The Bowel Cancer Screening Programme in West Herts Alistair King Consultant Gastroenterologist
ANDRÉ PICARD From Saturday's Globe and Mail LONDON — John Dobson prides himself on the healthy lifestyle that has left him lean and fit at 70. He is an avid walker and non-smoker. He eschews the greasy, meaty British diet in favour of one rich in fruits and vegetables. And he lives in one of the most pristine parts of England so he can breathe the fresh sea air.
So when he received an invitation from the British National Health Service to participate in a bowel-cancer screening program, Mr. Dobson was only too happy to join in. An avid diarist, he noted it in the black, spiral notebook he keeps handy. Little did he know it was the beginning of a life-altering journey.
Luckily for Mr. Dobson, the cancer journey in Britain has a good road map, with clear goals, standards and wait guarantees. Diagnosis and treatment are done quickly, and the quality is excellent all over the country. Mr. Dobson dutifully completed the fecal occult blood test -- which detects minute traces of blood in stool -- and mailed it off on Sept. 6. "It's a messy affair, but easily got over," he says with a laugh.
A week later, a letter arrived, saying test results were "abnormal" and urging Mr. Dobson to undergo a colonoscopy. He met with a nurse to discuss the procedure and booked an appointment. On Sept. 29, he underwent a colonoscopy, watching the test -- in which a flexible, camera-equipped tube is guided into the colon as a means of looking for potentially cancerous polyps -- on a video screen. "Some people would be squirmish, but I was fascinated
Fascination turned to fear when the gastroenterologist, snaking the tube around the bends, arrived at the caecum, the pouch at the beginning of the large intestine, where he detected a large growth. "The good professor said it looked malignant," Mr. Dobson recalls. "Cancer."
Laboratory tests confirmed the unexpected diagnosis a few days later Laboratory tests confirmed the unexpected diagnosis a few days later. A CT scan (a 3-D X-ray) showed the cancer had not spread beyond the bowel. On Oct. 12, Mr. Dobson met with the oncology surgery team. After a discussion of his options, he booked a date to go under the knife. On Oct. 23, at Norfolk and Norwich University Hospital, about a third of his bowel was removed.
Leafing through the diary, he notes that the whole process, from simple screening test through to complex cancer surgery, took only six weeks. It is a speediness of care Canadians can only dream of. Moreover, he was accompanied through the entire cancer journey by a single nurse, ensuring co-ordinated, consistent, quality treatment. Her role was to serve as an educator and an advocate as Mr. Dobson tried to navigate the complex health system. "She guided through every step and answered every question. There was no bull about it," he says. "I can't fault anything at all in the process. It was brilliant."
Bowel Cancer Screening Programme National screening programme 1st involving men! 60-69yr olds sent FOB test every 2 yrs Sent back to ‘hub’ Positives advised to have colonoscopy- at screening centre ‘Roll out’ programme- currently 2nd wave
FOBT We send 60-69yrs data to ‘hub’ (Nottingham) with plan for roll out Hub send out explanatory letter 1 week before FOB test 59% kits returned 70+ age group can ask for test kits 2% abnormal – notified within 10 days + booked into our SSP clinics
Specialist Screening Practitioner (SSP) Specialist nurse Web based booking (from the hub) To see patient within 10 days Counselling + assessing fitness Stays with the patient throughout their ‘journey’ Rings pt 24hrs post colonoscopy Follows up polyps
Colonoscopy Dedicated lists with accredited screening colonoscopists Details collected by SSP 11% cancers Cancer CNS + MDT 30% polyps follow-up SSP Normal back onto FOBT programme
Benefits of being a centre Prestige Ensures survival of unit Retention of colorectal surgery Waiting lists Money! 92p per head of population x529,000 = £486,000 = £40,000 per month
The WHHT bid Feb 2007 Set to start 1/9/2007 Hemel as screening site Screening colonoscopists Sue Catnach Bruce Macfarlane Ralph Graham
The screened population West Herts population 529,011 Eligible population (p) 46,111 Y1 invitations (p/2) 23,056 2% Abnormal Colonoscopy ref 277 Yr 1 Yr 2 Colons/wk 5 10
What do we need to do? Waiting lists JAG visit Colonoscopists <6weeks routine <2weeks urgent JAG visit Quality, access, training Colonoscopists ‘Driving test’ Organisation Implementation Group
Waiting Lists Standard requests OK BUT: (May 2007- Hemel only) 243 ‘surveillance’ colonoscopies >6 wk deadline Extra Lists (would need 50!) Backfilling Validation
The Validation Exercise Notes reviewed for all ‘recall’ colonoscopies (AK, SC, RH, AA)- FH, polyp f/u, post CRC ‘Validated’ against BSG guidelines 40% cancelled, 19% deferred Patient and GP written to Extremely effective (24371 pts) BUT Also good medicine
The next step Inspection by JAG Oct 2007 Start BCSP before end 2007 Hub starts sending out FOBTs Information packs to GPs 1 week before Posters in surgeries etc ‘Discernible, albeit modest’ impact on primary care workload Paperwork, administration, information to patients
Faecal Occult Bloods Sensitivity 55-92% Specificity Not for symptomatic patients- Ix on merit False reassurance Specificity 11% CRC even in 60-69yr group Obvious bleeding (piles), upper GI, diet etc Often leads to ‘inappropriate’ investigation
BSG 2005
FOBT- individuals v population No evidence of benefit outside of BCSP Pts should be investigated on own merits Good evidence for benefits in BCSP We know we are missing up to 50% cancers! 15% reduction in bowel cancer deaths Overall population benefit