Nijmegen Colorectal Screening

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  • A national colorectal cancer screening programme

  • G e z o n d h e i d s r a a d P r e s i d e n tH e a l t h C o u n c i l o f t h e N e t h e r l a n d s

    To the Minister of Health, Welfare and Sport

    P. O . B o x 1 6 0 5 2 V i s i t i n g A d d r e s s

    N L - 2 5 0 0 B B T h e H a g u e P a r n a s s u s p l e i n 5

    Te l e p h o n e + 3 1 ( 7 0 ) 3 4 0 6 6 4 0 N L - 2 5 11 V X T h e H a g u e

    Te l e f a x + 3 1 ( 7 0 ) 3 4 0 7 5 2 3 T h e N e t h e r l a n d s

    E - m a i l : w a . v a n . v e e n @ g r . n l w w w . h e a l t h c o u n c i l . n l

    Subject : presentation of advisory report A national colorectal cancer screening programme

    Your reference : PG/ZP 2.289.635Our reference : U-5546/WvV/iv/842-CEnclosure(s) : 1Date : November 17, 2009

    Dear Minister,

    In reaction to your request for advice dated 27 November, 2008, I herewith present you the report A national colorectal cancer screening programme. It has been drawn up by a special committee, which has also taken advice from the Standing Committee on Public Health, the Standing Committee on Medicine, and the Health Councils Committee on the Population Screening Act.

    The Committee was in a position to draw on many sources, such as the knowledge and experience gained from trials which got off to a good start after the consensus meeting in February 2005 convened by the Dutch Cancer Society and the Netherlands Organisation for Health Research and Development (ZonMw).

    The Committee concludes that colorectal cancer lends itself admirably to population screening. It recommends a scheme based on the screening of men and women between 55 and 75 years old once every two years, on the basis of an immunochemical Faecal Occult Blood Test (iFOBT), a self test. At a 60 per cent participation rate, this may help to prevent 1,400 bowel cancer deaths a year. The implementation of a national screening programme is a major undertaking. Building up the necessary capacity (colonoscopy, pathology) is expected to take five years.

    I endorse the conclusions and recommendations of the committee.

    Yours sincerely,(signed)Professor J.A. Knottnerus

  • A national colorectal cancer screening programme


    the Minister of Health, Welfare and Sport

    No. 2008/13E, The Hague, November 17, 2009

  • The Health Council of the Netherlands, established in 1902, is an independent scientific advisory body. Its remit is to advise the government and Parliament on the current level of knowledge with respect to public health issues and health (services) research... (Section 22, Health Act).

    The Health Council receives most requests for advice from the Ministers of Health, Welfare & Sport, Housing, Spatial Planning & the Environment, Social Affairs & Employment, Agriculture, Nature & Food Quality, and Education, Culture & Science. The Council can publish advisory reports on its own initia-tive. It usually does this in order to ask attention for developments or trends that are thought to be relevant to government policy.

    Most Health Council reports are prepared by multidisciplinary committees of Dutch or, sometimes, foreign experts, appointed in a personal capacity. The reports are available to the public.

    This report can be downloaded from

    Preferred citation:Health Council of the Netherlands. A national colorectal cancer screening pro-gramme. The Hague: Health Council of the Netherlands, 2009; publication no. 2009/13E.

    all rights reserved

    ISBN: 978-90-5549-780-5

    The Health Council of the Netherlands is a member of the European Science Advisory Network for Health (EuSANH), a network of science advisory bodies in Europe.


    The Health Council of the Netherlands is a member of the International Network of Agencies for Health Technology Assessment (INAHTA), an international collaboration of organisations engaged with health technology assessment.

  • Contents 7


    Executive summary 11

    1 Introduction 191.1 Background to this advisory report 191.2 Request for advice 201.3 Structure of the report 20

    2 Colorectal cancer screening abroad 21

    3 Feasibility of population screening for colorectal cancer in the Netherlands 233.1 Maastricht 233.2 FOCUS, Nijmegen-Amsterdam 233.3 CORERO, Groot-Rijnmond 243.4 COCOS (Amsterdam-Rotterdam), NordICC 243.5 DeCoDe 253.6 SCRIPT 25

    4 Criteria for sound population screening 27

    5 Severity and scope of the burden of disease 315.1 Colorectal cancer, adenomas and early detection 315.2 Incidence 32

  • 8 Titel advies

    5.3 Prevalence 335.4 High-risk groups 345.5 Selective screening 365.6 Exclusion criteria 375.7 Prognosis and mortality 385.8 Prevention 385.9 Conclusion 39

    6 FOBT screening 416.1 gFOBT screening 426.2 iFOBT screening 446.3 Conclusion 51

    7 Sigmoidoscopy 537.1 Effectiveness 547.2 Test performance 547.3 Acceptance 567.4 Efficiency and cost-effectiveness 567.5 Conclusion 57

    8 Colonoscopy 598.1 Effectiveness 598.2 Test performance 608.3 Acceptance 628.4 Efficiency and cost-effectiveness 648.5 New developments in endoscopy 648.6 Conclusion 65

    9 Colonography 679.1 Effectiveness 689.2 Test performance 689.3 Acceptance 699.4 Efficiency and cost-effectiveness 709.5 New developments 719.6 Conclusion 72

    10 Molecular tests 7310.1 Testing for biomarkers in stool 74

  • Contents 9

    10.2 Testing for biomarkers in blood 7510.3 Conclusion 76

    11 Desirability of screening for colorectal cancer and selection of a screening method 7711.1 Desirability of screening 7711.2 Screening test selection 7811.3 Susceptibility to foreseeable developments 8111.4 Conclusion 82

    12 Cost-effectiveness and screening strategy selection 8312.1 Cost-effectiveness 8312.2 Screening strategy 9312.3 Conclusion 97

    13 Acceptance and participation 9913.1 The screening test 10013.2 Orientation, education and acceptance 10013.3 Organisational matters 10213.4 Participant characteristics 10413.5 Participation in follow-up colonoscopy 10513.6 Conclusions 105

    14 Quality assurance and organisation 10714.1 Policy context 10714.2 National organisational structure 10814.3 Target population, at-risk groups 11114.4 iFOBT screening 11314.5 Follow-up 11514.6 Surveillance 11914.7 Care consumption 12114.8 Phased introduction 12314.9 Capacity 12414.10 Conclusions and recommendations 127

    15 Answers to specific questions raised by the Minister 12915.1 Is introduction of a colorectal cancer screening programme desirable? 12915.2 Is the introduction of a colorectal cancer screening programme feasible?

    How should a possible screening programme be phased in, taking the available care capacity into account? 130

  • 10 Titel advies

    15.3 Which new methods of screening for colorectal cancer are likely to become available within five to seven years? (I wish to ascertain whether any foreseeable developments have infrastructural or operational implications.) 130

    15.4 Should the screening programme pay particular attention to groups with a non-hereditary elevated risk of colorectal cancer, e.g. by means of individual risk profiling? 131

    References 133

    Annexes 169A Request for advice 171B The Committee 173

  • Executive summary 11

    Executive summary


    The Committee has concluded that there is sufficient evidence to justify starting a national bowel cancer screening programme. The most appropriate screening method is an immunochemical Faecal Occult Blood Test (iFOBT). The Commit-tee recommends a programme based on the screening of people between fifty-five and seventy-five years old once every two years. People in the target group would be sent a faecal test sampling kit by the screening organisation. The faecal sample would have to be sent to a laboratory to be tested for invisible traces of blood. Persons with a positive (i.e. abnormal) test result would be referred for colonoscopy, which would take place in an outpatient clinic under sedation and with the aid of pain management.

    Recent trials in the Dutch cities of Nijmegen, Amsterdam and Rotterdam suggest that a 60 per cent participation rate may be expected. Under this assump-tion, modelling indicates that screening will in due course help to prevent an average of 1,428 bowel cancer deaths a year. In 2008, 4,843 people died from the disease in the Netherlands.

    Bowel cancer is a serious health problem

    Bowel cancer (colorectal cancer) is a common disease. In 2006, 11,231 cases were diagnosed in the Netherlands. In the general population, the lifetime risk of

  • 12 A national colorectal cancer screening programme

    bowel cancer is 4 to 5 per cent. The average five-year survival is 59 per cent, but an individuals chances of survival depend largely on how extensive the disease is when diagnosed. If the cancer is confined to the inner lining of the bowel (stage I), the five-year survival is 94 per cent; for patients wifh metastatic bowel cancer (stage IV), the five-year survival is limited to 8 per cent.

    Bowel cancer is preceded by a prolonged adenomal state, which is relatively easy to detect and treat. Furthermore, a person who has bowel cancer is unlikely to notice any health problems for several years. These two facts mean that bowel cancer is an ideal candidate for screening. From FOBT-based efficacy trials it has been known for some time that screening can reduce bowel cancer mortality by enabling early detection or prevention through the removal of adenomas. However, the implementation of a screening programme would be responsible only if other internationally re