Australia has one of the highest rates of bowel cancer in the world. Early detection saves lives, but delays and restrictions during the pandemic has led to missed screenings and a reduction in diagnostic procedures aimed at detecting bowel cancer, and there is now an urgent need to expand colonoscopy capacity to deal with the backlog.

In a joint white paper, Bowel Cancer Australia and Q-bital Healthcare Solutions highlight the importance of investing in the bowel cancer pathway and calls on the Australian Governments to increase colonoscopy capacity to ensure all patients have access to colonoscopy within 30 days, in accordance with colonoscopy categorisation guidelines.

The current situation

Just over 40 Australians are diagnosed with bowel cancer every day; and in their lifetime 1 in 13 people will develop the disease. This makes bowel cancer the third most commonly diagnosed cancer. Although it is also Australia’s second deadliest cancer, the five-year survival rate can be as high as 99 per cent – if detected early. However, even before the pandemic, only 46 per cent of bowel cancer cases were being diagnosed at an early stage.

Covid-19 has caused widespread disruption to cancer services including screening, diagnosis and treatment. Australia may have had seen a lesser impact of Covid-19 than other countries, but the scale of the pandemic is less important in this respect than the country’s response to the pandemic, and what that means for cancer services and outcomes. Australia endured one of the longest and most restrictive lockdowns anywhere in the world, and this has had a severe impact on cancer services.

Measures taken by governments to mitigate the spread of the virus have restricted patient traffic, and patients have also avoided attending medical appointments and diagnostic procedures for fear of contracting Covid-19. A recent Cancer Australia study showed that between March and April 2020 alone, the number of colonoscopies utilised to diagnose bowel cancers fell by 55 per cent, and referrals to oncology centres plummeted by 40 per cent in August compared with previous years.

It is easy to see why health experts are so concerned; it is now more likely that patients will continue to present with more advanced disease, requiring more complex treatments and resulting in poorer outcomes.

A worrying trend

Incidences of bowel cancer were rising already before Covid-19 arrived, particularly affecting the older demographic; the risk of developing bowel cancer rises sharply and progressively from age 50. However, the number of younger Australians diagnosed with bowel cancer has been increasing steadily.

More worrying still, statistics show that of the top 10 cancers in Australia, bowel cancer was the only cancer to show an increase in mortality rate between 2008 and 2018 in the 45-49 cohort, and even without the impact of Covid-19, this trend showed little sign of abating.

Although screening is done using other techniques that are often non-invasive, colonoscopy procedures are used to detect and confirm the presence of bowel cancer, and to remove pre-cancerous polyps to prevent these from developing into bowel cancer. Colonoscopies are associated with up to a 75 per cent reduction in risk of death for bowel cancers, and a reduced risk of developing the disease overall.

Covid-19 impact

Prior to the pandemic, it was anticipated that 1.1 million colonoscopies would be performed each year in Australia by 2021, or 90,000 each month, but between March and April 2020 the number of colonoscopies and sigmoidoscopy procedures performed more than halved reaching just over 25,000.

Although there was some recovery following the initial stage of the pandemic, when comparing the total national number of services provided in January to September 2020 to the same period in 2019, there were 15% fewer colonoscopies and sigmoidoscopies overall.

It is clear that there have been delays in the diagnosis and treatment of bowel cancer as a result of the Covid-19 pandemic. Victoria’s 112-day lockdown was the longest continuous lockdown anywhere in the world, and resulted in the postponement of elective surgery and diagnostic procedures.

General screening participation rates have also been lower during Covid-19. To catch up with the backlog, there are plans to increase screening through the National Bowel Cancer Screening Program, and as more referrals are made, we are likely to see a greater need for colonoscopy capacity.

This in turn will further increase demand on existing colonoscopy services, which are already under pressure to clear the backlog that stems from a reduction in procedures performed across Australia in 2020. Delays and backlogs can result in poorer patient outcomes, stage migration and additional deaths. In this context, colonoscopy capacity is a key concern as demand often exceeds supply, leading to long waiting times.

The impending crisis

Delayed screening means delayed diagnosis, later stage diagnosis leads to unnecessary waits for treatment – and delayed treatment leads to poorer outcomes. Put simply, delays can lead to unnecessary deaths. In fact, just a four-week delay of cancer treatment is associated with increased mortality.

The question now is how the country can address the need for additional diagnostic capacity to mitigate an impending bowel cancer crisis. As the new white paper concludes, it is key to invest in the entire bowel cancer pathway, and improving screening participation, optimising the use of existing facilities and staff by working longer days or extra shifts, and adding new capacity using of flexible healthcare facilities all play a part in improving outcomes.

In light of the dislocation that the Covid-19 pandemic has inflicted on Australia’s healthcare system, additional support for our hospitals has never been more vital. By ensuring timely access to colonoscopy, we can avert a potential bowel cancer crisis.

The white paper can be downloaded here.