Timely access to quality colonoscopy 


Bowel Cancer Australia has long advocated for referral to colonoscopy within 30 days for people with a positive screen or bowel cancer symptoms to minimise stress and anxiety, as recommended in the Optimal Care Pathway.

Newly released medical guidelines, however are now recommending patients be referred to colonoscopy within a 120-day threshold.

Research shows diagnostic intervals exceeding 120 days are associated with poorer outcomes.

Therefore Bowel Cancer Australia is calling on Federal, State and Territory Governments to commit to a national Colonoscopy Wait-time and Performance Guarantee – with recording, reporting and resourcing - to address delays in diagnosing Australia’s second biggest cancer killer.

Visit our Colonoscopy Wait-time and Performance Guarantee webpage to learn more about Bowel Cancer Australia's proposal.

Bowel Cancer Australia Colonoscopy Wait Time Guarantee


Colonoscopy Clinical Care Standard

The Australian Commission on Safety and Quality in Health Care is currently developing a Colonoscopy Clinical Care Standard, as a key component of a national safety and quality model for colonoscopy.

The Colonoscopy Clinical Care Standard will provide guidance on the best evidence based care delivered in day procedure hospitals, private hospitals and public healthcare services.

The draft model incorporated three key elements:

  • A Colonoscopy Clinical Care Standard (CCS) for the delivery of high quality services
  • Certification and periodic re-certification of colonoscopist performance
  • Collation and review of indicators and performance targets in accordance with a standard national data set.

Bowel Cancer Australia advocates for the establishment of minimum quality standards and measureable performance indicators to define and shape a quality colonscopy service.

As part of our proposed Colonoscopy Wait-time and Performance Guarantee, Bowel Cancer Australia is advocating for:

  • the collection of patient-reported experience measures within 30 days via a questionnaire from all people who undergo a colonscopy, asking them about their pre-procedure experience (whether people understood the risks/benefits); the hospital experience (the procedure itself, issues of dignity/privacy); and post-procedure complications (bleeding/pain), with results publicly reported.
  • minimum quality standards and key performance indicators (KPI) for the deliver of colonoscopy within Australia, along with recording and public reporting of performance against the standards and KPIs. 

Train-the-Colonoscopy-Trainer Project

Bowel Cancer Australia representatives are working towards improving the quality of colonoscopy in Australia.

They have been instrumental in establishing and implementing the Train-the-Colonoscopy-Trainer Project under the umbrella of the National Endoscopy Training Initiative.  This comprises a series of practical workshops aimed at registrars and fellows who are in the process of learning colonoscopy.

Bowel Cancer Australia specialists are also contributing to the federal Colonoscopy Quality Working Group.

Both initiatives are important to the long-term success of the National Bowel Cancer Screening Program, since safe accurate colonoscopy is vital if the benefits of the program are to be realised and maximised.

The adequacy of training of endoscopists has a direct bearing on the quality of endoscopic care.


Nurse Endoscopy

A two-year program training nurses to help meet the growing demand for colonoscopy services is now in the evaluation stage.

The $2.6 million program by Health Workforce Australia has trained nurse endoscopists across a number of sites including the Logan and Beaudesert Hospitals in South-east Queensland and the Austin, Alfred and Heidleberg Repatriation hospitals in Victoria.
 
The Expanded Scope of Practice: Advanced Practice in Endoscopy Nursing program includes 100 hours training under medical supervision.
 
Bowel Cancer Australia chief executive Mr Julien Wiggins said the issue of access to colonoscopy services was identified many years ago in the early days of the National Bowel Cancer Screening Program (NBCSP).
 
"There was always a concern that the health system would need to ramp up access to colonoscopies as the National Bowel Cancer Screening Program got underway.  In particular, there was a need to ensure timely access to colonoscopies for people who returned a positive screening test," Mr Wiggins said.
 
While the medical profession responded with additional colonoscopy training for their colleagues, medical workforce shortages and increasing demand have created a need for additional strategies.
 
"Bowel cancer is already our second most common cancer and with an ageing population there will be an ongoing demand for colonoscopy services."
 
"Quality, consistency and availability of colonoscopy have always been the agreed goal and Bowel Cancer Australia is supportive of initiatives that can help deliver on that," Mr Wiggins said.


Update
 
A proposal from the Grattan Institute by former health department secretary, Stephen Duckett, has identified the potential role of nurses in bowel cancer screening.
 
Under the plan, about 2,000 registered nurses would receive extra training to conduct 40 per cent of endoscopies that screen for bowel cancer.
 
While the plan is relatively new for Australia, endoscopy nurses in the United States have been practicing since the 1970s and more than 300 practice in the United Kingdom. Canada has also recently introduced this expanded role for nurses.


Queensland
 
In November 2014, Queensland Health and Queensland University of Technology have partnered to deliver the Master of Nursing with a specialty focus on Nurse Endoscopy, the first program of its kind in Australia.
 
With public demand for endoscopies set to double over the next five years, the masters program will help build a workforce of senior nurses able to perform the procedures.
 
The course builds on the clinical experience of previous pilots in Victoria and Queensland where nurses were trained in endoscopy through the University of Hull in the United Kingdom.
 
The new masters level course is based on the national standards for gastroenterology meaning that nurses will need to reach the same level of competency as doctors in order to become qualified.
 
Queensland's Chief Nursing and Midwifery Officer Dr Frances Hughes said the partnership would lead to better health outcomes for Queenslanders.
 
The course has been developed by QUT in consultation with senior medical and nursing gastroenterology specialists to ensure that the procedures are performed safely.
 
Professor Yates said the program would provide a pathway for experienced and specialised nurses in the field to advance their skills through formal qualifications so that they meet all necessary professional and higher education standards.
 
The first cohort of up to 15 nurses will commence study in the masters program in January 2015.

Timely Access to Surgery

About Bowel Cancer Surgery 770

Data released in October 2014 on the Australian Government's My Hospitals website shows most bowel cancer patients (88%) on the public hospital waiting list receive their surgery within the recommended 30 days.

However, the data does not tell the whole story for bowel cancer patients - with no information available in the report on private hospital waiting times.

The National Health Performance Authority's (NHPA) report into Hospital Performance: cancer surgery waiting times in public hospitals in 2012-13 covers bowel, lung and breast cancer - three of the most common malignant cancers.

It found 96 per cent of breast cancer patients received their surgery within 30 days and 90%of lung cancer patients. Overall, 92% of cancer surgeries were performed within 30 days and 97%within 45 days.

Bowel Cancer Australia chief executive Mr Julien Wiggins said the fact that the majority of bowel cancer patients were receiving their surgery within the recommended 30 days was good news.

"Most of those 4,533 bowel cancer patients would have been reassured that they were receiving surgery reasonably quickly."

"Unfortunately, the data also shows that 216 bowel cancer patients did not receive timely surgery. They remained on the public hospital waiting lists for longer than 45 days."

Mr Wiggins said he would like to see more comprehensive data detailing the full bowel cancer journey from screening to diagnosis and treatment.

"Time on the hospital waiting list is just one component of cancer care. For example, we really need to know how long people are waiting between a positive bowel cancer screening test or seeing their doctor about symptoms and accessing colonoscopies that will provide a definitive diagnosis."

"We know that timely access to colonoscopies was flagged as a workforce issue in 2005 prior to the National Bowel Cancer Screening Program being introduced. This is a critical piece of the puzzle."

Mr Wiggins said with bowel cancer survival rates lagging behind that of other common cancers, it was reasonable for the bowel cancer community to be asking more questions of the health care system.

"Bowel cancer patients have a five year survival rate of 66 per cent compared to 89 per cent for breast cancer patients. So we need to find improvements at every stage of the cancer journey from earlier diagnosis, to timely surgery, more treatment options and better supportive care."

"We also need to know the facts on patients treated in private hospitals as they represent about 60 per cent of total cancer surgeries," he said.

The NHPA report found cancer patients were not disadvantaged with respect to waiting times by being treated in regional hospitals rather than metropolitan facilities.


Access to Medicines

Timely Access. Affordable Treatment Options. Better Outcomes.

While screening is important for the prevention and early detection of bowel cancer, it is also important for health policy to recognise that bowel cancer patients require improved access to affordable treatment options.

Bowel Cancer Australia welcomed the 2013 Coalition Government's commitment to restore transparency, certainty and confidence to the process by which medicines are listed on the Pharmaceutical Benefits Scheme (PBS) – ensuring medicines are listed on the basis of advice from the independent Pharmaceutical Benefits Advisory Committee.

The Health Minister will have the authority to list medicines recommended by the PBAC that do not cost more than $20 million in any of the first four years of listing.

The previous Labor Government changed PBS approvals (previously approved after a positive Pharmaceutical Benefits Advisory Committee (PBAC) recommendation) by requiring Cabinet approval. Following pressure from industry groups and consumer organisations the Government began to automatically allow PBAC-approved treatments onto the PBS if they cost less than $10 million a year.

Fewer than 40% of bowel cancers are currently detected early, which underscores the need for improved access to affordable treatment options.

Treatment Options

Patients with advanced bowel cancer want to live as full a life as possible, for as long as possible, and will actively seek out new treatments.

Australians with advanced bowel cancer say they still have more they want to do with their lives and want access to new treatments to enable them to live as full a life as possible according to Bowel Cancer Australia's My Cancer My Voice Patient Survey.1

More than three quarters (77 per cent) said more life-extending treatments were needed for advanced bowel cancer; If a new treatment was available overseas (but not in Australia), more than 40 per cent would travel overseas and a similar number (45 per cent) would write to the Government seeking access;

More than two thirds (68 per cent) would ask their doctor to try and get access to the treatment and about three in five (59 per cent) would try to get included in a clinical trial to access the treatment.

There are limited treatment options currently available to extend life for those with advanced bowel cancer.

A limited number of treatment options which have been shown to deliver modest incremental life-extending benefits are currently available in Australia for people with advanced bowel cancer.

Bowel cancer patients have had the longest wait for treatment funding, with one life-extending medication taking more than six years and a record eight submission before being subsidised.2

Despite this, median overall survival rates for people with advanced bowel cancer have increased over the last three decades from 5 months to 24 months,3 and in a select group of people (patients with KRAS wild type tumours) up to 33 months.


Therapeutic progress in advanced (metastatic) bowel cancer


Accessing Medicines - 2009 to 2017

2009

Avastin (bevacizumab) was added as a PBS-subsidised treatment, in combination with first-line chemotherapy, for patients with previously untreated metastatic bowel cancer with a WHO performance status of 0 or 1.  Avastin is also listed as a continuing PBS-subsidised treatment for patients who have previously received PBS-subsidised treatment with Avastin who do not have progressive disease and the treatment must be in combination with first-line chemotherapy.



2011
Erbitux (cetuximab) was added as a PBS-subsidised treatment, as monotherapy or in combination with an irinotecan based therapy, for patients with a WHO performance status of 2 or less and with KRAS wild-type metastatic bowel cancer after failure of first-line chemotherapy.  The treatment must be the sole PBS-subsidised anti-EGFR antibody therapy for this condition.  Patients who have progressive disease on Vectibix (panitumumab) are not eligible to receive PBS-subsidised Erbitux. Patients who have developed intolerance to Vectibix of a severity necessitating permanent treatment withdrawal are eligible to receive PBS-subsidised Erbitux.
 
Erbitux is also listed as a continuing PBS-subsidised treatment, as monotherapy or in combination with an irinotecan based therapy, for patients who have received an initial authority prescription for Erbitux for treatment of KRAS wild-type metastatic bowel cancer after failure of first-line chemotherapy.  Patients must not have progressive disease and the treatment must be the sole PBS-subsidised anti-EGFR (Epidermal Growth Factor Receptor) antibody therapy for this condition.  Patients who have progressive disease on Vectibix are not eligible to receive PBS-subsidised Erbitux. Patients who have developed intolerance to Vectibix of a severity necessitating permanent treatment withdrawal are eligible to receive PBS-subsidised Erbitux.
 
The PBS-subsidised treatment Xeloda (capecitabine) was extended to patients with stage III (Dukes C) colon cancer, following complete resection of the primary tumour in combination with another chemotherapy, Eloxatin (oxaliplatin) or as a monotherapy.  The combination therapy is known as XELOX
 
 
2012
KRAS mutation testing listed on the Medicare Benefits Schedule (MBS).
 
2013 The Pharmaceutical Benefits Advisory Committee (PBAC) rejected the submission to list Zaltrap (Aflibercept rch) as a PBS-subsidised treatment for patients with metastatic bowel cancer. 

2014
 
Vectibix (panitumumab) was added as a PBS-subsidised treatment, as monotherapy or in combination with an irinotecan based therapy, for patients with a WHO performance status of 2 or less and with KRAS wild-type metastatic bowel cancer after failure of first-line chemotherapy. The treatment must be the sole PBS-subsidised anti-EGFR antibody therapy for this condition. Patients who have progressive disease on Erbitux are not eligible to receive PBS-subsidised Vectibix. Patients who have developed intolerance to Erbitux of a severity necessitating permanent treatment withdrawal are eligible to receive PBS-subsidised Vectibix.
 
Vectibix is also listed as a continuing PBS-subsidised treatment, as monotherapy or in combination with an irinotecan based therapy, for patients who have received an initial authority prescription for Vectibix for treatment of KRAS wild-type metastatic bowel cancer after failure of first-line chemotherapy.  Patients must not have progressive disease and the treatment must be the sole PBS-subsidised anti-EGFR antibody therapy for this condition.  Patients who have progressive disease on Erbitux are not eligible to receive PBS-subsidised Vectibix.
 
Patients who have developed intolerance to Erbitux of a severity necessitating permanent treatment withdrawal are eligible to receive PBS-subsidised Vectibix.
 
The Pharmaceutical Benefits Advisory Committee (PBAC) rejected the submission to list Stivarga (regorafenib) as a PBS-subsidised treatment for patients with metastatic bowel cancer. 
 
The Pharmaceutical Benefits Advisory Committee (PBAC) recommended that the current PBS restrictions for Vectibix (panitumumab) and Erbitux (cetuximab) be amended to urgently include only patients with RAS wild-type metastatic bowel cancer in coordination with corresponding amendments to the related MBS item descriptor to extend mutation testing to cover all RAS mutations.
 
The Pharmaceutical Benefits Advisory Committee (PBAC) rejected the submission to amend the current PBS restrictions for Vectibix (panitumumab) to include first-line treatment of patients with RAS wild-type metastatic bowel cancer.
 
The Pharmaceutical Benefits Advisory Committee (PBAC) recommended extending Erbitux's (cetuximab's) existing listing to include first-line treatment of metastatic bowel cancer.  The availability of first-line Erbitux on the PBS would increase choices of first-line treatment for patients with a RAS wild-type status.
 
The PBAC considered that the requested restriction should 1) include a note stating "Patient must not switch chemotherapy partners whilst maintaining an anti-EGFR antibody backbone in the face of progressive disease" in order to help prevent Erbitux being used beyond disease progression; 2) amend WHO performance status to be 1 or less; 3) limit use to a course of Erbitux for metastatic bowel cancer once in a life time (and allow a switch to Vectibix (panitumumab) during a course only according to the arrangements already in place for PBS subsidy of later-line therapy); 4) indicate anti-EGFR antibody and anti-VEGF antibody cannot be used at the same time.

2015

KRAS mutation testing on the Medical Benefits Schedule (MBS) amended to RAS mutation testing.
 
The PBS-subsidised listing for Erbitux (cetuximab) was amended to include treamtnet in combination with first-line chemotherpy of RAS wild-type metastatic bowel cancer patients who do not have progressive disease.
 
The PBS-subsidised listing for Avastin (bevacizumab) was amended to include treatment in combination with second-line chemotherapy for patients with RAS wild-type metastatic bowel cancer who have previously been treated with PBS-subsidised first-line anti-EGFR antibodies and who have not previously received PBS-subsidised treatment with Avastin for this condition, who have a WHO performance status of 0 or 1.  
 
The PBS-subsidised listing for Vectibix (panitumumab) was amended to include treamtnet in combination with first-line chemotherpy of RAS wild-type metastatic bowel cancer patients with a WHO performance of 0 or 1, who do not have progressive disease.

2016 The Pharmaceutical Benefits Advisory Committee (PBAC) rejected the submission to list Lonsurf® (trifluridine with tipiracil) on the PBS for the treatment of patients with metastatic bowel cancer who have been previously treated with, or are not considered suitable for, currently available therapies.

2017 The Pharmaceutical Benefits Advisory Committee (PBAC) rejected the resubmission to list Lonsurf® (trifluridine with tipiracil) as a PBS-subsidised treatment for patients with metastatic bowel cancer.

2018 The Pharmaceutical Benefits Advisory Committee (PBAC) rejected the resubmission to list Lonsurf (trifluridine with tipiracil) as a PBS-subsidised treatment for patients with metastatic bowel cancer.
 
The Pharmaceutical Benefits Advisory Committee (PBAC) considered that the targeted therapies for metastatic bowel cancer, including PBS listed Avastin (bevacizumab), Erbitux (cetuximab), and Vectibix (panitumumab), are being used largely as expected.  The PBAC noted the Drug Utilisation Sub-Committee's (DUSC) report and recommended no further action.
 
The PBAC recommended the listing of Lonsurf (trifluridine with tipiracil) as a PBS-subsidised treatment for patients with metastatic bowel cancer who have been treated previously or are not considered suitable for current available therapies.

The PBAC considered that in the context of limited treatment options in this disease setting, the small treatment benefit of Lonsurf may be meaningful for some patients.

 

1. Stollznow. 2014. My Cancer My Voice Bowel Cancer Patient Survey. April 2014.
2. Wonder Drug Consulting. 2014. Reimbursement success rates and timelines for new medicines for cancer; and international comparison. Available at http://medicinesaustralia.com.au/files/2013/07/140323_OIT_Wonder-Report_FINAL.pdf
3. Vickers M (2013). Slow and steady: incremental survival improvement in advanced colorectal cancer. OE 2013: 12,1.


Senate Inquiry into Access to Cancer Medicines
Greater affordability of, and access to, advanced bowel cancer treatments 

Bowel Cancer Australia Advocacy Senate Committee 770

 

In our submission to the Senate Inquiry, Bowel Cancer Australia recommended greater affordability of, and access to, advanced bowel cancer treatments.

Cancer patients with advanced disease cannot afford to wait months or years for effective, affordable treatment options.

Some patients and their families are faced with the decision of going into debt or mortgaging their homes to pay for high cost medications.

Bowel Cancer Australia has consistently called for the Federal Government to return to the process of automatically listing on the PBS any proven, effective bowel cancer treatments that have received a positive PBAC recommendation.

There is also concern that many new treatments for bowel cancer only extend life for relatively short periods of time (e.g. months). However, the cumulative effect of such incremental gains has transformed the treatment landscape for bowel cancer patients over recent years.

Prolonging quality life enables a patient to normalise their life in many basic areas such as returning to work, so that they can continue to support family and feel valued again, or spending precious time with family and friends. This is important for the patient and their loved ones to help come to terms with the illness.

Drugs for advanced bowel cancer can in some cases reduce tumour size so significantly that surgery is then possible, providing further hope to patients and the possibility of eventual remission.

When it comes to treatment options which have been shown to deliver modest incremental life-extending benefits, there remains a very limited number currently available in Australia for patients with advanced bowel cancer.


The Senate Inquiry Report

After many months of deliberations, the Senate Community Affairs Committee published their report on 17 September 2015.

The Committee acknowledged Bowel Cancer Australia's submission numerous times throughout their report, and agreed that the provision of timely and affordable access to new and innovative cancer medicines provides a significant challenge to Australians.

The Committee noted that it can take more than one and a half years to get a subsidy for new cancer medicines under Australia's system.

They acknowledged Bowel Cancer Australia's view that for cancer patients and their families, maintaining a normal life and enhancing the quality of that life is of utmost importance. The Committee stated that the uncertainty and significant financial cost associated with off-label use of cancer drugs results in significant physical, emotional and financial stress.

In formulating this view, the Committee acknowledged Bowel Cancer Australia Patient Ambassador, Robyn Lindley, who wrote about the financial burden of cancer on her family.

The Committee concludes that a complete review of Australia's medicine system, including the registration and subsidisation of medicines, is needed.

The Senate committee are also calling on the government to consider a national register of cancer medicines.

Other recommendations include: expanding the use of post-market reviews; and evaluating current data collection mechanisms for cancer medicines.


Where to Now?

Bowel Cancer Australia agrees with the Senate Committee that there is an urgent need to provide timely and affordable access to new and innovative cancer medicines, to ensure Australia achieves world's best practice.

We urge the Australian Government, the Department of Health and other stakeholders to act now on the recommendations contained within the report.

To view the Senate Inquiry Report and Bowel Cancer Australia's submission visit the Parliament of Australia website.