Direct Access Colonoscopy Service (DACS) Dr Rob Palmer, C&H CCG Gastro Lead Dr Ellie Hitchman, C&H Cancer Lead Dr Nora Thoua, Consultant Gastroenterologist, HUH A pilot scheme that will be started in April

Background Bowel cancer is the UK's second biggest cancer killer and the fourth most common cancer Colorectal symptoms are common in the population, and the majority of patients with symptoms do not have colorectal cancer 

Nationally, only 6.4% of 2ww referrals lead to a cancer diagnosis At the Homerton, the 2012/13 data showed that of the colorectal cancers diagnosed 35% were via a 2ww referral 28% were via an A&E presentation The remaining 37% were via routine referrals

Bowel cancer 5 year relative survival rates and percentage of cases by Dukes’ Stage at diagnosis, England 1996-2002 (CRUK bowel cancer survival statistics) Duke's stage at diagnosis Percentage of cases Five-year relative survival A 8.7% 93.2% B 24.2% 77.0% C 23.6% 47.7% D 9.2% 6.6% Unknown 34.3% 35.4% Relative survival = relative to the rest of the population (takes into account the fact that the person may have died even if they did not have bowel ca) Bowel ca v treatable if diagnosed early

The local picture City & Hackney has a lower incidence of bowel cancer than the national average (39.3 per 100,000 vs 46.5 per 100,000, 2008-2010 NCIN E-atlas) We have a slightly higher incidence of right sided cancers than the national average However the proportion of colon and rectal cancers which present at stage 4 (already metastasised) is high

If we can influence the stage at diagnosis this may translate into increased survival for our patients The new service aims to help decrease “routine” waiting time for our “low risk but not no risk” patients

Plans to improve early diagnosis Public health approaches: awareness campaigns eg Be Clear on Cancer National screening: Bowel cancer screening FOB testing for 60-75 year olds Over 75s can request a kit Bowelscope programme – one off flexi-sig at 55, planned to start at Homerton early 2015 The NHS England: Best Practice Commissioning Pathway for the Early Detection of Colorectal Cancer

CRUK are currently piloting approaches aimed at increasing uptake of bowel cancer screening in NE London: Advertising A flyer from CRUK with the test kit An “enhanced” test kit, with more information, gloves etc

Approaches aimed at changing GPs’ referral behaviour, to increase rates of investigation at an earlier stage, and to offer colonoscopy sooner Changing 2ww criteria to widen net (changes to apply to hospitals in the London Cancer area – North and East London) GP direct access to diagnostic endoscopy “straight to test”

New 2ww criteria for Suspected Colorectal Cancer Rectal bleeding with change of bowel habit towards looser stools of ≥ 3 weeks duration (age 40 and over) [previously >6w] Rectal bleeding without change in bowel habit with no obvious cause ≥ 3 weeks duration (age 50 years and over) [previously aged >60y with sx >6w] Change of bowel habit with tendency towards looser stools persisting for 3 weeks or more without bleeding (age 50 years and over) [previously aged >60y with sx >6w] Abdominal mass thought to be large bowel cancer (any age) Palpable rectal mass (any age) Unexplained iron deficiency anaemia Males of any age with Hb ≤ 110; Ferritin ≤30; MCV ≤ 79 Non menstruating female with Hb ≤ 100; Ferritin ≤30; MCV ≤ 79 Other high clinical suspicion of colorectal cancer Not yet launched – need final IT stuff to be worked out within the CCGs

Transforming Cancer Services for London (part of NHS England) Recommended increased access to colonoscopy and flexible sigmoidoscopy for “low-risk but not no risk” patients CCGs to determine most appropriate service provision for their patients Flexi-sig pathway already available in C&H, so colonoscopy service commissioned to complement this Age criteria go beyond those initially recommended by TCSL

DACS Inclusion Criteria Aged 40-70 (essential) Presents with: New alteration in bowel habit (towards diarrhoea) >3w Altered bowel habit and rectal bleeding (any duration) Rectal bleeding alone if aged >55 Strong family history of colorectal cancer (colonoscopy recommended at age 50-55 if asymptomatic)*: CRC in 1 FDR aged <50y CRC in 2 FDR of any age A lot of overlap with new 2ww criteria Go to BSG webiste: colonoscopy in high risk groups for more details

Exclusion Criteria Mental health problems or dementia Recent MI or CVA within 8w eGFR <30 Obesity (weight >135kg) Had full colonoscopy within last 2y CPs at rest Colonoscopy esp through BCSP

Medical Considerations U&Es within last 3m esp if comorbidities (CKD, DM, CVD) Medications: Iron tablets – stop 7d before Aspirin – ok to continue Clopidogrel / warfarin – safe to stop 10d before? Diabetics on insulin: Get advice from diabetes centre

The GP Consultation Refer for DACS appointment Directly bookable through C&B  Diagnostic Endoscopy  Colonoscopy  Homerton Print and give patient the Patient Information Leaflet on Colonoscopy Found on City and Hackney CCG website and on Homerton website  Highlight need for dietary changes in 48hrs prior to procedure and timing of taking bowel prep  Prescribe Moviprep 2 sachets and  give to patient instructions on when to take found on patient information leaflet Tuesday afternoon

The GP Consultation Complete City and Hackney DACS Referral Form ESSENTIAL – REFERRALS WILL BE REJECTED UNLESS REFERRAL FORM COMPLETED (as this acts as checklist that all above measures have been done)  Advise patient that they need to have an adult available to accompany them home PREFERABLE – UNABLE TO RECEIVE SEDATION UNLESS ESCORT AVAILABLE

On the Day of the Procedure Patient attends for procedure at appointment time (with relative available to accompany them home after sedation) Admitted by nursing staff, observations, get changed Brief history and consent form by Endoscopist Procedure with sedation Detailed report to GP, patient and hospital notes Patient advised not to drive, return to work, use machinery for 24hrs

After the Procedure All patients discharged back to GP care, except if diagnosis of: colorectal cancer (added to lower GI MDM) IBD (referred to Gastro clinic) adenomatous polyps (to be removed at the time and added to polyp surveillance (1, 3 or 5year time) If biopsies taken, results to be reviewed in a paper clinic 2-3 weeks later and communicated to GP and patient with guidance on appropriate action

New 2 week wait forms Look out for these! We will have new 2ww forms for most cancers A few have slightly different referral criteria We will cascade these through the CCG when they are ready to be integrated with EMIS

They highlight the different choices of hospitals for the different referrals For more information on comparing the services at different hospitals go to: www.mycancertreatment.nhs.uk

CRUK Primary Care Engagement Facilitator Ben Tunstall has just started as the City & Hackney Primary Care Engagement Facilitator 1 year post Working closely with GP practices to look at strategies to improve early diagnosis of cancer Support with risk assessment tools, looking at GP practice profiles, audit and significant event analysis