Guidance

UK NSC annual call submission example

Updated 15 August 2023

The following is an example of the information required for a UK NSC annual call submission.

Topic

Bowel cancer screening based on faecal occult blood testing (FOBT) followed by colonoscopy when the test is positive for all people aged 50 to 74.

Type of programme (population, targeted or stratified)

Population screening programme

Name

Organisation

Proposal for new screening programme

A population screening programme for colorectal cancer based on faecal occult blood testing (FOBT) followed by colonoscopy when the test is positive for all people aged 50 to 74. The purpose of this programme would be to diagnose colorectal cancer at an early stage in order to improve outcomes in terms of disease specific mortality. This is predicated on the observation that survival after treatment of this disease is highly stage dependant, and significant lead-time bias has been excluded as an explanation by population-based randomised trials (see below). In the long-term, a secondary outcome would be a reduction in disease incidence, as FOBT can detect people harbouring adenomas, pre-malignant growths that can be removed at the same time as colonoscopy.

Summary, using published evidence

The condition

Colorectal cancer is diagnosed in over 40,000 people in the UK every year, and accounts for around 16,000 deaths, making it the second most common cause of cancer death in this country. It usually presents with rectal bleeding and change of bowel habit and, when advanced, with intestinal obstruction necessitating emergency surgery.

The test

The FOBT is a card-based test that can be posted to an individual’s home. It requires the participant to place small amounts of faeces from 3 separate bowel motions on the card, and then to mail the sealed card to a central laboratory for analysis. The analysis determines whether or not blood is present in the faeces and, if so, the participant will be invited for colonoscopy to examine the large bowel for the presence of cancer or adenomas. There are several types of FOBT commercially available, but all the evidence to date is based on the Haemoccult II test.

The treatment

The treatment of colorectal cancer is primary surgical, consisting of removal of the part of the bowel affected. In most cases, intestinal continuity can be restored, but some patients with rectal cancer may require a permanent colostomy. In very early cases, it is possible to remove the cancer by endoscopic means at the time of colonoscopy, and this can account for up to 16% of all screen-detected cancers. In patients with more advanced disease, where local lymph nodes are involved by tumour, the patient is usually offered adjuvant chemotherapy, which increases the expense and the morbidity of treatment. Radiotherapy may also be used in patients with more advanced rectal cancer, and this is also associated with potentially debilitating side-effects. When the cancer has spread beyond the bowel, treatment is usually palliative and can involve the use of toxic chemotherapy.

Randomised controlled trial evidence showing benefit from screening

There are 4 randomised trials of FOBT screening for colorectal cancer in the published literature, all of which have demonstrated significant reductions in disease specific mortality. These come from the US, England, Denmark and Sweden. In addition, there is a non-randomised, but controlled, study form France that found the same. A Cochrane review has estimated that offering FOBT screening to a population can reduce disease specific mortality by 16%, rising to 27% when corrected for participation. There is also some evidence from one of these trials that, with long-term follow-up, FOBT screening can result in a reduction in disease incidence.

References supporting application:

Mandel JS, Bond JH, Church JR, Snover DC, Bradley GM, Schuman LM et al. Reducing mortality from colorectal cancer by screening for faecal occult blood. N Engl J Med 1993; 328; 1365-1371

Hardcastle JD, Chamberlain JO, Robinson MHE, Moss SM, Amar SS, Balfour TW et al. Randomised controlled trial of faecal occult blood screening for colorectal cancer. Lancet 1996, 348; 1472-1477

Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomised study of screening for colorectal cancer with faecal occult blood test. Lancet 1996; 348; 1467-1471

Kewenter J, Brevinge H, Engaras B, Haglin E, Ahren C. Results of screening, rescreening, and follow-up in a prospect randomized study for detection of colorectal cancer by fecal occult blood testing. Results for 68,308 subjects. Scand J Gastroenterol. 1994; 29:468-73.

Faivre J, Dancourt V, Lejeune C, Tazi MA, Lamour J, Gerard D, Dassonville F, Bonithon-Kopp C. Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study. Gastroenterology. 2004;126:1674-80

Towler B, Irwig L, Glasziou P, Kewenter J, Weller D, Silagy C. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, Hemoccult. BMJ 1998; 317: 559-65

Mandel JS, Church TR, Bond JH, Ederer F, Geisser MS, Mongin SJ, Snover DC, Schuman LM. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 2000; 343: 1603-1607

Flowchart

Fig 4.4, page 97 from Screening Evidence & Practice by Raffle and Gray (2019). Reproduced with permission from Oxford University Press. Note that this illustration is exempt from the Open Government Licence and cannot be copied or reused.