'Bowel cancer is the third most lethal cancer, but a simple home test is improving survival rates'

“The five-year survival rate of people diagnosed with bowel cancer has increased from 50% to 66% over the past 20 years, thanks to early detection, more targeted treatments, and people being more aware of symptoms and not being as reluctant to get them checked out,” he says.

“To that we have added BowelScreen and the 2022 National Cancer Registry Report shows that the largest increase in survival rates has occurred in those in the age group that participates in this screening programme.”

BowelScreen became part of the National Screening Service in 2012, joining the already established BreastCheck and CervicalCheck cancer-screening programmes.

Professor Padraic Mac Mathúna is the clinical director of BowelScreen.

“BowelScreen is a free screening programme that targets the age group with the highest incidence of bowel cancer,” he says. “It’s currently offered to all men and women aged between 59 and 69 on a two-yearly cycle, and it aims to detect and treat bowel cancer as early as possible. Approximately 1,000 people die from bowel cancer in Ireland every year and this programme can significantly reduce that mortality rate.”

So, how does it work? Ann Cooney, a registered nurse practitioner in the BowelScreen endoscopy unit in Louth County Hospital, says that the BowelScreen team compiles a register of people in the eligible age group by using details supplied by the Department of Social Protection. 

Those people are then sent a letter, inviting them to be screened. Once they accept, they are sent a faecal immunochemical test or FIT kit in the mail, which can be done in the privacy of their home.

The test is straightforward. “It’s basically a test tube with a screw-top lid,” she says. 

“You unscrew the lid and there’s a stick attached. After going to the toilet, you insert the end of the stick into a sample of your stool and pop it back in the test tube. 

"There are step-by-step instructions and diagrams that show you exactly how to do this. Then, all you have to do is date the sample, place it in the envelope provided and send it back by freepost for analysis.”

During that analysis, the sample is tested for the presence of blood. “It’s minute levels of blood,” says Smith. 

“We’re not talking about blood, people might notice when they go to the toilet. That’s a worrying symptom that should always have people making an appointment to go to their GP straightaway. 

"Most cancers and pre-cancers bleed a small amount that’s invisible to the naked eye and the FIT kit is designed to pick up these tiny traces of blood.”

Mac Mathúna points out that most people tested have no blood in their stool. They are sent letters confirming their normal results and informing them that they will be asked to complete another home test in two years.

“But blood is detected in about 5% or 6% of cases and these people are advised to have a colonoscopy to investigate further,” he says.

Blood in stool has many causes

Cooney is quick to reassure people that just because blood is found in their FIT sample, it doesn’t mean they have cancer.

In fact, the cause is likely to be something else.

“You can have blood in your stool because of haemorrhoids, diverticulosis or certain medications, like blood thinners or painkillers,” she says. “All a positive FIT kit result means is that you should have a colonoscopy to make sure it’s not cancer.” 

A colonoscopy examines the bowel via a small camera attached to the end of a flexible tube. This tube is inserted into the patient’s bottom, usually while they are sedated, allowing medics to check for signs of cancer.

A BowelScreen nurse prepares patients for the procedure. “We go through a pre-assessment process over the phone,” says Cooney.

“We talk patients through what’s involved, answer any questions they might have, allay any fears and ensure they understand how important it is for them to have their colonoscopy.”

Smith says there are two reasons why BowelScreen is so important. One is the detection of cancer. The latest HSE figures reveal that more than 286,000 FIT kits were returned to the BowelScreen programme in 2022 and 2023. Just over 8,900 tested positive and were referred for colonoscopy and 488 cancers were detected — a rate of 1.5 in every 1,000 people who returned a FIT kit.

The other is cancer prevention. “Polyps are small growths in the colon that are usually benign, but can become cancerous over time,” says Smith. “All polyps are removed during a colonoscopy, which lowers the risk of bowel cancer developing in future.”

In 2022 and 2023, when BowelScreen referred some 8,900 people for colonoscopy, more than 4,000 of those people had polyps removed. “That shows how common polyps are,” says Smith. 

“Many of us develop them as we get older. And while not all will go on to become cancerous, removing them eliminates that risk entirely.”

Considering that the BowelScreen programme can detect and prevent cancer, its uptake rates remain low in comparison with the other two cancer-screening programmes run by the National Screening Service. BreastCheck had an uptake rate of 70.3% in 2022. The rate for CervicalCheck was 73%. But the latest statistics for BowelScreen show an uptake rate of just 46.6%.

Smith points out that research has identified several reasons for this reluctance to participate in the programme. There’s the yuck factor. “People are embarrassed about anything to do with poo,” he says.

There’s fear. “This includes the fear of a possible cancer diagnosis, as well as the fear of colonoscopies,” says Smith. “People can confuse the home test kit with the more invasive colonoscopy. But neither are to be feared.”

The other reasons are people’s lack of awareness of the effectiveness of the screening programme; their low perception of their own risk, particularly in the absence of symptoms; and the fact that people are busy and simply forget to carry out the test.

“There’s no one thing that’s behind the low uptake,” he says. “It’s a combination of all of these things and more.”

There is also a slight gender difference in uptake, with statistics showing that men are approximately 5% less likely to participate in the programme than women. Smith puts this down to traditional masculine norms. 

“Men generally avoid preventative healthcare and tend to wait until there’s something that needs to be fixed,” he says. “Irish men would not be unique in that regard.”

Mac Mathúna believes there may be another reason men aren’t as likely to participate in BowelScreen as women. 

“Women are familiar with the concept of screening, because they are invited to participate in CervicalCheck and BreastCheck as they move through life, but this is the first time men have been involved in any screening programme,” he says.

The BowelScreen team wants men and women to realise there is no reason they shouldn’t accept their invitation to participate in the BowelScreen programme. “The FIT kit is a test you can do alone in the privacy of your own bathroom,” says Smith. 

“It’s simple. It takes a minute or two. There’s no cost involved, and it could add years to your life. Your family will thank you.”

Smith points out that more than 90% of those who participate in BowelScreen once go on to participate again two years later, proving that there’s no reason why anyone should feel reluctant to send off for a FIT kit.

“It’s very apparent that once they overcome their fear, anxiety and nerves, they become strong advocates for the programme,” says Smith. “They know that the effort involved in carrying out the test is more than outweighed by the reassurance it brings.”

False negative and positive results

This is not to suggest that screening doesn’t have limitations. Mac Mathúna acknowledges there can be false negatives and false positives. 

“FIT looks for blood in the stool and some people can have cancerous tumours or polyps that only bleed intermittently and aren’t bleeding at the time of the test, so that test will be a false negative,” he says.

“Other samples may contain blood for a reason that has nothing to do with cancer, so that’s a false positive.”

False negatives and positives exist in all screening tests and it’s why research is ongoing to find better alternatives. “What we have now is a test that has been internationally proven to reduce mortality from bowel cancer,” says Mac Mathúna.

“But we’re always trying to find something better. For example, we’re working with APC Microbiome Ireland in University College Cork to reduce the false positive rates, and the unnecessary colonoscopies that are carried out as a result, by developing a test that detects changes in the gut microbiome that occur in people with polyps or cancer.”

For now, though, FIT represents the best screening tool we have. In the coming years, the age range for the BowelScreen programme will be increased from the current 59 to 69 to 55 to 74, and Cooney encourages everyone offered the test to take it.

“BowelScreen allows us to detect cancer and pre-cancerous polyps before patients ever show any symptoms,” she says. “This means it finds cancer early, and the earlier you detect a cancer, the better the prognosis. 

"For the most part, our patients are healthy and ready and able for surgery and any further therapies that may be required. The BowelScreen team minds them through every step of that process.”

• To find out more about the BowelScreen programme, call the free phone number 1800 454555. If you’re within the eligible age range and haven’t received a letter inviting you to take part, check the online registry at exa.mn/BowelScreen-register.

Spot the symptoms 

• Changes in bowel habits — diarrhoea, runny bowel movements, constipation, needing to poo more or less often than usual.
• Blood in your poo, which may look red or black.
• Abdominal issues — cramps, general abdominal pain, bloating that doesn’t go away.
• Weight loss when you’re not trying to lose weight.
• Tiredness and lack of energy when you’ve had enough rest.
• Any unusual change you know isn’t right for you.
• If you experience one or more of these symptoms, you should make an appointment to see your GP.

• For information on bowel cancer screening and using home test kits, click here.