We’re calling for the upper age limit for bowel cancer screening to be increased from 74.
Introduction
Bowel cancer screening is one of four main cancer screening programmes currently in use in the UK which cover cancers of the bowel, breast, cervix and lung. Overall stewardship of the programmes resides with the Dept. of Health and Social Care, with the UK National Screening Committee (UKNSC) advising the department on introducing and amending screening programmes.
The UKNSC does some excellent work in the advice it gives to the cancer screening programmes in all four UK nations. It is also an innovative organisation, pro-actively looking for new potentially efficacious screening programmes as well as considering the use of more stratified and targeted methods of screening relevant populations.
Bowel Cancer Screening Test
Aimed at both men and women aged 50 to 74, Faecal Immunochemical Test (FIT) tests are sent to people at home every two years. Around 4.4 million people are invited for screening of whom almost 3 million typically return a sample. There was 57.7% uptake in 2017/18, (using the old gFOBt test) which has now risen to 68% in 2021/22[1] probably due to the introduction of FIT as an improved test. It is estimated to save about 2500 lives a year[2].
In England, stool samples are sent by post to one of five screening hubs across the country. Further investigation is taken when a sample has 120 micrograms(mg/g) or above of haemoglobin per gram of stool. Around 2% of patients can be expected to have a positive result. Such patients are followed up with a colonoscopy and around 10% of these patients will be found to have cancer.
Important improvements that have recently been established, or are being considered, include reducing the lower age limit to 50 for inclusion in the programme, and making the test more sensitive in order to catch cancers at an earlier stage.
Prior to Covid, a Bowel Scope screening test was experimentally introduced, as a one-off test aimed at people aged 55, known as flexible sigmoidoscopy. This involves the introduction of a thin flexible tube into the lower end of the bowel to identify small growths or “polyps” with the aim of removing them before they become cancerous. Introduced in 2018/19, 385,000 people were invited for testing of which 182,000 underwent the test. This programme was interrupted by Covid and it has now been discontinued[3].
Additionally, in recent years there is greater cognisance of cases of Lynch syndrome, which is a genetic issue that makes people more prone to certain cancers, including bowel cancer. Everyone who gets bowel cancer is supposed to be screened for Lynch syndrome and offered enhanced surveillance if necessary.
Recent Improvements
In general terms there have been considerable advances in screening over the years, such as the move from the old gFOBT bowel cancer test to the FIT test in recent years, which has led to a higher take-up and increased early diagnosis.
Additional improvements have been delivered in making the screening test more sensitive, thereby catching the disease at an earlier stage. In Scotland and Wales the limit is already 80 ug/g (micrograms of haemoglobin per gram of stool) but in England and N. Ireland it is currently 120 ug/g. There are plans to reduce the screening threshold and make the test more sensitive In England and N. Ireland as capacity to do so becomes available.
An important recent improvement is the extension of the eligible population in England and Wales to those aged 50, the same as in Scotland, which is now complete and will imminently happen in N. Ireland. As a result, the proportion of bowel cancer cases in those aged 50-59 years diagnosed through screening has increased from 4.6% in 2019/20 to 10.8% in 2022/23. This reflects the expansion in the screening programme to people aged 50 in England and Wales. However, the proportion of people aged 60-74 years diagnosed through screening remains stable at 26.5% in 2019/20 and 25.8% in 2022/3. The disparity in the diagnosis of bowel cancer in the younger compared to the older age group is striking, and must represent a lost opportunity to make real advances into earlier diagnosis for this cancer.[4]
Drawbacks
Key drawbacks in improving the outcome of screening are colonoscopy capacity restraints, which are a major limiting factor, as well as limitations to pathology output. There have been many calls for an increase in trained colonoscopists in the NHS and greater access to imagery equipment where the UK is noticeably deficient. Many commentators make the point that extending screening programmes is being restricted due to limited capacity in the NHS. However, in general terms we know that it is much cheaper to deal with cancer in its early stages than to try to effect curative treatments once the cancer has advanced. Late diagnosis normally exerts a heavier strain on NHS resources than the implementing of screening programmes. Therefore, there should be a strong financial case for investing in the capacity we need to fully extend bowel cancer screening.
Our Comments on the NHS Bowel Screening Programme
We believe that with advances in awareness and information, and with advances in screening we could get very close to the eradication of deaths from bowel cancer.
In many respects the Bowel Cancer Screening Programme is a superb screening programme. It is non-invasive, easy and effective. However, it is an unfortunate fact that the more likely you are to get bowel cancer, the less likely you are to be screened. This is because the cancer tends to be a disease of old age, and bowel cancer screening has an upper age limit of 74. This severely affects the efficacy of screening; bowel cancer screening only catches some 10%[5] of all cases, in spite of the fact that the screening process uses a highly efficacious test.
Increasing the age range for taking part in bowel cancer screening has traditionally been done at the lower age groups, (and we commend the reduction of the lower age limit to 50) rather than at the upper age limit, in spite of the fact that some 45% of bowel cancers occur in the over 74 age group. There are some sensible medical reasons for ceasing screening in the elderly, namely the side effects of false positives/negatives and over-diagnosis. However, given advancements in medicine and clinical practice since the inception of the screening programme in 2006, we believe there should now be a full assessment and review of this upper age limit.
The response by the NHS to this issue is that it is possible for an individual to “opt-in” to screening after the upper age limit. However, no information is given to the individual as to why screening has stopped or on what grounds it is sensible to continue to be screened, and in fact, very few people take up the offer. This contrasts to the efforts that are made at the commencement of screening to inform the patient of the pros and cons of screening. Bearing in mind that the statistics show considerably better outcomes for all cancers caught by screening, this is an important issue.
We are pleased that there is an intention in England and N. Ireland to increase the sensitivity of the screening test to 80ug/g so that there is parity with Scotland and Wales. Increasing the sensitivity of the test even further to 20 ug/g, could lead to still further improvements and many campaigners have called for this. We recognise that a lower threshold will realistically take time to implement, but it could have considerable effects on early diagnosis of the disease and so we should proceed towards this as an objective.
It is unfortunate that the Bowel Scope test has been discontinued. We believe that the NHS should persevere with the test now that the disruptions of the pandemic are behind us. The test is purely preventative in that it detects with a view to removal any polyps (growths) in the bowel that may mutate to cancer. This contrasts with most types of screening which simply aim to catch cancers earlier. Bearing in mind the high financial costs, let alone the human cost of treating bowel cancer, we believe that the Bowel Scope screening project should be kept on the agenda, and further analysis be made as to its benefits.
Finally, we recommend that more information should be available to the patient on the prevention of this disease. Bowel cancer is estimated to be some 50% preventable through changes in diet and lifestyle changes[6], it must be the case that if catching the cancer early is beneficial, it is infinitely more beneficial to prevent the cancer in the first place. Information and awareness are a key weapon in the armoury against cancer.
The key modifiable risks for bowel cancer are:
- 28% too little dietary fibre;
- 13% red and processed meats;
- 24% being overweight (11%); 7% tobacco (7%) 6% alcohol (6%)[7].
Consuming more dietary fibre and less red and processed meat might be considered one of the easiest dietary modifications for individuals to make. Bearing in mind that the NHS sends out several million individual notifications regarding the bowel cancer screening programme each year, we would like to see greater written information included in the notifications about how people can protect themselves from developing this dread disease. This could lead to a material improvement in reducing the incidence in this cancer in future years.
[1] https://www.nboca.org.uk/wp-content/uploads/2024/02/NBOCA-SotN.pdf
[2] https://www.england.nhs.uk/wp-content/uploads/2019/02/report-of-the-independent-review-of-adult-screening-programme-in-england.pdf p115
[3] [3] https://www.england.nhs.uk/wp-content/uploads/2019/02/report-of-the-independent-review-of-adult-screening-programme-in-england.pdf p117
[4] https://www.nboca.org.uk/wp-content/uploads/2025/01/NBOCA-State-of-the-Nation-Report-2024_v1.0_09.01.2025.pdf p10
[5] https://www.natcan.org.uk/wp-content/uploads/2025/07/NBOCA-2022-Final.pdf p16 Section 4.1
[6] https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer
[7] https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer#BowelCS3