Publication - Strategy/plan

Bowel Cancer Framework for Scotland

Published: 20 Apr 2004
Part of:
Health and social care

Bowel cancer is an improtant health issue worldwide and, in Scotland, it represents a major problem. In this framework the key components of a national bowel cancer service programme are outlined.

29 page PDF

0 B

29 page PDF

0 B

Bowel Cancer Framework for Scotland
Page 3

29 page PDF

0 B



The best way to reduce mortality from bowel cancer in Scotland is to ensure earlier diagnosis and treatment. This means more rapid access to services as well as trying to ensure that patients seek advice earlier whenever they have symptoms suggestive of cancer. There is clear evidence that the earlier the stage of disease at presentation the better are the chances of cure.

Bowel cancer awareness raising programmes as set out above, such as the West of Scotland Cancer Awareness Project (WOSCAP) and the joint Lanarkshire/Forth Valley Bowel Cancer Awareness Project (BCAP) initiative have a clear role to play in helping people understand the signs and symptoms of bowel cancer.

A Cancer Genetics service is well established with clear referral and risk stratification protocols in place (Guidance available on Cancer in Scotland website at The Scottish Cancer Group's Cancer Genetics Sub-group is currently updating the guidance in light of new developments and emerging new evidence.

Cancer in Scotland: Action for Change (2001) confirmed the Scottish Executive's strategy for preventing as many cancers as possible (see section on Cancer Prevention above). It also stated that, "The next best strategy is to detect and treat cancer early and national population screening programmes aim to do that."

New screening programmes are introduced only after rigorous assessment to ensure that they are effective in doing what they set out to do, according to nationally agreed criteria. The UK National Screening Committee was established in 1996 to advise UK Health Ministers about the introduction of new screening programmes. The advice of the Committee is taken into account in the Scottish Executive's consideration of screening issues.

The Scottish arm of the pilot bowel screening programme - The Cancer Challenge - undertaken in Fife, Tayside and Grampian NHS Board areas, completed its first two-year round of screening in 2002 and is now in its second round. The evaluation report published in July 2003 confirmed that population screening for bowel cancer using Faecal Occult Blood testing was feasible.

European Union health ministers backed a plan in December 2003 calling on member states to implement more effective screening programmes for breast, colon and cervical cancer. The Council of the European Union recommended the introduction of faecal occult blood screening for bowel cancer in men and women aged 50-74.

The Minister for Health and Community Care has reaffirmed the Scottish Executive's commitment to introduce a bowel cancer screening programme, taking into account the recommendations of the UK National Screening Committee. As a first step NHS Boards have been asked to start planning for the introduction of such a programme. It is expected that the planning process will take at least five years as further consideration requires to be given to a range of issues including the appropriate upper age range for screening.

There are significant resource and workforce implications for NHSScotland and it is important that symptomatic services are able to absorb the impact of patients being referred from screening programmes. The estimated target screening population (based on the age range 50-69) is around 1.1m - approximately 557,000 a year. If a decision is taken to screen up to the age of 74 (in line with the EU recommendation) the target population each year would rise to around 660,000 people that are likely to be involved in a nationwide call-recall system for bowel cancer screening. Based on a number of predictions (from the evidence of the pilot) i.e. screening uptake, positivity rate of the returned tests, and the number of people who will go on to have diagnostic tests it is estimated that the number of colonoscopies each year will be around 6360 (based on screening age range 50-69). As will be seen in the next chapter, the pressures on endoscopy/colonoscopy services are already severe. However, much can be learned from the experiences in the bowel cancer screening pilot area (Fife, Tayside and Grampian).

The following pages set out the current position and the actions that need to be taken in readiness for the introduction of a national bowel screening programme in due course.

To help plan towards that and to ensure an agreed approach across the country, the Scottish Executive Health Department will set up a National Steering Group to map out next steps and agreed approach to build capacity and ensure services are ready to support a national screening programme over the next three to five years.

Further guidance about a colorectal cancer screening programme is expected to issue later this year.

Basic Elements

  • Early reporting of symptoms

  • Prompt, high quality investigations

  • Population screening and surveillance of High Risk Groups

What is required?

What is already happening?

Next steps

Service Implications

Early reporting of symptoms

  • Patient, GP and Community Pharmacist education

  • Development of referral criteria

  • Implementation of Scottish Referral Guidelines for Suspected Cancer

  • Reduce time between GP referral and patient receiving appointment

  • West of Scotland oral and bowel cancer awareness campaign (NOF funded)

  • Forth Valley and Lanarkshire Bowel Cancer Awareness Project (NOF funded)

  • SCAN Cancer Information Network for patients and professionals (NOF funded)

  • Lanarkshire Cancer Information Service (NOF funded)

  • Scottish Referral Guidelines for Suspected Cancer published May 2002 and circulated throughout Scotland

  • A joint initiative between South Glasgow hospitals and South East Glasgow LHCC has redesigned referral pathways for patients with colorectal symptoms resulting not only in reduced waiting times for access to diagnostic procedures, e.g. barium enema, flexible sigmoidoscopy and colonoscopy but also more effective use of investigative services

Improving healthcare for people most in need - pilot projects backed by 15m investment over the next two years are to be set up in three NHS Board areas in order to improve access to healthcare for those in Scotland's poorest communities

Population screening and Surveillance of High Risk Groups

  • Introduction of a national screening programme

  • Protocols for the surveillance of high risk groups

Population screening

  • Scottish arm of UK bowel screening pilot now in second round of screening (in Fife, Tayside and Grampian)

  • Evaluation report confirmed potential benefits of bowel cancer screening and that faecal occult blood (FOB) testing was feasible

  • Colorectal Cancer Screening Pilot Project Board established to oversee and co-ordinate second round of screening and to assist with the roll out of the screening programme

  • Public awareness campaign already taking part in some parts of the country (see prevention above)


  • Protocols for the surveillance of high risk groups are already available from the latest SIGN guidance on Bowel Cancer

  • High risk (HNPCC and FAP) genetics programme in place nationwide


  • Scottish Executive Health Department to set up National Steering Group to map out next steps and agree approach over the next three to five years to build capacity and ensure services are ready to support a national screening programme

  • Guidance on screening programme to be prepared

Population screening

  • Further work needed on the impact on primary and secondary care services, workforce and training requirements and upper age range for invitation

  • NHS Boards/Health Promotion Departments may wish to consider role of public awareness campaigns


Audit/evaluation of high risk programme under consideration by Cancer Genetics Sub-Group (Scottish Cancer Group)

Research Implications

Prompt, high quality investigations

  • As above

  • What is the cost-effectiveness of endoscopy undertaken by nurses? - a multi-institution nurse endoscopy trial (MINUET), Professor J G Williams, Centre for Postgraduate Studies, (End date: 31/10/2004)

Report awaited

Population screening and Surveillance of High Risk Groups

  • Research into improving the sensitivity and specificity of the test

  • Research into improving uptake while providing informed choice

  • Research into the identification of high risk groups

  • Trials of flexible sigmoidoscopy

  • Immunological test research

  • See section on prevention

Report awaited
Findings awaited