Every two years I receive a letter from myself. I know what it is before I open it, from the NHS logo on the envelope and the shape and feel of the contents. This is, of course, my bowel screening test, and the invitation letter is signed by me as Clinical Director of the Scottish Bowel Screening Programme. Thus, by virtue of my age, I send myself a letter on a regular basis.
When it comes, I find it slightly comical, but it also gives me reason to reflect on the programme, as it suddenly becomes real to me as an individual. Most of the time, bowel screening is something that happens to other people, and I eagerly await the production of the statistics that tell us (the screening team) how the programme is performing.
Encouragingly, we continue to see that the majority of cancers detected by screening are early and therefore almost certainly curable, and we have also seen a steady increase in uptake of the screening test over the years since the programme started. However, when I complete the test (which I always do), I wonder if this time it will be positive (which it never has been). And if it is – how will I feel? Will I go for the colonoscopy? I perform colonoscopy on a regular basis but I have never had one myself, and, frankly, I’m not sure that I fancy it.
I know that several of my colleagues and friends have had a colonoscopy as a screening test without a positive faecal test, and when I ask them why, they say that they don’t want to rely on the test provided by the Programme. And I can see their point. While a positive test indicates a high risk of bowel cancer, a negative test doesn’t mean much, and it certainly doesn’t mean that you definitely don’t have cancer. We only need to look at the number of interval cancers recorded in the Programme to see this. However, colonoscopy is not necessarily a walk in the park. Although most people sail through it with no ill effects, it does carry risks, and we have no evidence that the benefits of colonoscopy as a first-line screening test are greater than the harms caused by colonoscoping many normal people.
So I prefer to throw my lot in with the simple test, that will tell me if I am at higher risk than normal – and the research that I have been involved with over many years tells me I can be confident, that the benefits of doing this do outweigh the harms. And if it is positive, I will go for the colonoscopy. Complacency is dangerous, though, and I am acutely aware that Bowel Screening is far from perfect. This is why I and my colleagues (please see blogs by Callum Fraser) have been so interested in new tests, and next year we will see the introduction of faecal immunochemical testing (FIT) into bowel screening in Scotland. This will give us a new handle on risk, as it will provide the Bowel Screening Centre with quantitative information on everyone who completes the test, rather than the ”yes or no” answer that we get today. Thus, with a bit of careful thought and planning, we should be able to give Scotland a Screening Programme that is much more “FIT” for purpose.