2012-01-27 20:13:31 UTC

Colorectal Cancer Screening Around the World

Jan. 27, 2012

Peter R. Holt, MD, AGAF

Chair, International Committee


Screening for colorectal neoplasia varies markedly around the world. Some of the differences relate to inadequate income, social factors or a careful evaluation of cost benefit versus harm. The following comments from senior experts in various parts of the globe provide us with a broader view of what is actually done overall in the world. All countries recognize the value of screening for cancer at its earliest stages and detection of precancerous colonic neoplasms. Most countries that have colorectal cancer (CRC) screening use fecal diagnostic testing as the primary screening tool rather than colonoscopy; the immunochemical fecal occult blood test (iFOBT) method is preferred to the guaic-based fecal occult blood test (FOBT) by most. We will await the results of differing methods upon CRC incidence and mortality in these countries with interest.

Asia Pacific

Victoria P. Y. Tan, MD

Clinical Assistant Professor, Department of Medicine, University of Hong Kong

Joseph Sung, MD, PhD

Mok Hing Yiu Professor of Medicine, Vice Chancellor and President, Department of Medicine and Therapeutics, The Chinese University of Hong Kong

Benjamin C. Y. Wong, MD, PhD

Honorary Clinical Professor, Department of Medicine, University of Hong Kong

Incidents of CRC in Asia Pacific on the Rise

In the Asia Pacific region, the incidence of CRC has been increasing rapidly. Mortality rates have also increased in this region — Japan and Singapore being notable exceptions.1-3 Using colonoscopy as a screening tool in Asia yields similar results compared to the west.4 However, knowledge and attitude towards CRC screening in this region have much room for improvement.5 Financial considerations and lack of doctors’ recommendations remain the main obstacles. Despite significant progress in the Asia Pacific region, national screening programs do not exist in all countries. A national screening program exists in Taiwan, Japan, Korea, Australia, and commencing in 2011, Singapore. Screening in this region for average-risk patients in the fifth and sixth decades is ostensibly through fecal immunohistochemical testing (FIT) or in the case of Australia, Japan and Korea, FOBT. Follow-up for abnormal FIT or FOBT is usually by flexible sigmoidoscopy or colonoscopy.1, 2 Unfortunately, with the exception of Australia, Taiwan and Korea, the screening programs are not free, although it is questionable whether cost is the most important barrier to uptake. Even in countries where the cost of screening is borne by the state, uptake rates are approximately 25 to 40 percent.1, 4 Clearly, there is much more work to be done in this region, where the rates of CRC mortality are less than the western world trend, but are increasing incrementally.


1. Hyodo I, Suzuki H, Takahashi K, et al. Present status and perspectives of colorectal cancer in Asia: Colorectal Cancer Working Group report in 30th Asia-Pacific Cancer Conference. Jpn J Clin Oncol;40 Suppl 1:i38-43.
2. Sung JJ, Lau JY, Young GP, et al. Asia Pacific consensus recommendations for colorectal cancer screening. Gut 2008;57:1166-76.
3. StatBite: International cancer control programs: who's getting screened? J Natl Cancer Inst 2009;101:843.
4. Sung JJY,  FKL Chan, Leung WK, Wu JCY, Lau JYW, To KF, Ching JCL, Lee YT, YW Luk, Kwok SPY, Li M, Chung SCS. Screening for Colorectal Neoplasms in Chinese: Fecal occult blood test, Flexible Sigmoidoscopy or Colonoscopy? Gastroenterol 2003;124:608-14.
5. Sung JJY, Choi SYP, Chan FKL, Ching JYL, Lau JTF, Griffiths S. Obstacles to colorectal cancer screening in Chinese: a study based on health belief model. Am J Gastroenterol 2007. 

Drs. Sung, Tan and Wong had no conflicts to disclose.


Eduardo Fenocchi, MD

Director of Digestive Cancer Program, Ministry of Public Health; Chief of Digestive Cancer Center, National Cancer Institute, Montevideo, Uruguay

Uruguay Screenings Lead the Way

Simple and cost-effective tests (FIT) have been used in Uruguay since 1996 by the national program to screen the asymptomatic average-risk population above the age of 45 years with a one-day method. iFOBTs (OC-Micro/Eiken, Japan) are used at home and processed in a single center with OC-Sensor Micro (cut-off level: 100 ng/hb), followed by colonoscopy in positives.

As of June 2011, 46,693 patients received the test, and 44,279 (94.8 percent) of them returned the test for processing. Of these, 4,779 (11 percent) were positive. Colonoscopies were performed in 2,923 (61.2 percent) of the positives, and 752 (25.7 percent) did not have colorectal lesions. A total of 1,005 patients (46.3 percent) had no neoplastic lesions, while 1,166 (53.7 percent) had neoplastic lesions. In this group, adenomas were detected in 81 percent of patients; advanced adenomas were detected in 35.2 percent of patients. Cancers were detected in 19 percent of patients (advanced cancers: 11.9 percent, early cancers: 7.1 percent).

With high compliance and high rates for detection of CRC and advanced adenomas, our positive experiences can be used in other Latin American countries. For example, Argentina is now introducing a similar approach to our own.

Dr. Fenocchi had no conflicts to disclose.

Australia, England, Ireland, New Zealand, Scotland and Wales

Wendy Atkin, PhD

Professor, Imperial College London, U.K.

FIT Goes International

Australia’s National Bowel Cancer Screening Program includes a biennial FIT offered to Australians turning 50, 55 or 65 years of age. Participants with a positive FOBT result are advised to discuss the result with their doctor, who will generally refer them for a colonoscopy.

In October 2011, New Zealand began a four-year screening pilot study using the FIT similar to Australia’s program. The test will be offered to approximately 130,000 individuals (including a minimum of 6,000 Maori) aged between 50 and 74 years of age. A person with a positive result will be offered a diagnostic colonoscopy.

England, Scotland, Wales and Northern Ireland have adopted the guaiac FOBT. Started in 2006, England offers the test to men and women aged 60 to 69 (from April 2010, the age range was extended to 75 years, with 31 of 58 centers on board by February 2011). Those who test positive are offered an appointment with a specialist nurse who will arrange a colonoscopy. In 2007, Scotland started offering the test to individuals between the ages of 50 and 74 years. In 2008, Wales began to invite people aged between 60 and 69 (with a view to extend the age range to between 50 and 74 by 2015). Northern Ireland started their program in 2010, offering the test to men and women aged between 60 and 69. In Scotland and Northern Ireland, those who return an unclear result are offered a repeat test using FIT.

In 2012, Ireland will introduce a national population-based CRC screening program using FIT, offered to men and women aged 55 to 74. The program is scheduled to start in 2012 and will be implemented on a phased basis starting with men and women aged 60 to 69. All of these programs recall participants every two years to take a new test.


Australia: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-about
New Zealand: http://www.moh.govt.nz/moh.nsf/indexmh/cancercontrol-strategyandactionplan-bowelcancerscreening
England: http://www.cancerscreening.nhs.uk/bowel
Scotland: http://www.bowelscreening.scot.nhs.uk
Wales: http://www.wales.nhs.uk/sites3/home.cfm?orgid=747
Northern Ireland: http://www.cancerscreening.n-i.nhs.uk/bowel/toc.html
Ireland: http://www.cancerscreening.ie/colorectal.html

Dr. Atkin receives equipment and test kits from Eiken Chemical Company for research into the sensitivity of the tests. She is also a member of the English Department of Health Bowel Screening Advisory Committee.


Robert Benamouzig

Head of Service, Gastroenterology Unit, AP-HP, Avicenne Hospital; Professor, Paris 13 University, Bobigny, France

Screening Program in France Spreads

The French nationwide colon cancer screening program, targeting about 17 million people, has been gradually implemented since 2002. National coverage has been fully effective in all 100 districts since 2009. A guaiac FOBT (Hemoccult II) is proposed to average-risk subjects, aged 50 to 74, every two years. Men and women receive letters from a monitoring center and are invited to consult their general practitioners who provide the FOBT. People who do not attend will receive the test at home.

Test readings by biologists are centralized, and people with a positive test result are offered colonoscopy. Various quality issues such as participation and type of screened lesion are monitored in the local screening unit and aggregated in national dedicated agencies. Currently, the participation rate is 34 percent (31 percent male and 36 percent female) ranging from 16 to 55 percent, depending on the district. The positive test rate was 2.7 percent, and 85 percent of the expected colonoscopies were performed. The predictive positive value of colonoscopy was 8.4 percent for cancer and 33.6 percent for adenomas.

The cost of the colon cancer screening program is 80 to 100 million euros per year, excluding colonoscopy costs. The shift to FIT has been decided, but not yet implemented. Furthermore, an undetermined proportion of the targeted population is undergoing opportunistic colonoscopies (estimated to be around 20 percent, but it is likely to be more since colonoscopy is easily and fully reimbursed for symptoms of any abdominal pain or change in bowel habit).

Professor Benamouzig provided lectures under the direct sponsorship of Given, Nycomed and VivaTech Ltd, and received research support from Danone, Given and VivaTech Ltd. He is also a member of La Société Nationale Française de Gastroentérologie, Haute Autorité de Santé, Agence Française de Sécurité Sanitaire des Produits de Santé, and the French National Institute for Agricultural Research.

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