Exploring factors beyond age in bowel cancer screening programme

In an effort to improve the efficiency and effectiveness of bowel cancer screening in England, a pioneering research study has taken a closer look at NHS England's screening programme.

The study, known as the ‘At Risk’ research project, ventures beyond the current age-based criteria to explore a number of risk factors that could transform the landscape of colorectal cancer detection and prevention.

Bowel cancer is the fourth most common cancer in England and the risk of developing bowel cancer increases with age.

People aged 60 to 74 who is registered with a GP and lives in England are automatically sent an NHS bowel cancer screening kit every two years.

The programme is gradually expanding so that everyone aged 50 to 59 years will be eligible for screening, which is in line with current bowel cancer screening in Scotland.

This nationwide initiative has played a vital role in identifying colorectal cancer in its early stages, allowing for more effective treatments and ultimately reducing the risk of mortality.

However, the screening's reliance solely on age has presented challenges — smoking, alcohol, diet and lack of exercise also increase the risk of colorectal cancer.

If someone has a history of bowel cancer in their family, or has had another type of cancer themselves, they are also more likely to develop bowel cancer. There is also a lower risk in some ethnic groups.

There are also varying bowel cancer screening uptake rates based on socio-economic factors.  

The At Risk research study, led by Dr Jo Cairns, a Research Fellow at Hull York Medical School, and funded by Yorkshire Cancer Research, aimed to investigate a risk-stratified approach to bowel cancer screening – one that goes beyond age and considers a range of factors that could contribute to an individual's susceptibility to colorectal cancer.

Dr Cairns explains, “Currently, the screening programme revolves around age as the primary criteria, but there is a growing realisation that considering additional risk factors – such as sex, ethnicity, genetic predisposition, and lifestyle choices – could lead to more targeted and effective screening.”

The At Risk study explored public perceptions as well as involving healthcare practitioners to gain insights into the feasibility and acceptance of a risk-stratified approach. This interdisciplinary collaboration provides valuable insights that could inform the way bowel cancer screening is conducted, ultimately saving lives.

The findings

Uptake of screening varies considerably across different socio-economic groups. The recent disruptions caused by the COVID-19 pandemic have further exacerbated existing inequalities.

To address these challenges, Dr Cairns explored the concept of risk-stratified bowel cancer screening as a potential solution. This approach aims to move away from the traditional one-size-fits-all screening model by tailoring screening strategies to individual risk profiles.

This shift in approach could lead to modifications in screening techniques and frequencies — offering more targeted interventions and addressing the growing demand for colonoscopy procedures.

The 'At Risk' study explored the feasibility and acceptability of risk-stratified bowel cancer screening, to understand perceptions, concerns, and preferences around this approach to screening.

Dr Kathryn Scott, Chief Executive at Yorkshire Cancer Research who funded the research, said, “We know that screening saves lives, and Yorkshire Cancer Research is proud to fund studies that will help ensure people in the region are effectively screened for cancer.

The study included five online virtual focus groups, bringing together a diverse panel of participants, including members of the public (through the University of Hull’s ‘Involve Hull’ and Bowel Research UK’s People and Research Together networks) and healthcare professionals.

The study brought to light certain acceptability concerns that already exist within the current screening program. With uptake rates below target and substantial variations in participation across different regions in England, it was unknown whether altering the screening criteria could exacerbate these challenges or pave the way for greater inclusivity.

Individuals voiced apprehensions about no longer having control over their screening schedules. Questions were raised about whether anyone could inadvertently be excluded from the screening process. The balance between personalised risk profiles and equitable access emerged as a focal point of concern.

Dr Cairns explained, “Currently, people are offered bowel cancer screening every two years. Shifting towards a risk stratification approach could result in a potential decrease in screening frequency for those classified as low risk, while individuals at high risk might undergo more frequent screenings. The current screening programme was regarded as a ‘safety net’, as everyone is offered two-yearly screening irrespective of their risk profile.”

Healthcare professionals engaged in the study raised concerns about implementation challenges, for example a screening hub's prolonged search for accredited colonoscopists, extending over a period of six months without any takers. The strain on capacity and staffing within the NHS added an additional layer of complexity to the prospects of implementing changes to screening.

The scoping review is published in Cancer Causes and Control.

Dr Cairns said of the findings, “There was an appreciation and understanding of risk-stratifying bowel screening, but it was clear that there are crucial considerations and challenges to consider if this approach was to be investigated further.”

Comic book

In the pursuit of making complex information about bowel cancer screening accessible and engaging and recognising the need for an approach that resonates with a diverse audience, the study co-created a comic to help convey critical information and encourage discussions.

The comic aimed to ensure that information about bowel screening was understandable and relatable to those offered the opportunity.

The creation of the comic was a collaborative effort that brought together artist Lilly Williams and ten public contributors. The collaborative process was facilitated through partnerships with public involvement networks, Involve Hull at the University of Hull, and Bowel Research UK’s People and Research Together. Dr Cairns also ensured cultural sensitivity through the involvement of the Humber All Nations Alliance.

The comic is centred around characters that have relatable personalities, each embodying a level of risk for bowel cancer — bringing to life discussions about sensitive health matters in a way that is relatable with its target audiences.

The comic was very well received by healthcare professionals, with one GP from Yorkshire and Humberside saying, “…it helps to disseminate the message and more of a clear sort of very accessible way.”

An article about the creation of the comic book is published in Research Involvement and Engagement.

It became evident that the comic extended beyond its use in the research study and has wider potential to raise awareness about bowel cancer risk and screening. This is something that Dr Cairns acknowledged could be a future step for her work.

The findings of the At Risk project have laid the groundwork for future larger scale studies into risk stratification and bowel screening, which could inform the future of colorectal cancer detection.

By expanding the understanding of risk factors beyond age and embracing a more tailored approach, this study has the potential to pave the way for a more equitable and effective screening approach, reducing the impact of colorectal cancer on individuals and the NHS.

For more information about At Risk, please contact Dr Jo Cairns, Research Fellow in the Cancer Awareness, Screening and Diagnostic Pathways Research Group.