The role of general practitioners in the follow-up of positive results from the Australian National Bowel Cancer Screening Program – a scoping review

Introduction

Bowel cancer accounted for almost one million deaths globally in 2020, and is expected to be the fourth most diagnosed cancer and second leading cause of cancer death in Australia for 2023 (Australian Institute of Health and Welfare 2023; World Health Organization 2023). Early detection improves the chance of successful treatment and survival (Cancer Council Australia Colorectal Cancer Screening Working Party 2023). The disease typically forms slowly through a series of epithelial cell mutations that form benign polyps, which may mutate into benign adenoma, and then into a malignant bowel cancer (Australian Institute of Health and Welfare 2022). Precancerous polyps and adenomas often bleed for years before more advanced symptoms are experienced, and identifying this microscopic blood in stool is highly effective for early detection and is the aim of screening programs worldwide (Australian Institute of Health and Welfare 2022).

The Australian Government launched the National Bowel Cancer Screening Program (NBCSP) in 2006. Without screening, the usual care for the detection of bowel cancer is general practitioners (GPs) being alerted to the presence of a potential bowel cancer by patient reports of symptoms, and GPs may order tests in persons whom they consider to be high risk. The NBCSP entails biennial screening of asymptomatic individuals at average risk of bowel cancer via a free home sample collection kit for an immunochemical faecal occult blood test (iFOBT) delivered to them in the mail (Australian Department of Health and Aged Care 2024a). Healthcare providers may also provide kits directly to eligible patients via the Alternative Access to Kits Model, which facilitates uptake among those who require support to participate (National Cancer Screening Register 2022).

From 1 July 2024, the eligible screening age for the NBCSP was lowered from 50 to 45 years, with 45- to 49-year-olds able to request their first kit from the National Cancer Screening Register¹ (NCSR) or a GP, and eligible 50- to 74-year-olds continuing to receive a kit in the mail biennially, or from a GP (Australian Department of Health and Aged Care 2024a). Test results are sent to participants and, if nominated, their GPs (Australian Department of Health and Aged Care 2024b). The screening pathway comprises elements that are the responsibility of the Australian Government and of ‘usual care’ services that are delivered by public and private healthcare providers, such as GPs and hospitals (Fig. 1) (Australian Department of Health 2016; Doherty et al. 2021).

Fig. 1.

National Bowel Cancer Screening Program participant pathway showing Participant Follow-Up Function (Doherty et al. 2021). GP, general practitioner; iFOBT, immunochemical faecal occult blood test; NBCSP, National Bowel Cancer Screening Program; PFUF, participant follow-up function.

Within the Australian healthcare system, GPs are typically the initial point of contact for those seeking medical attention and, as the primary source of medical referrals, bear the responsibility of facilitating patient access to specialists (Royal Australian College of General Practitioners 2019; Australian Department of Health and Aged Care 2024c). It is advised that those with a positive iFOBT result from the NBCSP be referred for further diagnostic investigation, typically colonoscopy (Australian Department of Health 2017; Cancer Council Australia Colorectal Cancer Screening Working Party 2023). As such, GPs are the ideal medical professional to encourage participation and support participants in the NBCSP (Christou et al. 2010; Bobridge et al. 2013; Dawson et al. 2017; Dodd et al. 2019; Brown et al. 2020).

Methods

This scoping review was performed between November 2023 and January 2024 in accordance with the Joanna Briggs Institute updated methodology for scoping reviews, which is based upon the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Peters et al. 2020).

Results

A total of 24 records were identified as sources of evidence in this scoping review (Fig. 2, Table 2). This included the National Health and Medical Research Council (NHMRC) endorsed Cancer Council guidelines for colorectal cancer screening; a Royal Australian College of General Practitioners’ (RACGP) letter of response to the review of NBCSP Phase 4; eight NBCSP records including program reports and resources; and 14 articles published in peer-reviewed journals. No systematic or scoping reviews were found on the topic. Most Australian published research focused on bowel screening generally and not the specific steps of the NBCSP or the role of GPs in the follow-up stage. Holden et al. (2020) provides a comprehensive analysis of GP involvement in bowel cancer screening but only one of 57 studies in their review was performed in Australia, and only eight examined GP involvement at the results follow-up stage.

Fig. 2.

Data charting process of records as sources of evidence.

Hereafter is a summary of findings from the literature presented across three key themes: (i) screening process and GP follow-up; (ii) follow-up rates and facilitation; and (iii) recommendations for improved follow-up.

Discussion

This scoping review was undertaken to consider evidence examining GP involvement in the follow-up of positive iFOBTs from the NBCSP and uncovered the integral position they hold throughout the program. The NBCSP has the potential to considerably reduce bowel cancer prevalence and mortality with the efficient transition of positively screened participants from the point of engagement to that of diagnostic assessment (Australian Institute of Health and Welfare 2023). Statistics show individuals with bowel cancer detected through the program are more likely to be diagnosed with less-advanced cancer and have a lower risk of mortality (9.6%) compared to those diagnosed outside of the NBCSP (23.8%) (Australian Institute of Health and Welfare 2018). However, the structure of the Australian healthcare system means this progression is reliant upon GPs consulting positively screened participants within the suggested two weeks and referring them onto colonoscopy (Australian Department of Health 2016). The following discussion draws attention to several such factors related to the general practice setting and the NBCSP and acknowledges the instrumental part played by GPs in each of these.

Although PFUF officers may encourage participants to attend GP appointments, it is the domain of GPs to then refer positively screened participants for further diagnostic investigation via colonoscopy, if appropriate (Foreman 2009; Royal Australian College of General Practitioners 2019). Although the accepted benchmark is 30 days from GP referral to colonoscopy, NHMRC advises participants undergo the procedure as soon as possible to reduce psychological distress and within 120 days to minimise risk of advancing the severity of disease, if cancer is present (Clarke et al. 2019; Cancer Council Australia Colorectal Cancer Screening Working Party 2023).The timing of a positively screened participant’s follow-up appointment with a GP and the efficiency of the subsequent referral is key to the colonoscopy being performed within this desired timeframe.

General practitioners are expected to report NBCSP participant information to the NCSR, which relies upon voluntary provision of clinical data to work effectively. Participant reminders and program monitoring data are potentially inaccurate if clinical interactions are not reported (Doherty et al. 2021; Australian Institute of Health and Welfare 2023). The HCP Portal was launched to support identifying participants, accessing screening histories, and reporting by allowing clinical data to be shared between practices and the NCSR at the time of consultation via a desktop integration portal for selected clinic software (Australian Department of Health 2017; Doherty et al. 2021; Verbunt et al. 2022). Data gaps continue to exist and are often attributed to poor integration between practice software and the NCSR and GP lack of time (Royal Australian College of General Practitioners 2022; Verbunt et al. 2022).

The provision of financial incentives has been posited as a means of encouraging the promotion of bowel cancer screening within the general practice setting and the reporting of data to the NCSR by GPs (Christou et al. 2010; Dodd et al. 2019; Holden et al. 2020, 2021; Royal Australian College of General Practitioners 2022; Verbunt et al. 2022). Financial reimbursements were previously given to GPs for reporting screening data to the NCSR but were removed in 2021 to coincide with the transition from paper-based reporting to digital reporting via the HCP Portal (Doherty et al. 2021). Clinicians and peak body organisations objected to this change citing its failure to acknowledge the time taken to submit information online and suggesting it would in fact lead to an increase in non-submissions and subsequent data gaps (Doherty et al. 2021).

None of the research studies included in this review specifically investigated Australian GPs’ follow-up procedures of NBCSP iFOBT results (Table 1). Furthermore, the authors were unable to locate any grey literature that investigated the timing of positively screened participants being contacted by clinic staff, the method by which participants were contacted, the urgency of the appointment to discuss their positive result with their GPs, and/or the software employed by clinics to book and monitor this appointment. Research into specific steps taken and systems employed in general practice clinics following a positive iFOBT may help to implement better support of the transition from participation to diagnostic investigation for those who participate in the NBCSP.

Conclusion

This first review of sources of evidence that describe GP procedures following a positive iFOBT result has indicated a dearth of information on the usual care process for participants and GPs. General practitioners play a pivotal role in the success of the NBCSP, further enhanced by the implementation of the Alternative Access to Kits Model and the on-demand kit requests for 45- to 49-year-old screening cohort, which generate additional layers of patient engagement and management by GPs. General practitioners’ prioritisation of participation, follow-up practices, and the value they assign to bowel screening are key driving forces in the effectiveness of the NBCSP. Clarity on factors that support and hinder this follow-up process is essential. Further research would contribute towards improving efficacy of the NBCSP and a better understanding of the ways in which work within the general practice setting supports screening pathways.