The NHS Bowel Cancer Screening Programme: A Public Health Review - Essay Example

? The NHS Bowel Cancer Screening Programme: A Public Health Review Table of contents Introduction 2. The impact on people and populations 2 Burden of BOWEL CANCER in relation to the public health 2.2 Published evidence to support the use of guidelines for the screening programme 2.3 National priorities or targets for Health or the Health Service (specific to the UK NHS service). 3. Resource implications for implementing particular health care policies in THE UNITED KINGDOM 3.1 Statistics and the burden of illness 3.2 Cost issues 4. Bowel cancer 4.1 Research into the aetiology/cause of this condition 4.2 How can this research be applied to treating or preventing disease? 4.3 Risk factors related to this condition 4.4 Is there a public health policy for preventing this condition – is this a population strategy or a high risk one? Why? 4.5 Evidence of the effectiveness of treatment or prevention 5. Conclusion References 1. Introduction The expansion of severe diseases in West countries has been related to the Western style of life. The increased industrialization and the limitation of healthy eating, as a daily practice, have led to the appearance and the development of diseases, which are often quite difficult to be confronted. Of course, the fact that many efforts are made by governments worldwide for increasing the protection of local populations towards these diseases cannot be ignored. Current paper focuses on the examination of the NHS Bowel Cancer Screening Programme especially regarding its impact on public health. The above Programme is a scheme indicating the support of the British government towards the improvement of health of people across Britain. Indeed, the findings of the empirical research regarding the effectiveness of the particular programme are encouraging. On the other hand, there are signs that the performance of the scheme is not equal towards all parts of the population – British citizens seems to be more benefited by the Programme compared to minorities (Robb et al. 2008), a problem though that can be related to the different level of interest of the above parts of population for diseases and their effective prevention. The literature and, mainly, the empirical research published on the particular field is analytically presented. It is made clear that the specific Programme is quite valuable, especially when combined with other similar initiatives – for example, the Public Health Responsibility Deal of the Department of Health in 2011. However, it is necessary that certain parts of the Programme are reviewed. Particular emphasis should be given on the following points: a) the increase of awareness of people of all backgrounds on healthy diet and its effect, b) the provision of information to people across Britain regarding the requirements of the Programme and its potential benefits, c) the improvement and the increase of control over the application of the Programme in practice – meaning that the development of the various phases of the Programme should be monitored closely ensuring that the guidelines referring to the screening process are strictly applied. 2. The impact on people and populations 2.1 Burden of BOWEL CANCER in relation to the public health Bowel cancer is a common health problem in Britain – as also in other countries worldwide. In accordance with a series of statistics published by DH in 2011, approximately 36,000 cases of bowel cancer are likely to appear in Britain annually. Among these cases, 16,500 will be fatal (Department of Health 2011). The burden of bowel cancer for the public health in Britain can be made clear through the following figures: in accordance with a report published by the NHS – Yorkshire and the Humber (2011) ‘the bowel cancer is the UK’s second biggest cancer killer’. Because of the expansion of this illness, the Department of Health in UK has developed a programme aiming to support people already suffering from bowel cancer but also, mainly, to inform people across UK on the effects of the illness and the preventive measures (precautions) available. The programme is entitled as ‘the Public Health Responsibility Deal’ and aims to increase the awareness of people on the effects of their diet. Also, it aims to urge the businesses in Britain to contribute in the protection of public health, by promoting eating practices, which do not threaten the health of employees or customers – in case of businesses that operate in the food industry (Bowel Cancer UK, 2011, Public Health Responsibility Deal). In order for the above targets to be achieved, the Department of Health initiated the establishment of a Working Group focusing on the monitoring of the Programme’s performance both in the private and the public sector of Britain. At the same time, the Department of Health supports the development of the NHS Bowel Cancer Screening Programme that aims to prevent the expansion of bowel cancer in Britain through carefully designed screening methodologies. The above initiatives prove the burden of bowel cancer for public cancer, as the problem has been identified and is addressed by specialists in NHS and other organizations operating in the British healthcare industry. 2.2 Published evidence to support the use of guidelines for the screening programme The screening programme of NHS is based on a series of guidelines; in fact, particular guidelines have been developed for each part of the test. Different guidelines have been introduced for explaining the phases of the process to the patients and the public health commissioners (NHS Bowel Cancer Screening Programme, 2007, guidelines). The level at which these guidelines have been followed by the patients is presented in a report of NHS referring to the specific issue. In accordance with this report, the beginning of the Programme has been delayed because of various procedural issues – finally, it came in force in 2006. In order to understand the response of the patients to the Programme’s guidelines, it would be necessary to explain the key points of the process. The Screening Program of NHS is based on the following concept:’ Faecal Occult Blood test (FOBt) kits are distributed to those of eligible age by post’ (NHS, Cancer Screening UK, 2007, p.8). Then, the recipients are asked to follow the process described in the guidelines in order for a potential rectal bleeding to be identified – if existed. Indeed, the recipient of the test has ‘to wipe stool samples on a card included in the kit’ (NHS Cancer Screening, UK, 2007, p.8). Then, the card needs to be returned to NHS – its laboratories – for analysis. The recipient will be notified for the results within a short period of time – he is informed in advance that after a few days he should make a phone to NHS regarding the phase of the process of his test. The process of the test is described in Figure 1, below. Figure 1 – Screening pathway (Source: NHS Cancer Screening, UK, 2007, p.9) In the case that the sample sent is not clear so that the potential bleeding of rectal cannot be identified, then the recipient/ individual is asked to repeat the test. The screening process may seems simple but in practice various problems have appeared. By 2007, about 20 screening centers had been established across Britain (NHS Cancer Screening, UK, 2007, p.9). The complexity of the guidelines of the test is probably a reason why the returned tests are at rather low level – as reflected in Figure 2, only 50% of the recipients are likely to return the test completed, a fact leading to the assumption that the test is considered as complex. Another reason would be the following fact: people across Britain are still not aware of bowel cancer – at a high percentage, as explained earlier. So, the development of the test is considered as non-necessary. Figure 2 – percentage of recipients of the test who returned the completed test – in 2007 2.3 National priorities or targets for Health or the Health Service (specific to the UK NHS service). The priorities of the Health Service involved in the particular case, i.e. the NHS, in regard to bowel cancer are the following ones: a) people across Britain need to be informed on the benefits of a healthy diet. In this way, it is expected that the risks for bowler cancer and other diseases will be decreased, both in the short and the long term; the term ‘people’ in the above case refers to individuals living in Britain no matter of their race or economic status. However, in a relevant research it was revealed that people in minorities are less likely to pass a screening test for bowler cancer – compared to white British (Robb et al. 2008). In the context of the above study, a research was conducted among the major ethnic minority groups of UK; a series of 875 was developed; the survey showed that all participants were not aware of the particular type of cancer. After having been informed on the issue, they showed a high interest for the screening process, as included in the particular programme of NHS; in fact a percentage of 90% of the participants noted that the above exam would ‘provide peace of mind’ (Robb et al. 2008, p.8). The above findings show that the effects of bowel cancer are unknown to a high percentage of people. This result indicates that the targets of NHS to increase the protection of people across Britain towards the particular type of cancer have not been, yet, achieved. 3. Resource implications for implementing particular health care policies in THE UNITED KINGDOM 3.1 Statistics and the burden of illness Despite the severe effects of bowel cancer on health – leading commonly to the death of the patient involved – the awareness of people in Britain of bowel cancer seems to be quite low. Indeed, in a survey developed recently – in 2011 – by the National Charity Bowel Cancer UK, it was revealed that ‘more than half of two thousand people they surveyed could not name a single symptom of bowel cancer’ (Paddock 2011). The results of the above survey were published in April 1st of 2011 indicating the current level of awareness of bowel cancer. It is explained that the particular type of cancer is responsible for about 1,350 deaths monthly and the results indicating the awareness of bowel cancer are characterized as quite discouraging (Paddock 2011). 3.2 Cost issues When referring to the cost of the particular process, the following issues need to be taken into consideration: a) the Screening test is available to all people over a particular age, as indicated in the relevant criteria of the NHS; this means that the recipients of the test do not have to pay for the particular test; the test is part of their contributions to the NHS, as an organization of the public sector. In this context, the question over the cost of the process would be related to the following issue: in case that the particular test is required for checking the potential existence of rectal bleeding in a person out of the criteria of NHS – meaning those who have been characterized as recipients automatically – then, which would be the cost of such service? At this point, the cost at which an individual out of the target-part of the population could ask for the particular test, would be depended on the agreement between NHS and his health insurance provider. In any case, when referring to the specific text and cost the following fact should be mentioned: through the particular test, as explained above, bowel cancer can be detected at early stage and then the treatment of the patient is successful. In this way, the cost that the illness would have for the state – if the patient would have to be treated for a well-developed bowel cancer – would be significantly increased (BBC News 2000). However, the exact difference between the cost of screening test and the cost of treatment in case of a fully developed bowel cancer cannot be estimated in accuracy. It can be only noted that the cost of the test is expected to be significantly less than the cost of the treatment at a late phase of bowel cancel (BBC News 2000). In the study of Lee et al. (2010) the difference in the above costs has been examined. It has been made clear that the cost of the test for colorectal cancer can be up to 48% lower compared to the cost of the treatment of the particular illness - referring especially to the case that the illness is fully developed mostly because there was no effort of detecting the bowel cancer through the particular test. 4. Bowel cancer 4.1 Research into the aetiology/cause of this condition An extensive research has been developed regarding the potential causes of bowel cancer; in accordance with the most common view, the specific type of cancer is considered as related to faulty (unhealthy) diet. Indeed, it has been proved that the consumption of certain types of food and drinks can increase the chances for the particular type of cancer. An indicative research is published by the Department of Health (2011). The Scientific Advisory Committee on Nutrition (SACN), the organization that developed the above research, has helped significantly to understand the impact of daily diet on health, especially in relation to bowel cancer. In accordance with the particular study ‘people who eat a lot of red or processed meat - around 90g or more of cooked weight per day’ (Department of Health 2011) are more likely to face bowel cancer. It has been also proved that the reduction of the level of red or processed meat consumed daily could reduce the risks for the specific type of cancer – it is suggested that the daily consumption of red or processed meat to be within the limit of 70g daily. It should be noted that the research developed up today regarding the causes of bowel cancer has not offered quite clear answers. There have been indications that bowel cancer is strongly related to the style of life, especially the diet, however, no proof seems to exist that bowel cancer is depended on just one factor or that it can result in case that specific terms are met. In accordance with Paddock (2011) the bowel cancer, as also other types of cancer, is likely to be developed gradually under the terms that ‘intestinal stem cells and genes are modified’ (Paddock 2011). In other words, bowel cancer is described as a result of the development of a series of actions – put in hierarchy – the most critical of which is the alteration/ modification of genes (Paddock 2011). The above assumption is based on the findings of a relevant Spanish study, which focused on the effects of the modification of stem cells and genes out of their normal function. In other words, no specific facts or qualities seem to be related to bowel cancer. The specific illness is likely to be developed anytime, meaning that its causes are not standardized. There are however, certain risk factors, which, if existed, indicate the high risk for the development of bowel cancer – either in the short or the long term. These risk factors are analyzed below, in section 4.5. 4.2 How can this research be applied to treating or preventing disease? As noted earlier, the screening test on bowel cancer is based on the following concept: the recipient of the test sends the test completed and then the test is examined in the laboratories of NHS in order to identify the potential bleeding of rectal – if existed. The advantage of the test is that it can detect the existence of rectal bleeding even at a quite early phase – i.e. even if the patient has no symptoms. In this way, if rectal bleeding is detected, the recipient is suggested to make additional exams in order to verify whether it is bowel cancer or another form of rectal problem. At the next level, appropriate treatment can be suggested so that the following benefits are achieved: a) patient has increased chances to survive – compared to the case that the above test was not used, b) the cost of the process for the state is decreased – as explained above, even a decrease of costs of 48% can be resulted if the screening test is used. At this point, the following detail needs to be mentioned: NHS has acquired appropriate technology so that the returned tests are processed quite rapidly and any potential delay in responding to the individuals involved is limited. Moreover, appropriate schemes have been established ensuring that the response of the state in case that a test is proved to be positive (that is when signs exists for the existence of colorectal cancer) is minimized. This issue is examined in the study of Dua et al. (2009); the above researchers refer to the ‘Two – week rule’ of NHS, a rule introduced by NHS in 2000 – when the screening test was first established; in the context of the above rule, the employees in NHS would need to ask any person that would be proved positive to the test ‘to meet a hospital specialist within 2 weeks from referral’ (Dua et al. 2009). 4.3 Risk factors related to this condition The most common risk factors related to bowel cancer seem to be the following ones: a) the family health history; in case that relatives, especially of the first grade, have suffered from bowel cancer then the chances for an individual to face the particular type of cancer are increased (Paddock 2011), b) age; in accordance with the research developed in this field, people of middle age and elderly are more likely to develop bowel cancer – compared to young people; it should be noted that specifically for Britain,’ a percentage of 97% of bowel cancer are diagnosed in people of over 50’ (Paddock 2011), c) other known risk factors/ causes of bowel cancer are: ‘bad diet, obesity, alcohol and lack of exercise’ (Paddock 2011). In a report published by the Cancer Research UK (2011) emphasis has been given on the following activities/ factors as potential risk factors of bowel cancer; reference is also made to factors that can protect from bowel cancer (meaning to decrease the chances for the development of the particular type of cancer): a) Hormone Replacement Therapy; in accordance with a relevant study, the development of such therapy can result to the reduction of the risks for bowel cancer at a percentage of 34% (Grodstein et al. 1999, in Cancer Research UK 2011); it is not made clear however whether the protection from bowel cancer is standardized through all phases of the particular therapy or whether it is involved only in the initial phases of the particular activity, b) diet of ‘Western type’, meaning food which is not processed appropriately but also food which contains increased level of fat/ sugar; specifically regarding the red meat it is noted that an amount of 100g of red meat daily can increase the risk for bowel cancer at a percentage of 55% (European Prospective Investigation into Cancer and Nutrition (Epic Study), in Cancer Research UK 2011), c) it is also noted that the increase in the consumption of fibre could reduce the risks for bowel cancer – in the research developed in the context of Epic study (see above) it has been proved that the risk for bowel cancer has been decreased for 20-30% in people who have increased the amount of fibre consumed daily, d) on the other hand, the increase in the consumption of fruits and vegetables seems to have no particular effect on the reduction of risks for bowel cancer – as showed in the results of the relevant study of the International Agency for Research on Cancer (Cancer Research UK 2011), e) the role of fat in the development of bowel cancer is not clear; in accordance with a research developed by Larsson et al. 2005, Swedish women who consumed high levels of fat were less exposed to bowel cancer (Cancer Research UK 2011); on the other hand, the research developed by Beresford et al. (2006) led to different results: their study showed no particular relation between fat and the decrease of risk for bowel cancer, f) the consumption of certain vitamins and nutritional elements, like folate, increases the protection against the bowel cancer (Sanjoaquin et al. 2005, in Cancer Research UK 2011). 4.4 Is there a public health policy for preventing this condition – is this a population strategy or a high risk one? Why? British government has been strongly supported the efforts made towards the control of bowel cancer. Moreover, local authorities have actively participated in the relevant projects. For example, in Yorkshire, the local authorities decided to promote the ‘ life-saving bowel screening kits (parts of the Bowel Cancer Screening Programme of NHS)’ (NHS – Yorkshire and the Humber, 2011); the above kits offer the benefit of screening for bowel cancer without having to visit a particular healthcare institute, an initiative quite important especially for the elderly. The authorities of the above community have also decided to fund a project entitled as ‘Improving Outcomes – A Strategy for Cancer’ (NHS – Yorkshire and the Humber, 2011). The funds required for the development of this project have been estimated to ?450 million (NHS – Yorkshire and the Humber, 2011) but it is expected that the specific programme would help towards the increase of effectiveness of NHS existing screening programme on bowel cancer. The NHS Bowel Cancer Screening Programme can be characterized as the most important Programme of this type – compared to other similar initiatives of public or private organizations. In order to understand the value of the NHS Bowel Cancer Screening Programme for bowel cancer it would be necessary to refer to the scope of this Programme, i.e. the reason for its establishment. In accordance with the relevant explanations provided in the NHS website, the bowel cancer screening is used for checking the potential existence of bowel cancer in people who have no symptoms, i.e. the specific exam can reveal the existence of the specific type of cancer quite early. It is further explained that the identification of the bowel cancer at this level is particular valuable, increasing significantly the chances for effectiveness of the treatment provided (NHS Bowel Cancer Screening Programme 2011, About bowel cancer screening). In accordance with the explanations provided to the leaflet related to the above Programme, the detection of bowel cancer early – in its initial phase – would result to the success of the treatment – at a percentage of 90% (NI Direct, Department of Health, 2011). Moreover, it is explained that about 1 out of 20 people is expected to face the bowel cancer, so the use of the particular Programme would help significantly towards the limitation of the illness. As explained above, the NHS Bowel Cancer Screening Programme is quite effective, especially if used on time – i.e. before the signs of the illness are made clear, for controlling the effects of bowel cancer. However, because the Programme itself is not adequate for ensuring the limitation of bowel cancer as an illness expanded across Britain, the need for additional (supportive) programmes is clear. In February 2011, the Department of Health announced the development of ‘Be Clear on Cancer’ campaign; the campaign would be last for 7 weeks – beginning on the 1st of February and it would be based on adverts published through the media and the press (DH, Department of Health, 2011). The campaign aimed to inform people in East England and South West on bowel cancer – symptoms, effects and measures/ exams available for its detection/ treatment (DH, Department of Health 2011). As explained by the Care Services Minister, Paul Burstow the British government will fund several more campaigns across Britain for increasing the awareness of the particular type of cancer (DH Department of Health 2011). 4.5 Evidence of the effectiveness of treatment or prevention In accordance with the empirical research developed in this field, the performance of the screening test is quite satisfactory. However, there are certain implications. More specifically: a) as revealed through the statistics published by NHS, just 10% of the people proved positive in the test are at quite initial stages of the illness – this means that the test cannot manage to provide an effective answer regarding the existence of the illness when the latter is not well developed (Cancer Research UK, 2011), b) the performance of the screening test seems to be differentiated across people with different background (House of Commons, 2011), c) even in cases that the test is effective, i.e. if it manages to show the existence of a bowel cancer – or, more accurately, of a rectum problem – still the chances of the patient to survive may be limited; in the study developed by Faiz et al. (2010) it has been proved that patients over 75 were less likely to survive from such surgery – meaning those patients that have been proved positive to the screening test but the specific fact did not help them since they were proved unable to survive from the relevant surgery. Another implication of the particular process is described in the study of Jones et al. (2010); in the above study the following issue is explored: the time required for treated people that suffer from metastases can be quite long. Existing time limits regarding the process of the test and the provision of the necessary treatment to the patient are not applied on the cases of patients with metastases – in accordance with the existing rules of NHS. It is explained that the rules of the NHS National Care Plan as applied on primary diseases should be also applied on metastases, a case quite common in patients with bowel cancer (Jones et al. 2010). On the other hand, Quarini et al. (2009) refer to the following problem: existing empirical research related to the screening test of NHS for bowel cancer focuses on the effects and the implication of the test for younger people. It is explained that limited empirical findings exist for elderly, a problem that needs to be addressed through appropriate empirical research in the future, mostly because of the following reason: as explained the specific screening test addresses people (in the sense that the test is sent by post directly to people in this part of the population) over 60 across England – as qualified accordingly by the NHS; this means that the high level of the people involved in the process are people over 60. So, the empirical research developed in regard to this screening test has to include primarily findings for people over 60; then, other parts of the population could be examined, as of their involvement in the particular process. Finally, even if the performance of the screening test is significant, there is another issue that has to be addressed: the level of mortality in the 30-days period following a colorectal surgery is significant; the specific issue is highlighted in the study of Morris et al. (2011); it is explained that during the above period the mortality of patients has been estimated to 6.7% - at an average level from 1998 up to 2006. Moreover, the level of mortality seems to be increased for elderly – reaching the 15% for people over 95 (Morris et al. 2011). This means that the actual effectiveness of the screening test cannot be precisely measured. Estimations can be made based on the following facts: a) elderly are more exposed to implications of colorectal cancer compared to younger people, b) elderly are less likely to survive a difficult colorectal cancer surgery, c) people with metastases are more likely to be treated unfairly – because of the existing rules of NHS which focus on patients with primary disease, d) delays in the process of screening tests may occur especially in case that the test is not clear or if the test reached the NHS laboratories with delay. 5. Conclusion The use of the NHS Bowel Cancer Screening Programme has been proved to be an effective solution for protecting the public health in Britain. The above Programme refers to a field quite crucial for people in the above country – taking into consideration the level of the expansion of this illness across Britain, as described above. On the other hand, the risk factors related to bowel cancer are many; there are no sufficient signs that these risk factors have been reduced – compared to the past. This means that the risk for the development of bowel cancer in Britain, as in other countries worldwide, exists. However, at a first level, the effectiveness of the NHS Bowel Cancer Screening Programme is not negatively affected; this means, that if used the above Programme is effective, as proved through the empirical findings provided in the study. But in the case that people are not aware of the particular illness and its effects, then they are not likely to seek for the specific exam (screening for bowel cancer). In other words, the effectiveness of the specific Programme cannot be made clear unless it is combined with an effective strategy for informing people on the risk factors for bowel cancer but also on the impact of this type of cancer on their life. In this context, in order to evaluate the effectiveness of Bowel Cancer Screening Programme for public health, two different issues need to be discussed: a) whether the specific test is appropriately structured/ designed and b) whether people across Britain are aware of bowel cancer and, consequently, of this Programme. Regarding the first issue, the empirical research showed that the specific Programme is effective – when developed – and it is adequately supported by the state – through additional programmes of similar scope. However, regarding the second issue, it has been proved (through appropriate empirical findings) that people across Britain are not aware – at a high percentage – of bowel cancer and the measures available for its prevention. The above problem seems to involve particular in ethnic groups living in Britain (Robb et al. 2008). For this reason, it could be stated that the Bowel Cancer Screening Programme of NHS is quite effective for protecting people from the severe effects (referring especially to death) of bowel cancer; however, in order for the performance of the Programme to be increased it would be necessary for local authorities to increase their efforts for informing people across Britain on bowel cancer and its effects. At the next level, the provision of information on the particular Programme, as also on other similar schemes, would help people in Britain to be adequately protected towards the particular type of cancer. References BBC News (2000) Colorectal cancer screening 'cost-effective' Online, available from < http://news.bbc.co.uk/2/hi/health/977167.stm> Bowel Cancer UK (2011) Public Health Responsibility Deal. Online, available from < http://www.bowelcanceruk.org.uk/home/media-centre/latest-news/responsibility-deal-in-public-health> Bowel Cancer UK (2011) The Bowel cancer screening programme: a progress report on the roll-out of screening in England. Online, available from Cancer Research UK (2011) Bowel cancer - risk factors, online, available from < http://info.cancerresearchuk.org/cancerstats/types/bowel/riskfactors/> DH (Department of Health) (2011) Early signs and symptoms cancer awareness campaign pilots launched. Online, available from < http://www.dh.gov.uk/en/Aboutus/Features/DH_123889> DH (Department of Health) (2011) Red meat link to bowel cancer. Online, available from < http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_124670> Faiz O, Haji A, Bottle A, Clark SK, Darzi AW, Aylin P. (2011) Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007. Colorectal Disease – PUBMED, 13(7): 779-785 Jones C, Badger SA, McClements J, McKie L, Diamond T, Taylor MA. (2010) Can the National Health Service Cancer Plan timeline be applied to colorectal hepatic metastases? Annals of the Royal College of Surgeons in England - PUBMED, 92(2): 136-138 Lee D, Muston D, Sweet A, Cunningham C, Slater A, Lock K. (2010) Cost effectiveness of CT colonography for UK NHS colorectal cancer screening of asymptomatic adults aged 60-69 years. Applied health economics and health policy, 8(3): 141-154 Morris EJ, Taylor EF, Thomas JD, Quirke P, Finan PJ, Coleman MP, Rachet B, Forman D. (2011) Thirty-day postoperative mortality after colorectal cancer surgery in England. Gut – PUBMED, 60(6): 806-813 NHS Bowel Cancer Screening Programme (2011) About bowel cancer screening, online, available from and < http://www.cancerscreening.nhs.uk/bowel/about-bowel-cancer-screening.html#why-screen> NHS. Yorkshire and the Humber (2011) Beating bowel cancer. Online, available from < http://www.yorksandhumber.nhs.uk/news.php?id=355> NHS. The Information Centre. (2007) National Bowel Cancer Audit. Online, available from NI Direct. Department of Health, Social Services and Public Safety. (2011) Bowel Cancer Screening. Online, available from < http://www.dhsspsni.gov.uk/bowel-screening> Paddock, C. (2011) Low Bowel Cancer Awareness In UK. Medical News Today. Online, available from < http://www.medicalnewstoday.com/articles/221709.php> Quarini, C., Gosney, M. (2009) Review of the evidence for a colorectal cancer screening programme in elderly people. Age Ageing – PUBMED, 38(5):503-8 Robb, K., Solarin, I., Power, E., Atkin, W., Wardle, J. (2008) Attitudes to colorectal cancer screening among ethnic minority groups in the UK. BioMed Central Public Health, 8-34 Setshedi M, Epstein D, Winter TA, Myer L, Watermeyer G, Hift R. (2011) Use of thiopurines in the treatment of inflammatory bowel disease is associated with an increased risk of non-melanoma skin cancer in an at-risk population: a cohort study. Journal of gastroenterology and hepatology. 2011 Jul 28. doi: 10.1111/j.1440-1746.2011.06865.x. [Epub ahead of print] University of Oxford. Cancer Epidemiology Unit. (2011) Bowel cancer screening information. Online, available from < http://pcerg.ceu.ox.ac.uk/screening/31/> University of Sheffield (2007) Bowel Cancer Services: Costs and Benefits. Online, available from < http://php.york.ac.uk/inst/yhec/files/resources/FinalBowelCancerReport%20-%20Apr07.pdf> Read More