91 Bowel cancer is the fourth most common cancer in the UK, affecting roughly 1 in 15 men and 1 in 18 women. It is also the second leading cause of cancer-related deaths. Despite advancements in other nations, the UK lags behind when it comes to improving survival rates for this prevalent condition. Among comparable economically developed countries—such as Australia, Canada, the United States, France, and the Netherlands—the UK ranks lowest in bowel cancer survival. For instance, over 70% of people diagnosed with bowel cancer in Australia survive for at least five years, compared to 65% in the US. In the UK, however, the five-year survival rate is only 60%. There are likely many contributing factors to the UK’s low bowel cancer survival rate, but screening is a key area to examine. Broadly, bowel cancer is diagnosed in one of two ways: either through the appearance of symptoms—such as changes in bowel habits, abdominal pain, weight loss, or blood in stool—or via screening. Unsurprisingly, those diagnosed through screening rather than after symptoms appear are far more likely to have early-stage cancer and are approximately three times more likely to survive. In England, individuals are generally invited for bowel cancer screening from age 54, while screening begins at age 45 in the United States and age 40 in Japan. Although most bowel cancer diagnoses occur in those over 50, rates of diagnosis are actually rising fastest in people under 50. Additionally, while countries like the US and Japan offer annual screening, the UK screens only every two years. A significant difference between the UK and other countries lies in the specific screening tests used. Most countries employ a two-step approach: a quantitative faecal immunochemical test (qFIT) to detect blood in stool, followed by a colonoscopy for individuals with a “positive” qFIT result. However, what constitutes a “positive” result varies. In most countries, a qFIT result of 20µg of blood per gram of stool is considered positive, while in Scotland it’s set at 80µg/g, and in England and Wales, it’s 120µg/g. Using a lower cut-off means that more people test “positive” and are thus eligible for a colonoscopy, where cancer can be directly diagnosed. For example, with a threshold of 20µg/g used in the United States, approximately 8% of those tested are referred for a colonoscopy. In contrast, the UK’s threshold of 120µg/g means only 2% of people are referred. It’s no surprise, then, that only 10% of bowel cancers in the UK are detected through screening, compared to 45% in the US . Researchers estimate that the UK’s threshold of 120µg/g misses more than half of the bowel cancers present at the time of screening. Why, then, does the UK use such a high qFIT threshold, conduct screenings less frequently, and start screening at a later age? The answer largely comes down to funding. These screening limitations reduce the number of colonoscopies required, as the NHS does not currently have the resources to expand screening. This reality may surprise many, as people often trust the NHS to prioritise the best measures for cancer prevention. However, the reality is that patients are receiving suboptimal care simply because it’s all that current funding allows. If this information were more widely known, people might consider private options for additional screening. Unfortunately, many assume the NHS will “do what’s best,” but in the case of bowel cancer screening, the UK falls far short of the “best” standard by international comparison. Emily Johnson, PhD is a public health researcher focused on cancer prevention strategies.