some indicators of program performance

Erin Symonds

AUSTRALIA NEW ZEALAND- pilot

Participation with FIT 36% 57%

Re-participation 73.5% 81.7%

Positivity rate 7.5% 7.5%

Colonoscopy follow-up 67.6% 86.1%

PPV Cancer 5.2% 4.5%

Reduction in CRC incidence and mortality

? ?

80% is the desirable target for CRC screening, but should be at least 65% (and greater than 45% for a pilot program)


Erin Symonds








? ?

Rescreening rate has been proposed to be 80%


Erin Symonds








? ?

As both programs use FITs, positivity threshold can be adjusted to allow colonoscopy referrals to match capacity of health care system

National Bowel Cancer Screening Program for South Australia

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2012 2013 2014 2015 2016 2017 2018 2019 2020

No

. of

colo

no

sco

py

Projected colonoscopies needed in SA for the National screening program

40% participation

60% participation

Add 60yScreening for 50,55,65y

Add 70,74y Add 64,72y

Add 54,58,68y

Add 66y

Add 52,56y

Current recommendation is for colonoscopy within 30 days of GP referral for a positive FIT.By 2020, approximately 122,000 people will need a colonoscopy each year

In 2006-2009: 76% of colonoscopies were not done within 30 days


Erin Symonds








? ?Screening will be limited in its success at reducing CRC incidence and mortality if positive results are not followed up


Erin Symonds







? ?

The Australian program from 2002-2014 has detected 3496 CRC (60.2% stage I and II)The New Zealand program from 2012-2014 has detected 285 CRC (68.2% stage I and II)

Cole SR, et al Med J Aust. 2013; 198:327-330 Cenin DR, et al Med J Aust. 2014; 201:456-61

Screening every 2y

Potential outcomes on CRC incidence and mortality

Early detection = reduction in mortality


Erin Symonds







? ?

Early results and modelling are promising but further time and data are needed.

Conclusions• Room for improvement in participation rates in both

programs

• Need FIT that is stable in summer temperatures

• Need another screening test option to improve equity of access

• Need to ensure colonoscopy capacity (in Australia current guideline is 30 days post-positive FIT to have colonoscopy)

– Adjust FIT positivity threshold

– Have way to triage for colonoscopy

(eg. FIT quantitative levels, a 2nd test?)

• Will soon be able to see impact on CRC incidence and mortality Erin Symonds

weo crc sc meeting...invitation letter, test kit , consent form structure of the screening programs...

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