Introduction of Mass Screening by Once-Only Flexible Sigmoidoscopy in the English Bowel Cancer Screening Programme to Reduce Colorectal Cancer Incidence Rates
Submitting InstitutionImperial College London
Unit of AssessmentClinical Medicine
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Oncology and Carcinogenesis, Public Health and Health Services
Summary of the impact
Research undertaken by Professor Atkin has identified a feasible,
acceptable and cost-effective method of reducing colorectal cancer
incidence and mortality rates, which involves a once-only flexible
sigmoidoscopy screening for all men and women at around age 60. The
supporting research involved publishing the evidence, developing a
fail-safe, efficient, patient-friendly delivery system, developing a
surveillance strategy following adenoma-removal, and testing in
multicentre randomised trials. After 11 years, incidence and mortality
rates were reduced profoundly in the trials, with no observed attenuation
of effect. The entire screening strategy was rolled out in a national
programme from 2013, with complete population coverage expected by 2016.
Key Imperial College London researchers:
Professor Wendy Atkin, Professor of Gastrointestinal Epidemiology (St
Mark's Hospital, Imperial Category C, 1989 -2008; Category A 2008 -
Professor Brian Saunders, Adjunct Professor of Endoscopy (St Mark's
Hospital, Imperial Category C. 1997 - present).
In 1993 Professor Atkin hypothesised that a once-only flexible
sigmoidoscopy (FS) undertaken at around age 60 years, with removal of
detected adenomas, would provide substantial and enduring protection
against the development of colorectal cancer (CRC). Evidence supporting
this hypothesis was published by Professor Atkin and colleagues, with a
call for a randomised controlled trial (RCT) to test the idea (1). In the
following years, Professor Atkin undertook two parallel strands of
research with independent yet related goals: first, she designed and
performed a multicentre RCT to test this hypothesis, and second, she
assessed the feasibility of delivering a nationwide FS based screening
programme in the future.
In 1993 Professor Atkin performed a small feasibility study involving
4000 people (2) and a subsequent pilot trial with 16000 people was
undertaken in 1995. Finally, in 1996 a UK wide multicentre RCT, the UK
Flexible Screening Sigmoidoscopy Trial (UKFSST), was initiated, involving
Whilst testing her hypothesis, Professor Atkin planned and established
the fail-safe, efficient, patient-friendly processes necessary to invite,
screen and follow-up the whole population; instituted a population
demonstration project in two areas of London (including a deprived,
ethnically diverse region) that utilised specially trained nurse
practitioners to perform FS (she worked with the profession to develop the
training programme in its early phase); ensured that the UKFSST trial was
performed in a manner and at a pace that would be identical to a future
screening programme; and developed guidelines for surveillance strategies
following adenoma removal that were adopted by the existing Bowel Cancer
Screening Programme, that demonstrated that half of people with adenomas
are low risk and do not need surveillance (thus ensuring a future
screening programme that would be economically viable). Throughout this
time, research results were continually disseminated as high profile, high
impact publications, and independent, international corroboration for
Professor Atkin's trial protocol was obtained when it was used by the
Italian SCORE (Screening for COlon Rectum) trial.
The Norwegian NORCCAP (NORwegian Colorectal CAncer
Prevention) trial has also utilised parts of the UKFSST trial
strategy (once-only FS and the same participant age-range) and the results
are due to be presented shortly.
In 2002, baseline results of screening in the UKFSST and Italian SCORE
Trial were published (3-4). In 2002, Professor Atkin and Professor
Saunders developed the first UK guideline on colonoscopic surveillance for
people with colorectal adenomas (5): the guideline was adopted as the UK
standard. In 2010, the first results of the UKFSST were published (6). The
trial demonstrated that 11 years after a single FS screening, undertaken
in men and women between ages 55 and 64, CRC incidence was reduced by a
third and mortality by 43%. This was the first empirical demonstration
that removal of adenomas reduces CRC incidence and the effect was
substantial and long-lasting: no attenuation was observed over 11 years'
follow-up. FS was shown to be a feasible, acceptable and cost-effective
method of reducing CRC incidence and mortality, and Professor Atkin had
demonstrated a model for delivery of FS screening that was of high quality
in terms of safety and yield of significant neoplasia.
From 1989 to 2008, Professor Atkin was based at St Mark's hospital, where
she held an honorary position (Category C) with Imperial College initially
as Senior Lecturer, rising to Professor in 2004. In 2008 Professor Atkin
relocated to the St Mary's Hospital campus as Professor of
Gastrointestinal Epidemiology (Category A).
The underpinning research that led to this impact involved collaboration
with a number of institutions. Professor Atkin conceived of the idea,
published the hypothesis, designed and managed the trials and procedures,
and wrote many papers detailing the interim results and reviewing on-going
research and competing methodology in the field. Professor Jane Wardle and
her team at the Health Behaviour Research Centre at UCL undertook all
health psychology aspects of the trial, and 14 trial centres around the UK
screened the patients.
References to the research
(1) Atkin, W., Cuzick, J., Northover, J.M., & Whynes, D.K. (1993).
Prevention of colorectal cancer by once-only sigmoidoscopy. Lancet,
341 (8847), 736-740. DOI.
Times cited: 273 (as at 6th November 2013). Journal Impact
(2) Atkin, W., Hart, A., Edwards, R., McIntyre, P., Aubrey, R., Wardle,
J., Sutton, S., Cuzick, J., & Northover, J.M.A. (1998). Uptake, yield
of neoplasia, and adverse effects of flexible sigmoidoscopy screening. Gut,
42 (4), 560-565. DOI.
Times cited: 94 (as at 6th November 2013). Journal Impact
(3) Atkin, W. et al. (2002). UK Flexible Sigmoidoscopy Screening
Trial Investigators. Single flexible sigmoidoscopy screening to prevent
colorectal cancer: baseline findings of a UK multicentre randomised trial.
Lancet, 359 (9314), 1291-1300. DOI.
Times cited: 294 (as at 6th November 2013). Journal Impact
(4) Segnan, N., Senore, C., Andreoni, B., Aste, H., Bonelli, L., Crosta,
C., Ferraris, R., Gasperoni, S., Penna, A., Risio, M., Rossini, F.P.,
Sciallero, S., Zappa, M., Atkin, W.S. and SCORE Working Group — Italy.
(2002). Baseline findings of the Italian multicenter randomized controlled
trial of "once-only sigmoidoscopy" -SCORE. J Natl Cancer Inst, 94
(23), 1763-1772. DOI.
Times cited: 140 (as at 6th November 2013). Journal Impact
(5) Atkin, W.S., Saunders, B.P. (2002). Surveillance guidelines after
removal of colorectal adenomatous polyps. Gut, 51 (Suppl 5), V6-9.
cited: 81 (as at 6th November 2013). Journal Impact Factor:
(6) Atkin, W.S., Edwards, R., Kralj-Hans, I., Wooldrage, K., Hart, A.,
Northover, J.M.A., Parkin, D.M., Wardle, J., Duffy, S.W., & Cuzick, J.
(2010). Once-only flexible sigmoidoscopy screening in prevention of
colorectal cancer: a multicentre randomised controlled trial. Lancet,
375(9726), 1624-1633. DOI.
Times cited: 351 (as at 6th November 2013). Journal Impact
Factor: 38.28. This paper was the most frequently cited paper in The
Lancet in 2010 and was shortlisted, with two other papers, for the BMJ
group "Research paper of the year" award.
• KeyMed Ltd (Industry endoscope provider; 1994-1995; £511,116),
Principal Investigator (PI) W. Atkin, Feasibility study for flexible
• Cancer Research UK (CRUK; 2006-2008; £624,197), PI W. Atkin, Colorectal
• CRUK (2008-2013; £1,309,275), PI W. Atkin, Screening and Prevention of
• Medical Research Council (MRC; 1996-2000; £2,064,199), PI W. Atkin,
Multicentre randomised trial of `once-only' flexible sigmoidoscopy
screening for prevention of colorectal cancer morbidity and mortality.
• MRC (2001-2005; £739,920), PI W. Atkin, Flexible sigmoidoscopy
• MRC (2006-2010; £752,716), PI W. Atkin, Flexible sigmoidoscopy
• National Institute for Health Research (2011-2016; £721,408), PI W.
Atkin, FS extension 3.
• KeyMed Ltd and Department of Health, Cancer Screening Programmes
(2003-2009; £490,468), PI W. Atkin, Population flexible sigmoidoscopy
screening: evaluation of feasibility of a high-uptake nurse-led service.
Details of the impact
Impacts include: health and welfare, public policy and services,
practitioners and services, society Main beneficiaries include: patients
and the public, NHS, Department of Health, international health service
There are one million new diagnoses of CRC annually worldwide. It is the
third most commonly diagnosed cancer and the second most frequent cause of
cancer death in the UK and it is estimated that it costs the NHS in excess
of £1 billion annually. Only five months after publication of the results
of the UKFSST in October 2010, Prime Minister David Cameron announced a
£60m investment over four years to incorporate FS screening at around age
55 into the current nationwide Bowel Cancer Screening Programme . The
rapid decision to provide funding for incorporation of the FS screening
strategy in Bowel Cancer Screening Programme, was based on recognition
that the UK lags behind other EU countries in terms of CRC mortality
rates, and that the once-only FS screening strategy was seen as a way to
catch up with better performing countries. A model of delivery had already
been developed and tested in a demonstration pilot in a deprived and
ethnically mixed population in London, and the processes needed to invite,
screen and follow-up the entire population had been established (the Bowel
Cancer Screening System was subsequently modified by Connecting for Health
to incorporate Professor Atkin's model for delivery of FS screening for
use in a nationwide screening programme). From published research, it was
evident that FS screening was a feasible, acceptable and cost-effective
method of reducing CRC incidence and mortality rates, and independent
research had shown that once only FS was cost saving.
The 2011 NICE Colorectal Cancer guidelines recommend that FS be offered
to patients with major comorbidity [2; see page 8]. The EU guidelines for
colorectal screening and diagnosis state that `flexible sigmoidoscopy (FS)
screening reduces CRC incidence and mortality if performed in an organised
screening programme with careful monitoring...' . US guidelines
recommend that FS is used as one of the screening approaches for men and
women over the age of 50 . In its first annual report for improving
outcomes in cancer, the Department of Health stated that improving
sigmoidoscopy activity was a key priority for next year, stating
`introduction of flexible sigmoidoscopy bowel screening and the move to
more investigations of symptomatic patients mean that a key priority for
next year is to increase endoscopy activity' [5; see point 3.46 on page
FS screening was approved by the UK National Screening Committee in 2011
, and the English NHS Bowel Cancer Screening Programme initiated
Pathfinder FS projects between January and May 2011. The organisation and
bidding process, including development of the English database, was
initiated in 2012 . Roll-out of a pilot programme began in March 2013,
and roll-out of the first wave of the full programme (wave 1 of 3) was
subsequently initiated in October 2013, with the aim of achieving 30%
coverage by 2014, 60% by 2015 and full population coverage within England
The immediate beneficiaries of these impacts are the UK population: from
the UKFSST findings it has been calculated that FS screening at age 55
would prevent 5,000 CRC diagnoses and 3,000 deaths in the UK each year,
and rectal cancer could be rendered a rare disease as FS is so effective
in this region. Potential beneficiaries in the longer term include high
incidence countries in the EU and North America where the guidelines for
early detection of CRC have been recently revised, to include reference to
our work. . The delivery of screening strategy outcomes in England should
facilitate adoption by other countries and this may eventually prevent the
majority of deaths from distal CRC: evidence from the US that CRC
incidence rates in the distal colon are already falling dramatically as a
result of colonoscopy based screening further supports these efforts.
Sources to corroborate the impact
 Public Health England. NHS Bowel Cancer Screening news. "Flexible
Sigmoidoscopy to be introduced into the NHS Bowel Cancer Screening
Archived on 6th
 NICE Clinical Guideline. Colorectal cancer: the diagnosis and
management of colorectal cancer. Full Guidelines (November 2011), pages
1-186 (refer to page 8 for list of recommendations). Recommends that
flexible simoidoscopy is offered to patients with major comorbidity. http://www.nice.org.uk/nicemedia/live/13597/56957/56957.pdf.
on 6th November 2013.
 EU Guidelines for quality assurance in colorectal cancer screening
and diagnosis (2011). Refer to page 4. The Atkin trial is cited in section
on 6th November 2013.
 American Society Guidelines for the early detection of cancer:
colorectal cancer and polyps. http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.
Archived on 6th
 Department of Health. Improving outcomes for cancer: First Annual
(see point 3.46 on page 43). Archived
on 6th November 2013.
 UK National Screening Committee. http://www.screening.nhs.uk/cms.php?folder=3057.
Archived on 6th
 NHS Bowel Screening Programme. Piloting Flexible Sigmoidoscopy.
Advice to the NHS and bidding process. January 2012. https://www.gov.uk/government/publications/piloting-of-flexible-sigmoidoscopy-advice-to-the-nhs-and-bidding-procress.
on 6th November 2013.