This site is intended for health professionals only

Men and bowel cancer: the facts

David Wilkins
Policy and Projects Officer
Men's Health Forum

Men are more than one and a half times as likely to develop bowel cancer as women; and yet, research shows they are often reluctant to take part in screening to detect symptoms. How can this be addressed?

Bowel cancer is a disease serious enough, in many cases, to be fatal. The population group with the higher risk is men, who are more than one and a half times as likely to develop bowel cancer and to die from it as women.1 They also have poorer five-year survival rates (51% v 53%)2 
(see Box 1).

[[Box 1 men]]

As one would expect, this also means that men are more likely to test positive for the presence of faecal occult blood, the measure of risk used in the NHS Bowel Cancer Screening Programme (NHSBCSP). Since the programme began, 2.05% of men have tested positive compared to 1.57% of women. Despite this, men are less likely to take part in the programme. Figures vary by region but since the inception of the NHSBCSP, only 51% of men have taken up the offer of screening compared to 56.6% of women.

The NHSBCSP offers all men and women aged 60-69 the opportunity to take a faecal occult blood test (FOBt) via a self-administered home-testing kit. The test is offered to everyone every two years, and the upper age limit is gradually being increased to 74. Each person in the qualifying age group receives by post a kit that enables him or her to collect a tiny sample from each of three separate bowel movements.
 
These samples, each smeared on to a specially prepared card, are returned in a freepost envelope to one of the five regional NHSBCSP hub laboratories. At the lab the samples are subject to a chemical process that detects the presence of minute quantities of blood in the stool. Blood in the stool is an 'occult' (hidden) symptom that might indicate early stage bowel cancer. The FOBt is capable of detecting this symptom, in many cases long before the person taking the test would have become aware of it.

Blood in the stool does not in itself indicate that the person taking the test has developed bowel cancer, but it does make it advisable that he or she should have further investigations. Occult blood is detected in around two tests in every 100.
These people are invited to attend a screening centre for a colonoscopy (endoscopic examination of the colon and the
distal part of the small bowel with a camera on a flexible tube).
Of those people who require colonoscopy following the FOBt, around half will be found to have no problems, and will require no further investigation or treatment. Of the remainder, most (four out of every five) will be found to have polyps (small benign growths on the inside lining of the colon or rectum). Polyps can almost always be removed on sight during the colonoscopy. It is important that polyps are removed as they can become cancerous in time.

The remaining patients (10% of those who required colonoscopy, roughly 0.2% of those who initially took the FOBt) will be found to have bowel cancer. However, in many cases, these cancers will have been identified at an earlier stage than otherwise would have been the case. Research suggests that the risk of death from bowel cancer in the population as a whole can be reduced by around 16% where a regular screening programme of this kind is used.

Bowel Cancer Project
The Men's Health Forum has just completed a four-year project, funded by the Department of Health, that aimed to better understand why men are less likely to use their FOB testing kit when it arrives.

Method
An early part of the project involved conducting a series of discussion groups with randomly selected men in the target age group for the NHSBCSP. These group discussions were built around ideas emerging from an analysis of the existing literature on the subject of men's attitudes to cancer.

The discussion groups included men who had taken part in the NHSBCSP; men who had received an invitation to take part and had declined it; and men who had not yet been invited and were therefore largely unfamiliar with the whole idea.

Some of the discussion groups were given test kits to examine and were asked to describe their immediate reactions to them. The discussion groups were also encouraged to make suggestions for ways in which the NHSBCSP could better engage with men.These discussions identified a number of barriers to participation, some of which had been predicted by the literature review, some of which had not. Among the most important was anxiety about the possibility of needing further investigation, which was linked to a somewhat irrational fear of 'tempting fate' by taking the test in the first place. Some participants also identified feelings of discomfort with the actual test process, which of course involves people having to get close to their faeces.

Thinking about health matters more generally, many men felt that it was a 'male thing' to put off decision-making and help-seeking. It was also commonly believed that women are more in tune with their own bodies and their personal health needs. Some participants felt this was explained, at least partly, by women's greater familiarity with health screening processes in general. Participants also frequently identified their wives and partners as the most important influence on their health decision-making.

The findings from the discussion groups formed the basis of a questionnaire, which was used to conduct a postal survey of 2,200 randomly selected men and women in the target age range. The survey achieved a creditable response rate of 33% (579 men and 122 women).

Results
The survey findings suggest that men tend to have a more pessimistic view of health in general, and cancer in particular. Men are more likely to believe, for example, that poorer health is inevitable in older age. Men are also more likely to say they would "rather not know" if they were developing a serious illness, and to say that it is a gamble going to see a doctor when you are fit and well, as the doctor might find something wrong with you. A large majority of both men and women think that women are more relaxed about screening and that men need more encouragement to seek health advice than women - although interestingly, men are less likely to think these things of themselves than women are to think them of them. The findings about the FOB testing process proved more positive, however. Men were more likely to view the test as simple and achievable, and less likely to regard it as disgusting and embarrassing.

A very substantial majority of both sexes in this age group consider the GP and other primary care staff to be the greatest influence on their health behaviour. The survey also confirmed the degree of influence attributed by men to their wives in relation to their personal health decisions. Women were much more likely than men to identify a wider range of influencing factors on their decision making; in addition to their spouse, for example, women are more likely than men to be influenced by friends, other relatives and the media.

Conclusions
The report of the project highlighted two specific ways in which men's likelihood of participating in the NHSBCSP might be increased. These are:

  • Greater involvement of the patient's own GP and other primary care professionals in endorsing the programme.
  • Encouragement of the idea that men should always talk to someone before deciding whether or not to participate.
  • Whether there could be greater integration of local primary care services and the administration of the NHSBCSP is a complex question. At present all the administration is handled from the six NHSBCSP hubs (regional centres) and the involvement of primary care staff is limited to receiving routine confirmation of patients' FOBt results. Other pieces of research are being carried out examining whether there might be ways in which the relationship between the two systems could become closer.

In the meantime, it is clear that at an informal level there is much that primary care staff - particularly practice and community nurses - could do. In addition to the two central recommendations summarised above, the project highlights six positive mechanisms for engaging with men suggested by our research.

Tips for primary care
Although these mechanisms are described in our research in the context of the NHSBCSP, they are can all be used to inform practice in the primary care setting and that is how they are summarised below.

  • Practicalities. Our research suggests that men are more likely than women to regard the FOBt as simple and 'do-able'. This reflects other research, which has suggested that health processes that are streamlined and practical often appeal to men.
  • Gender-specific information. Men (and women) in this age group express a strong preference for gender-specific health information.
  • Simplicity. Both sexes in this age group prefer health information provided as simply as possible, within the constraints of ensuring that the information is comprehensive. Both sexes also favour health messages expressed in such a way as to make them easily memorable.
  • Delay. For a variety of reasons (anxiety, fatalism, denial or simple inertia) men believe themselves to be more likely to delay seeking help with health problems. It is important to actively encourage male patients to seek help in good time. Similarly, it is important to recognise in consultations that men may well have anxieties that they are not expressing and may even be actively concealing.
  • Staying well. Men who regard themselves as fit and well (who have no recognisable symptoms) may actively reject the idea of health checks, even those that are intended to identify hidden symptoms. In the case of our research this was in relation to hidden symptoms of bowel cancer but it might equally apply, for example, to hypertension or diabetes. The attitude of these men may be that to take part in a health check is to gamble that something might be found. This suggests perhaps that checks promoted to 'confirm wellness' may be more appealing than checks to identify illness.

Communicating health messages to men
There has been a fair amount of work in recent years on using imagery that reflects men's interests, and in using male-friendly settings for health promotion events and health checks. This has value and has been shown to work for some groups of men. It is important to remember, though, that not all men are interested in sports, or completely uninterested in their own health, and stereotypes such as these should be avoided. Our research indicated that men (at least in the 60-70 age group) are interested in their own health and that they will use conventional services. The key point is that there is potential to adjust existing services so that they are more sensitive to male attitudes and behaviours - and, therefore, more appealing to men.

Summary
Men are significantly more likely than women to develop bowel cancer. In fact, on average, men are 60% more likely than women to develop all of the 13 most common cancers that are not specific to one sex or the other and 70% more likely to die from those cancers.1 Men are also less familiar with cancer symptoms and warning signs.3

There is an important job to be done here. Many cancers from which men die are either preventable, or capable of a better prognosis if detected earlier. Practice and community nurses are a crucial part of bringing about improvements. It is important in consultations to look out for early indicators not just of the male cancers, such as prostate and testicular cancer, but of all cancers. It is especially important to encourage men to seek help and to create consultations in which men are helped to talk about their concerns. There is no doubt that if we can normalise help-seeking and participation in screening by men, then we will also detect cancer earlier.

References

  1. White A, Thomson C, Forman D. The excess burden of cancer in men in the UK. London: National Cancer Intelligence Network; 2009.
  2. Cancer Research UK. Bowel cancer - survival statistics. London: Cancer Research UK; 2009.
  3. Robb K, Stubbings S, Ramirez A et al. Public awareness of cancer in Britain: a population-based survey of adults. Br J Cancer 2009;3;101(Suppl 2):S18-23.