Review of Phase Four of the National Bowel Cancer Screening Program

The Department of Health (the Department) established the National Bowel Cancer Screening Program (the NBCSP or the Program) in 2006 to address the rising incidence and mortality of bowel cancer in Australia. This decision made Australia one of the first countries to offer free bowel cancer screening to a national population.

The Program aims to reduce the incidence of bowel cancer through detection of pre-cancerous growths (i.e. adenomas), and improve survival from bowel cancer through detection of cancer at an early stage. Screening was initially offered to Australians aged 55 and 65, and gradually expanded over time. In 2014-15, the Program committed to implementation of biennial screening of people aged 50 to 74 by 1 July 2020. This time period was consequently referred to as Phase Four of the Program.

The Program is now fully biennial for people aged 50 to 74, which aligns with the Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (the Clinical Guidelines). The Department commissioned Cancer Council Australia to develop the Guidelines through an independent group of experts. The National Health and Medical Research Council (NHMRC) subsequently approved these Guidelines.

The completion of Phase Four allows the Program to shift from a focus on expansion to optimisation, and thus represents an opportune time to review the Program and consider its strengths and opportunities for improvement.

Scope of the review
The Department engaged Deloitte Access Economics to undertake a comprehensive review of Phase Four of the Program. The purpose of the review was to assess:
• Appropriateness: The suitability of the Program design including the clinical pathway, diagnostic elements and the Alternative Pathway pilot.

• Fidelity: The extent to which the Program was implemented as intended, including Program delivery, data collection, reporting, as well as the operations of governance structures.

• Awareness and adoption: The extent to which consumers and clinicians are aware of, and have adopted, the Program.

• Effectiveness: The extent to which the Program is effective in achieving its stated objectives, including maximising benefits and minimising harms to individuals participating in the Program.
• Efficiency: The extent to which the Program is cost-effective relative to no screening, across different age brackets and participation rates.

Themes related to Program sustainability (i.e. identified opportunities for improvement as part of the next phase of the Program) and equity of access are discussed where relevant under each of the domains listed above.

Out of scope
The National Cancer Screening Register (NCSR) was implemented in 2019 (during Phase Four). The NCSR offers a digital infrastructure for the collection and reporting of screening data, and facilitates invitations for screening, mailing of test kits, and participant support. An evaluation of the functionality of the NCSR will be conducted separately, and was thus out of scope for the review. The Healthcare Provider Portal (HPP) is a second piece of enabling infrastructure for the Program, which was piloted during Phase Four. An evaluation of the implementation and functionality of the HPP was also out of scope for the review.

Methodology
A mixture of primary and secondary data informed the review.
Secondary data sources included publicly available Program reports from the Australian Institute of Health and Welfare (AIHW), academic literature, pathology data, and an extract of data from the NCSR.

As part of primary data collection, an extensive stakeholder consultation process was conducted (67 consultations with 117 stakeholders) with groups including Program officers, clinicians, peak professional bodies, non-government organisations and consumer representatives. Other primary data sources included a consumer survey, a clinician survey, as well as an online public submission process to ensure that all interested stakeholders could express their views.

Limitations
The review of Phase Four of the Program was limited by the following factors:
Data completeness. A longstanding challenge to the Program is the voluntary provision of data from General Practitioner (GPs), specialists and histopathologists related to follow-up consultations and the outcomes of these consultations. This issue affects the reporting of key Program performance indicators, notably diagnostic assessment rates, adenoma and colorectal cancer detection rates, interval cancer rates, and adverse events. Consequently, this issue limited the ability to reliably report on these indicators.

Inability to compare cancer-related outcomes for Phase Four participants vs. non-participants. To assess whether Program participation impacts bowel cancer morbidity and mortality, data linkage is required between:
• jurisdictional cancer registries (cancer diagnoses and stage at diagnosis)
• the National Death Index (deaths including cause-of-death)
• the NCSR (participation data).

A data linkage study was not in scope for the review. Analysis of this nature also requires a substantial lag period to observe mortality outcomes over time (e.g. five-year relative survival). The most recent project of this nature was the 2018 AIHW report Analysis of bowel cancer outcomes for the National Bowel Cancer Screening Program, using data from Program invitees between 2006 and 2010. Thus, reporting cancer-related outcomes linked to Phase Four was not feasible at the time of the review. In the absence of Phase Four-specific data, the review instead refers to the 2018 AIHW report as an indication of the impact of the Program on earlier detection and better survival.

Opportunities to address these data limitations are discussed in the ‘Fidelity’ sub-section of the Executive Summary.