Colorectal cancer in Australia
Introduction[edit source]
In Australia, colorectal cancer is a major cause of morbidity and mortality. In 2014, it was estimated to be the second most commonly diagnosed cancer in Australia (excluding non-melanoma skin cancer) and the second most common cause of cancer mortality (after lung cancer), representing 9% of all deaths from cancer.[1] The risk of being diagnosed with colorectal cancer by the age of 85 years is one in 11 for males and one in 16 for females.[2]
Australia has one of the highest rates of colorectal cancer in the world.[3] The high rates of colorectal cancer in Australia and other developed Western countries are likely to be due in large part to the increased prevalence of established environmental risk factors, including physical inactivity and obesity,[4] smoking,[5] heavy alcohol consumption,[6] and a diet high in red/processed meats[7] and low in fibre.[8]
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Incidence and mortality[edit source]
Population age-standardised rates[edit source]
Table 1.1 shows the Australian incidence and mortality rates for colorectal cancer in comparison with other countries for the period up to and including 2012.[3]
A total of 14,962 new cases of colorectal cancer were diagnosed in Australia in 2013 (8,214 males and 6,748 females). In comparison, there were 6,986 new cases diagnosed in 1982.[2]
The age-standardised incidence rate for colorectal cancer has remained stable from 58.2 per 100,000 persons in 1982 to 57.7 cases per 100,000 persons in 2013 (67.6 for males and 48.8 for females).[2]
The introduction of the National Bowel Cancer Screening Program (NBCSP) was expected to result in short-term increases in incidence rates due to the detection of previously undetected cancers in those participating in screening for the first time.[9] However, in the long-term it is expected that the incidence of colorectal cancer in those age groups eligible for population screening will begin to fall, as pre-cancerous lesions are detected and treated before they develop into cancer. This trend has been observed in cervical cancer incidence following the introduction of the National Cervical Screening Program.[10]
In 2014, 4,071 deaths from colorectal cancer in Australia (2,236 males and 1,835 females) were recorded.[10] In comparison, there were 2500 deaths recorded in 1968.[10] The age-standardised mortality rate for colorectal cancer decreased from 31 deaths per 100,000 persons in 1968 to 14.9 deaths per 100,000 in 2014 (18.1 for males and 12.1 for females).[10]
Although the age-standardised incidence rate for colorectal cancer in Australia is amongst the highest in the world, it has barely increased in 30 years, and in comparison with other developed Western countries the proportion of diagnosed patients dying from the disease is low.
i Numbers recorded by the Australian Bureau of Statistics (ABS) based on death certificates. These figures probably significantly underestimate the true number of deaths due to colorectal cancer because the coding methods used for national statistics can result in such deaths being attributed to nonspecific cancers such as ‘malignant neoplasms of other and unspecified digestive organs’ or ‘cancers of unknown primary site’.
Table 1.1 Incidence and mortality rates for colorectal cancer, selected countries, 2012[edit source]
| Country | Incidence (a) (ASRW) | Mortality (b) (ASRW) |
|---|---|---|
| Australia | 38.4 | 9.0 |
| New Zealand | 37.3 | 15.1 |
| Canada | 35.1 | 10.8 |
| UK | 30.2 | 10.7 |
| USA | 25.0 | 9.2 |
ASRW: age-standardised rate (standardised to World Standard Population for purpose of international comparison)
(a) Incidence is the number of new cases of colorectal cancer per 100,000 people, age-standardised to the World Standard Population; (b) Mortality is the number of deaths from colorectal cancer per 100,000 people, age-standardised to the World Standard Population. Source: GLOBOCAN (2012)[3]
Age and sex[edit source]
The trend in age-specific incidence rates for colorectal cancer in 2013 was similar to that of previous years, with incidence rates rising sharply for those aged 50 years and over, and remaining relatively low for those 49 years and under (with only 9% of cases diagnosed in those aged under 49 years) (Figure 1.1).[2] People aged 80 years and over demonstrated the highest incidence rates, with more than 400 newly diagnosed cases per 100,000 population.
Figure 1.1 Age-specific incidence rates for colorectal cancer, Australia, 2013[edit source]
Source: Australian Institute of Health and Welfare (2017).[2] The incidence (or mortality) rate has been age-standardised to the Australian population (ASR) at 30 June 2001.
Figure 1.2 shows the time trends in incidence of colorectal cancer in Australian men and women.[2] Between 2000 and 2012, the age-standardised incidence rates for colorectal cancer demonstrated a gradual decline in both males (1% per year) and females (0.7% per year).[2] However, over the same period the number of newly diagnosed cases of colorectal cancer increased by 20% in males, and 23% in females, due to the increasing size and ageing of the Australian population.[2]
Figure 1.2 Age-standardised incidence rates for colorectal cancer, Australia, 1982–2013[edit source]
Source: Australian Institute of Health and Welfare (2017).[2] The incidence (or mortality) rate has been age-standardised to the Australian population (ASR) at 30 June 2001.
The highest age-specific mortality rates for colorectal cancer in 2014 were observed in the oldest age groups, with those aged 80–84 demonstrating a rate of 132.7 deaths per 100,000 population, and those aged 85 years and over demonstrating a rate of 212.5 deaths per 100,000 (Figure 1.3).[2] Approximately 30% of all colorectal cancer deaths occurred in those aged between 50 and 69 years (1218 deaths). While death from colorectal cancer was relatively uncommon among those aged less than 50 years (213 deaths; 5%).[2]
Figure 1.4 shows the time trends in mortality from colorectal cancer in Australian men and women.[2] Between 1995 and 2014 there was a decline in the age-standardised mortality rate, which fell by an average of 2.5% per year overall.[2]
Figure 1.3 Age-specific mortality rates for colorectal cancer, Australia, 2014[edit source]
Source: Australian Institute of Health and Welfare (2017)[2]
Figure 1.4 Age-standardised mortality rates for colorectal cancer, Australia, 1968–2014[edit source]
Source: Australian Institute of Health and Welfare (2017).[2] The incidence (or mortality) rate has been age-standardised to the Australian population (ASR) at 30 June 2001.
Socioeconomic status[edit source]
In the 5 years from 2008 to 2012, those living in the most disadvantaged areas of Australia accounted for the highest age-standardised incidence rate for colorectal cancer (65 per 100,000).[11]
In the 5 years from 2010 to 2014, those living in the most disadvantaged areas of Australia accounted for the highest age-standardised mortality rateii for colorectal cancer (17 per 100,000).[11]
ii Age-standardised incidence according to socioeconomic status, jurisdiction and Indigenous status was not consistently reported for all time periods, so direct comparisons between the reporting periods cannot be made.
Remoteness area[edit source]
In the 5 years from 2008 to 2012, people living in outer regional areas of Australia had the highest age-standardised incidence rate for colorectal cancer (67.9 per 100,000).[11]
Between 2010 and 2014, age-standardised mortality ratesii for colorectal cancer were highest in Outer regional areas of Australia, with 16 deaths per 100,000. Age-standardised mortality rates were lowest in Very remote areas (10.9 deaths per 100,000).[11]
ii Age-standardised incidence according to socioeconomic status, jurisdiction and Indigenous status was not consistently reported for all time periods, so direct comparisons between the reporting periods cannot be made.
State and territory[edit source]
The incidence of colorectal cancer varied between jurisdictions in the period between 2008 and 2012. Tasmania (74 cases per 100,000 persons) and Queensland (63 cases per 100,000 persons) had the highest age-standardised incidence rates, while Western Australia (58 cases per 100,000 persons) and the Northern Territory (51 cases per 100,000 persons) had the lowest.[11]
Between 2010 and 2014, Tasmania had the highest age-standardised mortality rateii for colorectal cancer (19 deaths per 100,000 population), while Western Australia had the lowest (13 deaths per 100,000 population).[11]
ii Age-standardised incidence according to socioeconomic status, jurisdiction and Indigenous status was not consistently reported for all time periods, so direct comparisons between the reporting periods cannot be made.
Aboriginal and Torres Strait Islander peoples[edit source]
Between 2008 and 2012, colorectal cancer was the third most commonly diagnosed cancer among Aboriginal and Torres Strait Islander peoples (of the selected cancers reported for Indigenous Australians), with an average of 116 new cases per year, based on National Mortality Database data from New South Wales, Victoria, Queensland, Western Australia, and the Northern Territory.[11]
Colorectal cancer is one of the cancers for which the age-standardised incidence rate was lower for Indigenous Australians than non-Indigenous Australians, with a rate ratio of 0.9.[11] It is unclear why there is a lower incidence rate for some cancers among Indigenous Australians. However, it has been suggested that the lower rates of participation in screening and diagnostic testing among Indigenous people may play a role.[1] Indigenous Australians are more likely to have cancers that are diagnosed at a later stage, when the primary site is no longer apparent, which may contribute to lower incidence rates for specific primary sites.[1]
In 2010–2014, the age-standardised mortality rate for colorectal cancer was lower for Aboriginal and Torres Strait Islander people (11.5 deaths per 100,000) than for non-Indigenous Australians (15.5 deaths per 100,000), based on National Mortality Database data from New South Wales, Queensland, Western Australia, South Australia and the Northern Territory.[11]
ii Age-standardised incidence according to socioeconomic status, jurisdiction and Indigenous status was not consistently reported for all time periods, so direct comparisons between the reporting periods cannot be made.
Colorectal cancer screening[edit source]
The early detection of colorectal cancer through population screening programs is associated with earlier stage at diagnosis, better treatment options. A number of randomised controlled trials have shown that population screening programs using the faecal occult blood test (FOBT) can reduce colorectal cancer mortality by 15–33%.[12][13][14][15]
In Australia, screening for colorectal cancer is available through the NBCSP, which was introduced in 2006. The NBCSP aims to reduce the morbidity and mortality from colorectal cancer by actively recruiting and screening the target population for early detection or prevention of the disease using FOBT kits.[16] The program has been phased in gradually, and by 2020, will offer free biennial screening to everyone aged between 50 and 74 years.
In addition to the NBCSP, there are, currently, other ways that Australians can participate in screening for colorectal cancer, although these programs don't provide a reminder service for follow-up of positive screening tests. In conjunction with their general practitioner, individuals can purchase FOBT kits from many pharmacies without prescription, or obtain a kit from non-government organisations such as some Cancer Councils[17] or from community or consumer organisations such as Rotary or Bowel Cancer Australia.
Screening participation rates in the general population[edit source]
Of the 2,607,502 FOBT invitation kits that were sent out to eligible individuals (50-74 years) between 2014/2015, a total of 1,013,040 people participated in the program by returning a completed FOBT for analysis.[18] Therefore, the overall Australia-wide crude participation rate was 38.9 %.[11] Given the significant proportion of older Australians who may be participating in screening practices outside of the NBCSP, however, this may be an underestimate of true population screening rates.[17]
The national participation rate of 38.9 % for 2014–2015 was slightly higher when compared with the previous rolling 2-year period (2013–2014), which had a participation rate of 37%.[11]11 In addition, the participation rate was highest for individuals receiving their second or later (subsequent) screening invitation ((42% compared with 35%).[11]
A 2014 study compared the outcomes and cancer characteristics of individuals who had been invited to participate in the NBCSP in 2006–2008, as part of the target population turning 50, 55 or 65 (invitees), with those of individuals aged 50–69 in 2006–2008, but who did not turn 50, 55 or 65 during that period and were therefore not invited to screen then (non-invitees).[19] This study demonstrated that, of those diagnosed with colorectal cancer between 2006 and 2008, non-invitees had a 68% higher risk of colorectal cancer death, compared with NBCSP invitees.[19] For NBCSP invitees specifically, the risk of death from colorectal cancer was more than twice as high in those who did not participate but later had a colorectal cancer diagnosed, compared with those whose cancer was diagnosed through participation in colorectal cancer screening. In addition, colorectal cancers diagnosed in non-invitees had 38% higher odds of being more advanced than those diagnosed in NBCSP invitees.[19] For NBCSP invitees specifically, those with colorectal cancers detected through screening had 121% higher odds of being diagnosed at an earlier stage, compared with colorectal cancers diagnosed in invitees who did not participate. These findings suggest that the NBCSP is contributing to reducing morbidity and mortality from colorectal cancer in Australia.[19]
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Screening participation rates by population subgroups[edit source]
Data regarding NBCSP participation in certain population subgroups are incomplete or unavailable. Some participants, such as Aboriginal and/or Torres Strait Islanders, people with a disability or people who speak a language other than English at home must self-identify this on the participant details form. It is not possible to accurately report NBCSP participation rates for these subgroups.[16]
Screening participation rates by state and territory[edit source]
In 2013–2014, NBCSP participation ratesiii did vary by state and territory.[16] With the exception of New South Wales (34.5% crude participation rate), Queensland (36.6%) and the Northern Territory (27.6%), all other jurisdictions demonstrated participation rates that were above the overall Australian rate.[16]
While the reasons behind the observed jurisdictional variations in NBCSP participation are unclear, an analysis of participation by socioeconomic status and remoteness areas within each jurisdiction has demonstrated that participation in New South Wales and Queensland was generally lower across all subgroups (including Major cities, and Inner and outer regional areas), compared with the other jurisdictions.[16] These findings suggest that in these jurisdictions, which are larger and therefore have a bigger impact on the Australian participation rate, lower participation was an overall trend.
iii All colorectal screening participation rates (in the general population and by state and territory, age and sex, socioeconomic status and remoteness area) reported in the National Bowel Cancer Screening Program Monitoring Report 2016 were crude participation rates, and age-standardised participation rates were not reported.
Screening participation rates by age and sex[edit source]
Participation ratesiii were higher for females than males in each of the four age groups (Figure 1.5), with females 1.2 times more likely than males to participate in colorectal screening (34.7% for males, compared with 40.0% for females).[16]
Given that colorectal cancer risk and incidence is higher in men, this suggests an inequitable pattern of NBCSP participation on the basis of sex. It has been suggested that women may have higher screening rates for colorectal cancer due to the fact that they are involved in, and aware of, other population-based screening programs such as those for cervical cancer and breast cancer, and may therefore better understand the potential benefits of screening.[20]
Participation rates varied between the four target age groups, and were highest for those aged 65–69 years (44.2%), and those aged 60–64 years (43.9%). These were the only two age groups with participation rates above the national average (Figure 1.5).[16] Participation rates were lowest in 50 year-old men.[16]
iii All colorectal screening participation rates (in the general population and by state and territory, age and sex, socioeconomic status and remoteness area) reported in the National Bowel Cancer Screening Program Monitoring Report 2016 were crude participation rates, and age-standardised participation rates were not reported.
Figure 1.5 Crude participation in the National Bowel Cancer Screening Program, by age and sex, 2013–2014[edit source]
Source: Data from National Bowel Cancer Screening Program Register as at 31 December 2015(AIHW 2016)[16]
Screening participation rates by socioeconomic status[edit source]
Analysis of NBCSP data according to population-based socioeconomic status quintiles showed that invitees living within areas with the lowest socioeconomic status (areas with the most socioeconomic disadvantage) had lower participation ratesiii, when compared with those living in all other areas rated according to level of socioeconomic status (Figure 1.6).[16]
These results are consistent with the findings of studies in Australia and internationally. A UK study has shown that socioeconomic deprivation has a major effect on participation in screening.[21] It found that people from more economically deprived areas had less interest in and uptake of colorectal cancer screening than their counterparts in less deprived areas.[21] Similarly, a study in South Australia demonstrated a general pattern of lower screening participation in more disadvantaged socioeconomic groups.[20] This study found that key barriers to the NBCSP were lack of knowledge about colorectal cancer and screening tests in general, and the NBCSP in particular, suggesting a need for greater resources for social marketing to increase both awareness and health literacy in this area.[20]
iii All colorectal screening participation rates (in the general population and by state and territory, age and sex, socioeconomic status and remoteness area) reported in the National Bowel Cancer Screening Program Monitoring Report 2016 were crude participation rates, and age-standardised participation rates were not reported.
Figure 1.6 Crude participation in the National Bowel Cancer Screening Program, by socioeconomic status area, 2013–2014[edit source]
Source: Data from National Bowel Cancer Screening Program Register as at 31 December 2015(AIHW 2016)[16]
Screening participation rates by remoteness area[edit source]
Over 66% of all participants came from Major cities (with a 36.6% crude participation rateiii).[16] The proportion participating in screening was highest in Inner regional (40.0%) and Outer regional (38.7%) areas and lowest in Remote and Very remote areas (Figure 1.7).
iii All colorectal screening participation rates (in the general population and by state and territory, age and sex, socioeconomic status and remoteness area) reported in the National Bowel Cancer Screening Program Monitoring Report 2016 were crude participation rates, and age-standardised participation rates were not reported.
Figure 1.7 Crude participation in the National Bowel Cancer Screening Program, by remoteness area, 2013–2014[edit source]
Source: Data from National Bowel Cancer Screening Program Register as at 31 December 2015 (AIHW 2016)[16]
Colorectal cancer control in Australia: now and in the future[edit source]
Survival[edit source]
In 2009-2013, the 5-year relative survival for colorectal cancer in the Australian population was 68.7% (68.1% for males and 69.4% for females) (Figure 7.8).[11] Five-year relative survival has improved between 1984-1988 and 2009-2013; increasing by 19% from 49.7% to 68.7%.[11]
The improvement in colorectal cancer survival rates may be due to a number of factors, such as earlier presentation, earlier diagnosis, and improved treatments including safer and more effective surgical techniques[22] as well as the availability of new chemotherapeutic and biologic treatment agents.[23] Better management of families with Lynch syndrome and Familial Adenomatous Polyposis, more effective colonoscopic surveillance following cancer or adenoma detection, and ad hoc screening by FOBT or colonoscopy may also have contributed to improved colorectal cancer survival rates. It is unlikely that the NBCSP has had a significant impact on the observed increases in 5-year survival, given the small number of years the program has been active, the limited ages screened during those years, and the relatively low participation rates.
At the time of diagnosis, the probability of surviving for at least 5 years was 68%, which increased to 91% and 96% at 5 years and 15 years post-diagnosis, respectively (Figure 1.8).[16]
Figure 1.8 Relative survival at diagnosis and 5-year conditional survival from colorectal cancer, Australia, 2008–2012[edit source]
Conditional relative survival: Conditional survival estimates show the probability of surviving a given number of years provided that an individual has already survived a specified amount of time after diagnosis.
Source: Data from Australian Cancer Database (AIHW 2012)[9]
Incidence[edit source]
Projections for cancer incidence in Australia have been undertaken that involve mathematical extrapolations of past trends with the assumption that the same trend will continue into the future.[9] These projections are not forecasts and do not attempt to allow for future changes in areas such as population screening programs or treatment regimens. For colorectal cancer, projections are based on extrapolation of the trends in incidence up to 2007 and do not take into account the impact of the NBCSP on future incidence.[9]
In males, age-standardised incidence rates for colorectal cancer demonstrated an increasing trend between 1982 and 1996. However, between 1996 and 2007 there was a small but statistically significant reduction of approximately 0.3 cases per 100,000 males per year (Figure 1.9).[9]
While the age-standardised incidence rate for colorectal cancer is expected to fall to approximately 71 cases per 100,000 males by 2020, equating to approximately 10,800 new cases, the estimated number of new cases diagnosed is expected to continue to increase due to projected increases in the size of the elderly population (Figure 1.9). Males aged 45–64 years are expected to show the greatest reductions in colorectal cancer rates, while those aged 85 years and over are expected to show smaller reductions.[9]
Figure 1.9 Trends in number of new cases and age-standardised incidence rates(a) for colorectal cancer in Australian males, 1982 to 2007, projected to 2020[edit source]
(a) Rates are expressed per 100,000 males.
ASR: Age standardised rate (standardised to the Australian population as at 30 June 2001)
Source: Australian Cancer Database (AIHW 2012)[9]
In females, the age-standardised incidence rate for colorectal cancer demonstrated a slight increase of approximately 0.04 cases per 100,000 females per year between 1982 and 2007 (Figure 1.10), which was not statistically significant.[9]
By 2020, the age-standardised incidence rate for colorectal cancer is expected to remain steady at approximately 54 cases diagnosed per 100,000 females, which is equivalent to approximately 9160 new cases (Figure 1.10).[9] Females aged 45–64 years are expected to show reductions in colorectal cancer rates, although these reductions are unlikely to be as significant as those observed for males in the same age group.[9]
Figure 1.10 Trends in number of new cases and age-standardised incidence rates(a) for colorectal cancer in Australian females, 1982 to 2007, projected to 2020[edit source]
(a) Rates are expressed per 100,000 females.
ASR: Age standardised rates (age standardised to the Australian population as at 30 June 2001)
Source: AHW Australian Cancer Database (AIHW 2012)[9]
References[edit source]
- ↑ 1.0 1.1 1.2 Australian Institute of Health and Welfare. Cancer in Australia: an overview 2014. [Version updated 16 April 2015] Cancer series No 90. Cat. no. CAN 88. Canberra: AIHW;.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Australian Institute of Health and Welfare. Australian Cancer Incidence and Mortality (ACIM) books: Colorectal cancer (also called bowel cancer). [homepage on the internet] Canberra: AIHW; 2017 Feb 3 [updated 2017 Feb 3]. Available from: http://aihw.gov.au/acim-books/.
- ↑ 3.0 3.1 3.2 World Health Organization International Agency for Research on Cancer (IARC). GLOBOCAN 2012: estimated cancer incidence, mortality and prevalence worldwide in 2012. [homepage on the internet]; 2012 [cited 2016 Apr 23]. Available from: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx.
- ↑ Steins Bisschop CN, van Gils CH, Emaus MJ, Bueno-de-Mesquita HB, Monninkhof EM, Boeing H, et al. Weight change later in life and colon and rectal cancer risk in participants in the EPIC-PANACEA study. Am J Clin Nutr 2014 Jan;99(1):139-47 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24225355.
- ↑ Leufkens AM, Van Duijnhoven FJ, Siersema PD, Boshuizen HC, Vrieling A, Agudo A, et al. Cigarette smoking and colorectal cancer risk in the European Prospective Investigation into Cancer and Nutrition study. Clin Gastroenterol Hepatol 2011 Feb;9(2):137-44 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21029790.
- ↑ Ferrari P, Jenab M, Norat T, Moskal A, Slimani N, Olsen A, et al. Lifetime and baseline alcohol intake and risk of colon and rectal cancers in the European prospective investigation into cancer and nutrition (EPIC). Int J Cancer 2007 Nov 1;121(9):2065-72 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17640039.
- ↑ Norat T, Bingham S, Ferrari P, Slimani N, Jenab M, Mazuir M, et al. Meat, fish, and colorectal cancer risk: the European Prospective Investigation into cancer and nutrition. J Natl Cancer Inst 2005 Jun 15;97(12):906-16 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15956652.
- ↑ Murphy N, Norat T, Ferrari P, Jenab M, Bueno-de-Mesquita B, Skeie G, et al. Dietary fibre intake and risks of cancers of the colon and rectum in the European prospective investigation into cancer and nutrition (EPIC). PLoS One 2012;7(6):e39361 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22761771.
- ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Australian Institute of Health and Welfare. Cancer incidence projections: Australia, 2011 to 2020. Cancer series no. 66. Cat. no. CAN 62. Canberra: AIHW; 2012.
- ↑ 10.0 10.1 10.2 10.3 Australian Institute of Health and Welfare. Cervical screening in Australia 2012–2013. Cancer series no. 93. Cat. no. CAN 91. Canberra: AIHW; 2015 Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129550872.
- ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 Australian Institute of Health and Welfare. Cancer in Australia 2017. Cancer series no. 101. Cat. no. CAN 100. Canberra: AIHW; 2017.
- ↑ Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996 Nov 30;348(9040):1472-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8942775.
- ↑ Kewenter J, Brevinge H, Engarås B, Haglind E, Ahrén C. Results of screening, rescreening, and follow-up in a prospective randomized study for detection of colorectal cancer by fecal occult blood testing. Results for 68,308 subjects. Scand J Gastroenterol 1994 May;29(5):468-73 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8036464.
- ↑ Kronborg O, Fenger C, Olsen J, Jørgensen OD, Søndergaard O. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996 Nov 30;348(9040):1467-71 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8942774.
- ↑ Mandel JS, Church TR, Ederer F, Bond JH. Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst 1999 Mar 3;91(5):434-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10070942.
- ↑ 16.00 16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08 16.09 16.10 16.11 16.12 16.13 Australian Institute of Health and Welfare. National Bowel Cancer Screening Program: monitoring report 2016. Cancer series no. 98. Cat. no. CAN 97. Canberra: AIHW; 2016.
- ↑ 17.0 17.1 Zajac, I. T. Flight, I. Turnbull, D. Young, G. Cole, S. Wilson, C.. Self-reported bowel screening rates in older Australians and the implications for public health screening programs. Australas Med J 2013;6(8): 411-417.
- ↑ Australian Institute of Health and Welfare (AIHW), Australasian Association of Cancer Registries (AACR). Cancer in Australia. Cancer Series No 2. Canberra: AIHW; 2001.
- ↑ 19.0 19.1 19.2 19.3 Australian Institute of Health and Welfare. Analysis of bowel cancer outcomes for the National Bowel Cancer Screening Program. Cat. no. CAN 87. Canberra: AIHW; 2014.
- ↑ 20.0 20.1 20.2 Ward PR, Javanparast S, Wilson C. Equity of colorectal cancer screening: which groups have inequitable participation and what can we do about it? Aust J Prim Health 2011;17(4):334-46 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22112702.
- ↑ 21.0 21.1 Whynes DK,Frew EJ, Manghan CM, Scholefield JH, Hardcastle JD. Colorectal cancer, screening and survival: the influence of socio-economic deprivation. Public Health 2003;117(6):389-395.
- ↑ Wiegering, A. Isbert, C. Dietz, U. A. Kunzmann, V. Ackermann, S. Kerscher, A. Maeder, U. Flentje, M. Schlegel, N. Reibetanz, J. Germer, C. T. Klein, I.. Multimodal therapy in treatment of rectal cancer is associated with improved survival and reduced local recurrence - a retrospective analysis over two decades. BMC Cancer 2014;14: 816.
- ↑ Hu CY, Bailey CE, You YN, Skibber JM, Rodriguez-Bigas MA, Feig BW, et al. Time trend analysis of primary tumor resection for stage IV colorectal cancer: less surgery, improved survival. JAMA Surg 2015 Mar 1;150(3):245-51 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25588105.