Section of human colon showing sausage-shaped crypts. Section of human colon showing sausage-shaped crypts. The section has been stained for a protein called MAOA (shown in brown). The blue crypt carries a fault in the MAOA gene, which stops the protein being made and means the crypt no longer shows up as brown. Image courtesy of Winton lab.
This week, NHS England began to inform people that one of the bowel screening tests – bowel scope – will no longer be a part of the bowel screening programme in England.
The test, which uses a thin, flexible tube with a small camera and light at the end of it to look inside the lower part of the bowel, aims to find early-stage cancers that aren’t yet causing any symptoms. And in a trial we part funded, the test prevented more than half of the potential bowel cancers from developing in the bowel and reduced the risk of dying from these cancers by two thirds in people who were screened.
Based on the evidence, bowel scope implementation began in England in 2013, with a plan to offer it as a one-off test to men and women aged 55 years. The test was never introduced in Scotland, Wales or Northern Ireland.
At the time, NHS England said the roll out wouldn’t be immediate – it was estimated that it would take at least 3 years before the test would be offered to everyone eligible because of a shortage of trained staff – endoscopists – to carry out the test.
But 7 years after roll out began in England, bowel scope was still not being offered to everyone. And it’s now been removed from the roster altogether.
What happened to bowel scope?
Roll out of bowel scope had a number of challenges, with one of the biggest being the availability of staff to do the bowel scope test. Health Education England developed a clinical endoscopist programme to help train more staff to do bowel scope, but unfortunately this was still not enough to meet the full workforce need.
More recently, endoscopy services have been put under even more pressure by the introduction of a new test into the bowel screening programme – FIT (Faecal Immunochemical Test) – and services looked at ways to manage the demand. Some centres decided then not to do bowel scopes.
And then COVID-19 hit. The pandemic caused further disruption to the delivery of endoscopy services for both screening and symptomatic referrals. Bowel scope was often at the bottom of the list when it came to getting services back up and running and working through the significant backlog of patients that had built up.
With all that in mind, NHS England consulted with a range of organisations and experts, including the National Screening Committee (NSC) and recommended that bowel scope should be officially stopped in England. The Secretary of State has since supported this decision, so that attention could be focused on extending the age range for FIT bowel screening.
It’s disappointing that bowel scope screening is being formally stopped now, but we understand why this decision has been made. Ongoing staff shortages have meant that bowel scope never reached its full potential and the pressure of COVID-19 on the health system was the final straw.
– Dr Jodie Moffat, Cancer Research UK’s head of early diagnosis
What happens now?
The decision and the disruption of the past couple of years mean there are thousands of people who have accepted an offer of a bowel scope but have not had the test. And now that the decision has been made to formally stop bowel scope, they will not receive one. Instead, this particular group of people will be directly contacted by the NHS from mid-December, and will be offered a FIT, though our understanding is that this will not be sent out until Spring 2021.
Later, when this group of people falls within the eligible age range for bowel screening (60-74 year olds), they will be offered the FIT every 2 years, as will people who have either never been invited for bowel scope, or were invited but didn’t take up the offer.
While the loss of bowel scope is discouraging, there are positive changes to the bowel screening programme on the horizon.
NHS England has committed in line with National Screening Committee recommendations to extend the age range of FIT bowel cancer screening, so that anyone aged 50 years and above will ultimately be invited to take part in the bowel screening programme.
Bowel cancer screening
Bowel cancer screening, where a home testing kit is sent out, is currently offered to everyone between the age of 60 and 74 in England, Wales and Northern Ireland, and between 50 and 74 in Scotland. It aims to detect bowel cancer at an early stage when treatment is more likely to be successful.
It’s your choice to take part in cancer screening or not, but we would encourage people to consider taking part in the bowel cancer screening programme.
It’s important to remember screening is for people without symptoms. Whatever your screening history, if you notice any unusual or something that doesn’t go away such as blood in your poo or a change in bowel habit, tell your doctor.
And there are further changes that could be made to improve the at home bowel screening test. There is potential to increase the sensitivity of the FIT, to help pick up more cancers and more adenomas that could potentially develop into bowel cancer as we’ve written about before. We want to see all UK nations reducing their thresholds to that recommended by the UK’s National Screening Committee.
But importantly, we must learn the lessons of bowel scope. NHS England now needs to publish a timeline for when both of these changes will be comprehensively implemented, guarding against the geographical variation we had seen with bowel scope. To achieve this will require investment from the Government in endoscopy and pathology services.
In the recent Spending Review, the Government invested in training more staff in the next year, but we need to see a multi-year commitment to increasing the diagnostic workforce and kit if we are to improve bowel cancer outcomes in England and achieve the ambitions in the NHS Long Term Plan, as we’ve written about before.
Moffat says it’s vital that staff shortages do not continue to dictate what services the NHS is able to provide.
“The current FIT bowel screening programme will save lives from bowel cancer, but the NHS needs more staff and equipment to clear the backlog and to ensure that the improvement plans, which will mean more people are invited for FIT bowel screening, can be rolled out quickly and fairly across the country.”
Rachael Ogley is an early diagnosis manager at Cancer Research UK