Inclusion of flexible sigmoidoscopy in the UK Bowel Cancer Screening Programme

UCL evidence that a single flexible sigmoidoscopy dramatically reduced bowel cancer incidence and mortality, and that acceptability of the test was high, led to its inclusion in the UK National Bowel Cancer Screening Programme.

Bowel cancer is the second most common cause of cancer death, and among the most feared cancers because of the effects of surgical treatment. Professor Jane Wardle (UCL Institute of Epidemiology & Health) has a long-standing collaboration with Professor Wendy Atkin (Imperial College) to evaluate the potential of flexible sigmoidoscopy (FS) to prevent bowel cancer through finding and removing pre-cancerous adenomas.

The information I received in the post was concise and easy to understand. The test itself was carried out with dignity and I was very happy with the nursing staff. I would recommend this test to friends who are eligible for it. - Female patient, South of Tyne 

Professor Wardle, with Professor Atkin and colleagues, developed and piloted screening and pathology protocols, quality control procedures, patient management systems, patient information materials, and invitation protocols. This included pioneering the use of a mailed, self-administered enema to be carried out at home before the test. These were then tested, initially on a smaller but later on a much larger scale. Professor Wardle was responsible for the psychosocial elements of the trial, and showed that uptake and acceptability were high in both men and women, and the psychological impact was favourable. The trial achieved the best results ever reported in a cancer prevention trial, and the progressive divergence in incidence and mortality curves between screened and control groups indicates prolonged and continuing protection.

As a result of this research, FS has been implemented as a single examination at age 55 as part of the National Bowel Cancer Screening Programme (NBCSP). Following the publication of the trial outcomes in the Lancet in 2010, and the results of the successful pilot programme in the Journal of Medical Screening, the British Prime Minister David Cameron announced that once-only FS screening would be included in the NBCSP. £60m was pledged over the next four years to introduce this latest cancer screening technology, with estimates that FS could save 3,000 lives a year.

In 2011, the Department of Health's document Improving Outcomes: A Strategy for Cancer set out the plans for FS screening. Implementation of the programme began in early 2011 and plans are now finalised for national implementation. Six sites began screening in 2013.

Professor Wardle's group was then commissioned by Public Health England to carry out real-time audits of uptake, patient-reported outcomes 24 hours after the test, and patient satisfaction at 12 weeks, when any follow-up procedures should be completed. This has allowed identification of any problems and made it possible to implement small modifications to optimise procedures in advance of the national rollout. Data from the FS trial indicated that one bowel cancer diagnosis is prevented for each 191 people screened.

Funders included the MRC and Cancer Research UK.