Bowel Cancer Screening ProgrammeBowel Cancer Screening Programme Cheshire and Merseyside NHS North WestCheshire and Merseyside NHS North West

Aims and ObjectivesAims and Objectives

• To provide information about the BCSP

• To give a Public Health perspective

• To raise awareness of health inequalities

• To increase knowledge of Bowel Cancer symptoms

Public Health PerspectivePublic Health Perspective

• Bowel Cancer is the third most Bowel Cancer is the third most common cancer in the UKcommon cancer in the UK

• Approximately 34,900 new cases p.aApproximately 34,900 new cases p.a

• It is is the second largest cause of It is is the second largest cause of cancer deaths in the UK cancer deaths in the UK (Cancer Research UK, (Cancer Research UK,

2005. Cancerstats).2005. Cancerstats).

• In 2004 approximately 16,100 people In 2004 approximately 16,100 people died from bowel cancer in the UK, 737 died from bowel cancer in the UK, 737 deaths within Cheshire & Merseysidedeaths within Cheshire & Merseyside

• Life time risk of developing Bowel Life time risk of developing Bowel Cancer in the UK is about 1:18 for men Cancer in the UK is about 1:18 for men and 1:20 for womenand 1:20 for women

Public Health PerspectivePublic Health Perspective

Who is at risk of developing bowel Who is at risk of developing bowel cancer?cancer?

• Both men and women

• People who-

– Take little exercise

– Are overweight

– Have a diet high in red meat and low in vegetables, fruits and fibre

Warrington PCTWarrington PCT

• Strategy For Sport, Physical Activity and Strategy For Sport, Physical Activity and Health In Warrington 2007-2010Health In Warrington 2007-2010

• Chair Based ExerciseChair Based Exercise• Reach for Health SchemeReach for Health Scheme• Warrington Partnership for Food and Warrington Partnership for Food and

Health InitiativesHealth Initiatives• Healthy Weight StrategyHealthy Weight Strategy• Food and Health PlanFood and Health Plan• Food and Health WorkersFood and Health Workers

• People with a family history (CRC People with a family history (CRC Relatives)Relatives)

• Inflammatory Bowel DiseaseInflammatory Bowel Disease• Genetics-Genetics-

– Familial Adenomatous Polyposis Familial Adenomatous Polyposis (FAP)about 1% of cases(FAP)about 1% of cases

– Hereditary Non-Polyposis Colorectal Hereditary Non-Polyposis Colorectal Cancer (HNPCC) about 2-5% of cases Cancer (HNPCC) about 2-5% of cases

Who is at risk of developing bowel Who is at risk of developing bowel cancer? (continued)cancer? (continued)

• The risk of developing bowel cancer The risk of developing bowel cancer increases with age. increases with age.

• About 80% of people who get Bowel About 80% of people who get Bowel cancer are aged 60 and overcancer are aged 60 and over

Who is at risk of developing bowel Who is at risk of developing bowel cancer? (continued)cancer? (continued)

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Colorectal Cancer an Important Health Problem

www.statistics.gov.uk 35,579 new cases in 1999

Colorectal Cancer an Important Health Problem

www.statistics.gov.uk 16,152 deaths in 2001

• A persistent change in bowel habit, A persistent change in bowel habit, or diarrhoea for several weeksor diarrhoea for several weeks

• Rectal bleeding without any obvious Rectal bleeding without any obvious reasonreason

• Anaemia Anaemia

Bowel Cancer Symptoms

• Abdominal pain, especially if it is Abdominal pain, especially if it is severe; and a palpable lump in the severe; and a palpable lump in the abdomen.abdomen.

• Increased suspicion if symptoms last Increased suspicion if symptoms last for four to six weeksfor four to six weeks..

• Nausea, anorexiaNausea, anorexia

• Weight lossWeight loss

Bowel Cancer SymptomsBowel Cancer Symptoms

Wilson and Jungner Criteria Wilson and Jungner Criteria for Population Screeningfor Population Screening

• Is it an important Health problem ?Is it an important Health problem ?

• Is effective treatment available ?Is effective treatment available ?

• Does the disease have an early or Does the disease have an early or latent stage ?latent stage ?

• Is there a suitable screening test ?Is there a suitable screening test ?

• Are diagnostic and treatment Are diagnostic and treatment facilities available ?facilities available ?

Wilson and Jungner Criteria Wilson and Jungner Criteria for Population Screeningfor Population Screening

• Is the Natural History of the Is the Natural History of the condition known?condition known?

• Is there agreed criteria for who Is there agreed criteria for who should be treated ?should be treated ?

• Is the programme a continuing Is the programme a continuing process ?process ?

• Is the programme economically Is the programme economically viable?viable?

Why not increase access for Why not increase access for Symptomatic patients?Symptomatic patients?

• 30% of colorectal cancers present 30% of colorectal cancers present as emergenciesas emergencies

• The 2 week rule has had no The 2 week rule has had no impactimpact

• 5% 2 week rule referrals have 5% 2 week rule referrals have colorectal cancerscolorectal cancers

• As yet there has been no shift in As yet there has been no shift in Dukes stageDukes stage

Natural HistoryNatural History

Adenoma- Carcinoma SequenceAdenoma- Carcinoma SequenceMorson 1960sMorson 1960s

Normal MucosaNormal Mucosa AdenomaAdenoma High Risk AdenomaHigh Risk Adenoma CarcinomaCarcinoma

Prevalence in 50 yr olds 18%Prevalence in 50 yr olds 18% 4%4% 0.25%0.25%

Diagram of the BowelDiagram of the Bowel

Dukes Staging Diagram

100% 90% 65% 25% 15% 5 yr survival

11% 33% 33% 23% Proportion

A=85-95%

B=60-80%

C=30-60%

D=<10% 5 year survival

• In 2000 the Bowel Cancer screening Pilot In 2000 the Bowel Cancer screening Pilot began in Scotland (Dundee) and England began in Scotland (Dundee) and England (Rugby)(Rugby)

• Evidence from pilot studies showed that Evidence from pilot studies showed that early detection through regular Bowel early detection through regular Bowel Cancer Screening has a significant impact Cancer Screening has a significant impact upon overall survival ratesupon overall survival rates

• BCSP can reduce mortality (deaths) by BCSP can reduce mortality (deaths) by 16% in the population invited for 16% in the population invited for screeningscreening

Bowel Cancer Screening PilotBowel Cancer Screening Pilot

Nottingham studyStage shift

Dukes Dukes stagestage

AA BB CC DD

ScreenScreen 20%20% 33%33% 24%24% 21%21%

ControlsControls 11%11% 32%32% 31%31% 22%22%

Hardcastle, 1996

Health Inequalities of the BCSPHealth Inequalities of the BCSPPilotPilot

• Men were less likely to participate in FOBt

• Lower uptake in deprived areas.

• Poor uptake in Black and Ethnic Minority groups particularly Muslims.

• Ethnic groups more likely to DNA before colonoscopy.

• Other groups who may experience inequalities– Learning disabilities/ difficulties– Blind and Visual impairment – Deaf– People with mobility problems– Illiterate– Mental illness– Travellers– Homeless– Prison population

Health Inequalities of the BCSPHealth Inequalities of the BCSP

Responsibility for the BCSPResponsibility for the BCSP

• Cheshire & Merseyside NHS North West have Cheshire & Merseyside NHS North West have the lead responsibility for BCSP initially. the lead responsibility for BCSP initially. Thereafter PCT’s will commission the Thereafter PCT’s will commission the programme.programme.

• Central budget £10 million first wave, second Central budget £10 million first wave, second wave also funded approximately £461K per wave also funded approximately £461K per 500,000 head of population500,000 head of population

Agreed ModelAgreed Model

• Consortium ApproachConsortium Approach

• Local Implementation GroupLocal Implementation Group

• Key stakeholder consensus reached Key stakeholder consensus reached

• Operationally driven and managed by 1 Operationally driven and managed by 1 host Trust.( Aintree) This is the local host Trust.( Aintree) This is the local BCSP administration centre.BCSP administration centre.

• Endoscopy nurse-led screening Endoscopy nurse-led screening assessment clinics (community)assessment clinics (community)

Agreed ModelAgreed Model

Quality Assurance StandardsQuality Assurance Standards

• Global Rating Scores (Patient Global Rating Scores (Patient experience)experience)

• Satisfactory Joint Advisory Group Satisfactory Joint Advisory Group (JAG) assessment & visitation(JAG) assessment & visitation

• Accreditation of colonoscopistsAccreditation of colonoscopists

• Health Promotion and Health Inequality Health Promotion and Health Inequality considerations( Uptake, awareness)considerations( Uptake, awareness)

SHA BCSP StatisticsSHA BCSP Statistics

• Screening population 327,683Screening population 327,683

• Assume 60% uptake based on pilot figures = Assume 60% uptake based on pilot figures = 196,610 of which,196,610 of which,

• Approximate 2% will have a positive FOBt = 3,932 Approximate 2% will have a positive FOBt = 3,932 of which,of which,

• 11% of FOBt positive patients will have cancer 11% of FOBt positive patients will have cancer =433.=433.

• 35% will have polyps requiring surveillance =137635% will have polyps requiring surveillance =1376

Proposed organisationProposed organisation

HUB

HUBHUB

HUB

HUB

• 5 Programme Hubs across England, based on IT Local Service Providers (LSP) undertaking call/recall and lab functions

• 1 Programme Hub for approx 20 screening centres

Overarching Structure:

Role of HUBRole of HUB

• To Manage call and recall for the screening To Manage call and recall for the screening programmeprogramme

• To provide a telephone help line for people To provide a telephone help line for people invited for screeninginvited for screening

• To dispatch and process test kitsTo dispatch and process test kits

• Send results letters to participants and notify Send results letters to participants and notify GPGP

• Book the first appointment at a nurse led clinic Book the first appointment at a nurse led clinic for patients with an abnormal test resultfor patients with an abnormal test result

• Coordinate Quality assurance activitiesCoordinate Quality assurance activities

BCSP ProcessBCSP Process

• FOB testing will be offered FOB testing will be offered to all men & women aged to all men & women aged 60-69 - 2 yearly.60-69 - 2 yearly.

• 70+ can request to join the BCSP 70+ can request to join the BCSP but have to contact Regional Hub but have to contact Regional Hub at Rugby.at Rugby.

BCSP ProcessBCSP Process

Faecal Occult Blood Testing(FOBT) - Guaiac Testing

The participant is instructed to smear the stool onto the spots from 2 separate parts of the specimen on three separate days

Model in briefModel in brief

• Invitation letter is sent to participant Invitation letter is sent to participant from Rugby dispatch centre (HUB).from Rugby dispatch centre (HUB).

• Participants can opt out of the BCSP Participants can opt out of the BCSP by contacting Rugby.by contacting Rugby.

RugbyRugby

Administrative OfficesAdministrative Offices

PathologyPathology

LaboratoryLaboratory

Envelope PreparedEnvelope Prepared

FOBt KitsFOBt Kits

Preparing KitPreparing Kit

Preparation of KitPreparation of Kit

Solution Added To Process Solution Added To Process KitKit

Results to be checkedResults to be checked

Normal resultNormal result

Abnormal ResultAbnormal Result

Data baseData base

• National hub despatch kit

• Participants smear the stool sample onto the 2 Squares in the 1st flap indicated on the kit. This is repeated on 2 further days until all 6 Squares are completed

Model in briefModel in brief

Screening JourneyScreening Journey

• Completed kit is returned by post to Completed kit is returned by post to Rugby within 2 weeks of the 1Rugby within 2 weeks of the 1stst sample being smeared on the kit sample being smeared on the kit (foil-lined envelope supplied)(foil-lined envelope supplied)

ResultsResults Negative resultNegative result

Unclear Result (1-4 of the squares are Unclear Result (1-4 of the squares are positive)positive)

Spoilt KitSpoilt Kit

Technical FailureTechnical Failure

Positive ResultPositive Result

Screening CentresScreening Centres

•They will provide nurse led clinics for patients They will provide nurse led clinics for patients with an abnormal test resultwith an abnormal test result

•Arrange colonoscopy appointments for Arrange colonoscopy appointments for patients with an abnormal test resultpatients with an abnormal test result

•Arrange alternative appointments for patients Arrange alternative appointments for patients in whom colonoscopy has failedin whom colonoscopy has failed

•Ensure appropriate follow-up or treatment for Ensure appropriate follow-up or treatment for patients after colonoscopypatients after colonoscopy

Screening CentresScreening Centres

•Provide information about the screening Provide information about the screening programme for the local health communityprogramme for the local health community

•Promote the screening programme to the Promote the screening programme to the

general public in their localitygeneral public in their locality

•Provide information and support for local Provide information and support for local people in completing the FOB test(on referral people in completing the FOB test(on referral from the programme hubfrom the programme hub

• Appointment arranged at Endoscopy Nurse screening assessment clinic if the FOBt is positive. The participant will receive:

• Counselling • A health questionnaire• Information• Consent• Preparation for the procedure • Bowel Cancer Screening-The

colonoscopy Investigation (leaflet)

Screening JourneyScreening Journey

Screening journey Screening journey (Continued)(Continued)

• Referred to screening provider unit for colonoscopy

• Follow-up dependant on procedure results – Normal, sent a BCSP kit in 2 years– Polyps, surveillance by BCSP– Cancer detected cases referred to local

Multi Disciplinary Team (local Cancer Team)

Role of Primary CareRole of Primary Care

• Encourage members of the public to Encourage members of the public to participate in the BCSPparticipate in the BCSP

• Provide general information on the Provide general information on the BCSP to participantsBCSP to participants

• Direct inquiries to the national Direct inquiries to the national freephone help-line telephone servicefreephone help-line telephone service

Role of Primary CareRole of Primary Care

• Add results to the GP practice IT Add results to the GP practice IT systemssystems

• Encourage patients to complete the Encourage patients to complete the whole BCSP process. whole BCSP process.

• GP will be notified if patients DNA or GP will be notified if patients DNA or opt out of the programmeopt out of the programme

Contact DetailsContact Details

• Maureen Sayer Maureen Sayer

Health Improvement PractitionerHealth Improvement Practitioner

maureen.sayer@aintree.nhs.ukmaureen.sayer@aintree.nhs.uk