A study of the implementation of population-based bowel cancer screening in Malaysia

Colorectal Cancer (CRC) is the second most common cancer in Malaysia and CRC-related deaths are predicted to increase from 2,565 in 2015 to 4,562 in 2030. CRC-related deaths may be avoided by early presentation, detection and appropriate treatment. However, cancers in Malaysia present at late stages. The Ministry of Health recommends annual screening for Malaysians aged 50 years or above to diagnose CRC early and increase chances of survival. However, research indicates that over 90% of the Malaysia population in that age group do not follow these recommendations. Recently, our research group conducted a population representative survey of 953 adults and found that they reported that they did not know 'how to go about screening' and that they believed that they were 'not the right age to undergo routine CRC screening'. There is a need to design and develop or adapt a programme that will ensure that Malaysians will avail of CRC screening.

In order to support earlier presentation and diagnosis and to improve survival rates, the "Bowel Cancer Screening Programme" (BCSP) was launched in England in 2006 and, more recently in 2010, a BCSP was designed and implemented by Northern Ireland's Public Health Agency. Evaluation findings reported an increased screening uptake of CRC as well as a shift towards earlier stage disease. There is a clear need for a co-ordinated, population-based CRC screening programme in Malaysia. Previous population-based surveys indicate that particular attention should be paid towards targeting common cancer disparities among various ethnic, socio-economic and geographical groups in Malaysia. The main aim of the proposed project is to address the need to design and develop a programme that is theoretically informed, evidence-based and culturally appropriate for Malaysia by building upon the BCSP programmes in NI and England, and then to evaluate the feasibility and acceptability of the programme.

The project comprises four phases. Phase 1 will review and synthesise the evidence and experiential learning regarding the lessons about implementation of CRC screening in NI and elsewhere; and will assess the views and preferences of key stakeholder groups particularly the views of the general population regarding CRC screening, how to facilitate easy access to screening and views about a population-based CRC Intervention in Malaysia (CRC-SIM). Phase 2 will involve further partnership working and the co-design of a culturally sensitive population-based CRC screening programme and the identification and agreement of metrics for the evaluation of implementation in Malaysia. Previous learning and perspectives will be presented and discussed in order to finalise the design and evaluation framework for the appraisal of the CRC-SIM and the assessment tools in the context of the Malaysian infrastructure and health system. Phase 3 will involve conducting a study of the implementation of population-based CRC screening in a selected district in order to test appropriateness, feasibility and acceptability. We will run the CRC-SIM in the study district and evaluate its implementation and acceptability using process measures and surveys of participants. Phase 4 will develop a working (logic) model of CRC-SIM based on the findings from the previous phases and the results of an initial economic appraisal as well as developing a protocol for a pilot evaluation of the implementation model in order to inform a national scaled-up programme including planning requirements, resources and costs.

We aim to develop and evaluate a screening programme to promote colorectal cancer screening awareness and increase participation and early detection. Phase 1 will review and synthesise best available evidence and implementation lessons; and assess views and preferences of stakeholder groups. A survey will be conducted of health facilities in order to describe usual practice and assess capacity to run a large scale roll-out of screening. Approximately six focus group discussions (FGDs) will be conducted with males/females aged 50 years or older with different socioeconomic backgrounds and from the three ethnic groups in Segamat (the study area) to identify barriers towards screening and investigate views about methods to increasing uptake and facilitating access. Phase 2 will co-design a culturally sensitive screening programme for Malaysians in Segamat. NI Bowel Cancer Screening Programme materials will be translated and adapted to suit the Malaysian population based on findings from Phase 1. The clarity of materials and their acceptability will be tested via a further four FGDs. Key service provider, delivery and laboratory staff will be surveyed about implementation practice, procedural issues and ways to improve the programme. Phase 3 will comprise a random sample (n=780) of eligible residents in Segamat in order to provide a precise estimate of the true percentage uptake of screening by income and ethic group. Positive iFOBT test results will be followed-up with an invitation for a colonoscopy. Surveys will elicit views about acceptability and facilitating/inhibiting factors to participating in screening. In Phase 4, data from previous phases will be analysed and synthesised to produce a logic model and a protocol for an experimental/comparative effectiveness evaluation. Routinely available data and the data from the set of investigative activities presented here will be used to conduct an initial economic evaluation and budget impact analysis.

This research will have several benefits for society and the economy including impacting positively on (i) the general population in Malaysia, (ii) vulnerable communities, for example, people from low income communities with limited health literacy, senior citizens and their families, (iii) primary care physicians, (iv) academics (v) professional organisations and NGOs e.g. the National Cancer Society, the Health Promotion Board (vi) the Malaysian Ministry of Health and (vii) other low- and middle-income countries in South East Asia.
The immediate beneficiaries will be local communities in Malaysia. Our project will benefit Malaysian communities by facilitating ease of access to colorectal cancer (CRC) screening. The screening intervention will reduce or eliminate structural, economical and knowledge-related barriers towards CRC screening and early diagnosis. Often, cancer patients and families bear a substantial amount of the payment for health care and this burden may lead to serious economic consequences. Screening and earlier diagnosis has the potential to reduce the financial and related personal and psychosocial burden that is experienced by many cancer patients and their families.

Our project will help primary care physicians in term of improving their understanding about the community that they serve including barriers to and facilitators to CRC screening. Furthermore, the project has the potential to extend coverage of CRC screening to the general population, assist patient navigation and facilitate immediate referral of suspected cases. The study will provide novel data about the feasibility of population-based CRC screening programme in terms of, for example, sending screening invitations, delivering CRC screening tests to the community, acceptability of CRC screening tests and participation rates. Findings will benefit global public health researchers and other academics in LMICs who are planning to investigate similar issues in different cancers or to informing methods and plans for future upscaling of programmes at a population level.

Capacity building regarding global cancer research and NGOs will be enhanced and the project will provide inspiration and a tried-and-tested way of reproducing a successful screening intervention. The protocol will be published in an open access journal and will be widely available to academics, professionals and other interested parties. Since the Ministry of Health in Malaysia is a partner in our project from the outset, there is high potential for the findings to be used as the basis of an evidence-based strategy for CRC prevention and control for Malaysia. The findings of our study will be disseminated to Asian countries through national, regional and international conferences. Our proposed strategy for the implementation of the CRC screening Programme will serve as a blue print for cancer prevention and control policy in South East Asia where the burden of CRC is increasing and there are high CRC death rates.