GP endorsement letter - Bowel cancer screening

‘The National Bowel Cancer Screening Program saves lives- but it needs the support of general practices! The evidence is clear that a recommendation from a primary healthcare provider is an important motivator for participation in bowel cancer screening. If participation rates could reach 60 per cent in Australia, over 83,800 lives could be saved by 2040’1.

Australia has one of the highest rates of bowel cancer in the world. It is the second most common cause of cancer mortality after lung cancer and yet, if found early, 9 out of 10 cases can be successfully treated. Around 17,000 people are diagnosed with bowel cancer every year in Australia2.

The National Bowel Cancer Screening Program (NBCSP) has developed a population-based cancer screening strategy3 in response to the rising incidence and significant mortality associated with bowel cancer. This strategy utilises an immunochemical faecal occult blood test (iFOBT) sent to the home every two years commencing in the year one turns 504.

Randomised controlled trials have clearly established that screening asymptomatic populations with iFOB testing biennially reduces mortality from the disease. The new national ‘Clinical practice guidelines for the prevention, early detection and management of colorectal cancer’ presents the clinical evidence for this5.

Reducing mortality due to colorectal cancer relies on high levels of population participation. Participation rates are poor across Australia with the national rate estimated at 41 per cent. If participation rates could reach 60 per cent in Australia, over 83,800 lives could be saved by 20406.

NSW participation rates are below the national average at an estimated 37.8 per cent7. In comparison, the average rate across the CESPHN region is estimated at 34.6 per cent (some LGAs, such as Strathfield, City of Sydney, Rockdale and Canterbury, are below 33 per cent). It is acknowledged, however, that some screening does take place in general practice (and other primary care access points) that is not included in these statistics for various reasons. Participation from culturally and linguistically diverse populations and Aboriginal and Torres Strait Islanders is lower than average and needs specific encouragement.

Promoting Participation in Practice

The GP endorsement letter

The use of a GP endorsement letter has proven effective in South Australia. The letter, such as the template developed by the National Bowel Cancer Screening Program and available here8, can be sent in the patients 49th year. Several trials conducted by Young et al explored the use of differing styles of GP endorsement letter and the results led to significantly higher participation rates (32 per cent vs. 38 per cent and 40 per cent)9

This letter, written on the Practice letterhead and sent in the name of the patients own GP, could be sent by post or email. The National Bowel Cancer Screening Program would be willing to format an SMS message if advised.

Considering the positive impact this letter has been shown to have and the significant mortality rates due to bowel cancer, perhaps you might consider introducing this in your practice.

If you would like any support in doing this, please use the contact details provided below.

In addition to the endorsement letter, the 45-49-year-old preventative health check may be another opportunity to discuss screening that could be optimised.

The 45-49 yr. health check (MBS item) as a platform for cancer screening discussion

The 45-49-year-old preventative health check has been flagged by several stakeholders (and GP practices) as an opportunity for a cancer screening discussion for the three population-based cancer screening programs.

Bowel screening unfortunately does not appear on the template of all practice software systems and would need to be added at practice level (this is very simple to do) although Sydney Healthpathways have incorporated this as part of the 45-49-year health check guidelines.

It is acknowledged that this health check does not align perfectly for the start of breast and bowel screening participation but patients could at least be prepared for the arrival of the bowel kit aged 50 if it has been discussed beforehand (and further supported by the use of the ‘GP Endorsement letter’) and Breastscreen NSW do accept women for free screening from 40 years (although this is not advertised as such).

It has been suggested that a ‘prompt’ could be added to the practice template to ensure this conversation is not overlooked.

New resources are available

GPs in our region have fed back to us that low levels of health literacy around cancer screening, especially in culturally and linguistically diverse (CALD) groups, makes having conversations about screening with patients more challenging considering the time restraints. New resources have been developed that may assist with this.

The aim of the newly developed information leaflet and five videos is to increase health literacy around cancer screening, specifically in CALD groups and to encourage people to discuss screening with their GPs and practice nurses. We will be disseminating these resources within the community and offering the resources to general practices very shortly.

The resources were developed with funding support from the Cancer Institute and were a joint initiative by Central and Eastern Sydney PHN, South Eastern Sydney Local Health District (SESLHD) and Advance Diversity Services. The resources were co-designed by CALD community focus groups for CALD communities. The resources reinforce the message that “Taking care of yourself is the best way of looking after your family”. A message that the focus groups felt would resonate with their communities.

Print resource

The print resource/brochure addresses bowel, breast and cervical screening and will shortly be available in 12 community languages (Arabic, Bengali, Chinese -simplified and traditional, Greek, Indonesian, Italian, Korean, Nepali, Spanish, Thai and Vietnamese). Messages and design were specifically selected by the community groups for optimal impact.

The English version can be viewed here.

Audio-visual resources

The Audio-visual resources consist of five videos. Two of the videos focus specifically on the breast and cervical screening programs and have been developed for women from Bangladeshi and Nepalese backgrounds. These videos are available in English, Bengali and Nepali. The third video also includes additional information on bowel screening and, although targeted to people from South Asian communities, is suitable for anyone seeking information on these screening programs.

‘Screening saves lives’: Cancer screening audio-visual resources for culturally and linguistically diverse communities can be accessed through the SESLHD YouTube page but can be made available for use in your practice waiting area as requested (see below for contact):

Screening Saves Lives - South-East Asian Community in English

Screening Save Lives - Nepalese in English

Screening Saves Lives - spoken in Nepali

Screening Saves Lives - Bangladeshi in English

Screening Saves Lives - spoken in Bengali

Please visit the CESPHN website for more resources for general practice and patients related to bowel cancer screening.

If you have any comments or questions or would like to request support for these initiatives in your practice please do not hesitate to contact Program Officer for Cancer Screening, Alison Jones.

See: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/NBCSP-promoting-gp
2See: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/role-of-GPs#how
3Population screening is the ‘use of simple tests across a healthy population in order to identify individuals who have disease, but do not yet have symptoms’ (WHO 2015) NOTE: Healthpathways and the ‘Clinical Practice Guidelines' detail alternative screening pathways for those individuals considered above average risk for bowel cancer.
The staged-implementation of the biennial screening program will be complete in 2020.
Please see Clinical practice guidelines for the prevention, early detection and management of colorectal cancer https://wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer/Colorectal_Cancer_in_Australia
See: : http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/NBCSP-promoting-gp
Data supplied by CINSW for 2016.
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/gp-template-letter 
Please see: Emery J, Treven L, Mazza D, Fallon-Ferguson J, Shaw K, Williams B et al. The role of primary and community-based healthcare professional in early detection and follow-up in cancer care -a rapid review of best practice models: an Evidence Check rapid review brokered by the Sax Institute (http://www.saxinstitute.org.au) for the Cancer Institute.