Editorial: ‘Risk-Adapted Starting Ages of Colorectal Cancer Screening for People With Diabetes or Metabolic Syndrome’

Abstract

In 2019, at a symposium at the Royal College of Physicians in London, I first heard ‘FIT’ and ‘democratisation’ used in the same sentence [1]. What was being discussed was how the objectivity of a faecal immunochemical test (FIT) result could be applied across age, sex, symptoms and signs and other laboratory tests to identify a personalised and so fixed, or equitable, colorectal cancer (CRC) risk. Perhaps other risk factors, such as ethnicity and one's index of multiple deprivation might also be in the offing with FIT [2]. The paper by Seum et al. takes us into a new space [3]. However one defines or identifies people with diabetes or metabolic syndrome, evidence suggests that CRC is commoner at any given age in this population. The authors make the case that, should equity underpin screening, the age at which those with diabetes or metabolic syndrome enter CRC screening programmes should be reduced [4]. Is this the beginning of a new conversation? Where should we go from here?

Clearly, simplicity is key to the establishment of screening programmes. The logistics of identifying people with diabetes and, particularly, metabolic syndrome would be challenging. Where would one stop? For every cohort with an easily defined risk, are there not many others with inflammatory conditions, prior diseases and treatments, family and environmental factors that shift CRC risk? The Bowel Cancer Screening Programme (BCSP) in England has entered this space by bringing people with Lynch syndrome into its programme [5]. These people have different risk profiles and, unlike others, are not expected to provide a FIT to ‘qualify’ for colonoscopy. The targeted lung health check drifts away from ‘screening’ [6]. Here, those aged 55–74 with a smoking history are targeted for CT of the thorax (and upper abdomen). Clearly, there is a continuum between the seemingly contrived ‘indifference’ of screening and the ‘targeted approach’.

Then there is the population we serve. Recognising how powerful the BCSP has been in identifying people with stage I and II CRC, has not the wide disparity in uptake in, for example, Yorkshire and Humber (the region I serve) arguably added to inequity and so been ‘undemocratic’? [7] Colleagues have been talking about the socio-technical elements of the implementation of medical devices [8]. There are perhaps similarities in these interventions that might help in untangling this problem in screening. Rather than expecting people to embrace CRC screening equitably and spontaneously across society, the social arrangements that deliver, mediate and support screening need to be considered explicitly and deliberately. Encouraging engagement with CRC screening is one thing. The other might be to shift the FIT threshold in favour of those communities that are struggling. Let them see that they are valued. As a gastroenterologist and CRC screener, this latter role has been the high point of my clinical career. Getting (for once) ahead of the curve has been hugely rewarding. There is still room to nudge on CRC screening.

James Turvill: writing – review and editing, writing – original draft.

The author declares no conflicts of interest.

This article is linked to Seum et al. paper. To view this article, visit https://doi.org/10.1111/apt.18435 and https://doi.org/10.1111/apt.70111.