FOBt Bowel Cancer Screening & Bowel Scope Screening Lancashire Bowel Cancer Screening Programme Louise Newton & Cathy Corcoran Lead Specialist Screening Practitioner & Deputy Lead SSP We are based in Home 5 BVH , Team include Clinical Director MTH, PM, Lead SSP, Deputy Lead SSP, admin, 9 Screening colonoscpists based at either BGH RPH / CDH and BVH, 1 Dual Role Nurse Endoscopist / Senior SSP and 16 SSPs

Bowel Cancer: The Facts 16,000 deaths/year from Bowel cancer 2nd commonest cause cancer death Over 34,000 new cases/year Over 80% occur in over 60s Lifetime risk 1 in 20 Screening FOB 16% Mortality reduction Detect cancers earlier stage Bowel Scope - mortality reduction 31-43%

Bowel Cancer Screening Programme Aim of BCSP is to reduce the mortality rate of bowel cancer and to detect cancer at an early stage The BCSP provides screening for men and women aged between 60 and 75 years using a FOBt Participants who have a +FOB are invited to see a Specialist Screening Practitioner Cancer deaths 16,000 Reduces mortality by 16%

Lancashire BCSP Population Covers a population size of 1.3 million 160,000 of 60 – 69 year olds 50,735 of 69 – 75 year olds 8 CCGs commission the service Patient can self refer at & after age 75

Guaiac FOBt testing kit Patient applies sample Positive Spots

How is FIT different to gFOBT? Faecal Immunochemical Test gFOBT Guaiac Facal Occult Blood Test Measures HUMAN blood Measures any mamalian blood including that in the diet Single faecal sample 6 faecal samples from 3 bowel motions Sample put into plastic container Sample put onto cardboard Automated objective analysis Subjective visual assessment Adjustable Hb cut-off concentration Non-adjustable Hb cut-off (sensitivity) Higher participation rate than gFOBT Lower participation rate than FIT

How is FIT different to gFOBT? Faecal Immunochemical Test gFOBT Guaiac Faecal Occult Blood Test Higher detection rate of cancers & adenomas Lower detection rate of cancers and adenomas Estimated 22% reduction in CRC mortality Estimated 16% reduction in CRC mortality TRIAL positivity rate about 2.11% at 120µg/g faeces Current BCSP positivity rate 1.4% More expensive than gFOBT Less expensive than FIT

FIT Impact on Lancashire Screening Centre 20-30% Increase in demand with FIT kit vs FOBt kit 3 additional colonoscopy list p.w. required Overall Screening centre 3 additional Specialist Nurse pre assessment clinics required p.w.

BCSP Targets Specialist Screening Practitioner (SSP) assessment clinic within 7-10 calendar days of +ve FOB Colonoscopy appt within 14 days of SSP assessment clinic Post colonoscopy clinic or telephone clinic to be offered within 21 days – results

The Screening Centre The SSP is the 1st face of the screening pathway for the patient The Screening Centre is based in Secondary Care setting at Blackpool Victoria Hospital The Assessment clinics are based in appropriate locations to cover the wide area of the programme The Colonoscopy lists are within the 4 Accredited Hospital sites.

SSP Clinics – 9 per week Burnley Hospital Barbara Castle Way PCC, Blackburn Healthport Clinic Fulwood, Preston Eccleston Health Centre, Chorley Ashurst Clinic, Skelmersdale Blackpool Victoria Hospital Fleetwood Hospital Lytham PCC

The Role of The SSP Qualified Nurses providing Nurse Led service Establishment to cover Central Lancashire, East Lancashire, Blackburn with Darwen, Blackpool & Fylde and part of North Lancashire Role Pre-assessment of patients Intra-procedure Post-procedure

Nurse-Led Assessment Clinic 45 minute appointment Discuss the implications of a positive FOB Assess patient: Medically fit for colonoscopy Medically fit for bowel Prep Medically fit for sedation Obtains consent / starts consent process Offer Colonoscopy appointment SSP may need further information about a patient from notes, clinical specialist and GP 1 in 10 a cancer , 4 in 10 polyps, 5 in 10 normal

Colonoscopy Appointment 8 colonoscopy lists per week SSP attends colonoscopy and supports patient Data to be documented during colonoscopy Ensures Quality Assurance Standards SSP informs patient of findings Cancer suspected – suppport pt

Pathways Colonoscopy NAD Polyp Other pathology Recall 2 years Refer/treat /advise Cancer Refer MDT High Risk >5 adenoma or >3 adenomas at least 1 >1cm Intermediate Risk 3 or 4 small adenoma or 1>1cm Low Risk 1 or 2 small adenomas FOBt in 2 years <70 3yr col surveillance until 2 neg Col after 12 months then 3 yearly col Until 2 neg

Post Procedure/Follow up care Following day phone call after colonoscopy Once Histology results received, follow-up planned and verified with colonoscopist Nurse-Led Follow–up appointment arranged Surveillance Colonoscopy within the BCSP May need booking for further procedure, large EMR, site check of polyp site If failed colonoscopy, repeat if due to prep; book CTC if due to looping etc

Cancer Diagnosis Discuss findings with patient Initiate staging investigations (CT / MRI) Contact CNS and hand over patient Refer to MDT Co-ordinator Referral Pathways to 8 Trusts established

Cancer in polyps Experienced SSP will inform of diagnosis Attendance at MDT meetings Attendance of LJMU SSP Course Advanced Communication Course Local BCSP Training and competence in Breaking Bad News

National Comparisons in Dukes staging of cancers Symptomatic Pts Dukes A = 13% Dukes B = 38% Dukes C = 49% Screening Pts Dukes A = 48% Dukes B = 25% Dukes C = 27% This is reflected in our local figures, does this reflect anyone elses figures? This is great for the screening pt but also by providing the BCSP service and getting pts an the early stage of Dukes A we are saving the Trusts and PCTs so much money To treat a pt with Dukes A is just over £7,000 compared to an advanced Dukes C which is over £17,000

Development of Service Inclusion of prisoners Increase uptake especially in ethnic minority groups/deprived areas/learning disabilities LPMDM FIT test

Bowel Scope Screening

WHY? 2/3 of CRCs and adenomas are located in the rectum and sigmoid colon – which can be examined by flexible sigmoidoscopy, a well accepted, safe and quick test Professor Wendy Atkin and a team of researchers tested the hypothesis that ‘only one flexible sigmoidoscopy screening between 55 and 64 years of age can substantially reduce cancer incidence and mortality’

Bowel Scope Screening One-off FS examination for all 55 year olds Complements FOB programme Home self-administered phosphate enema Unsedated 5 minute procedure Aim to reach SF but low threshold for stopping if discomfort Remove polyps <10mm, defer larger polypectomies Refer for colonoscopy if 1 large of 3+ small adenomas

Lancashire B/Scope Roll Out Currently 4 lists at BVH – commenced Feb 2014 Currently 3 lists at ELTH commenced November 2016 Currently 1 list at LTH commenced November 2016 ongoing discussions

Conclusion Bowel Screening very cost effective 20- 30% reduction in mortality Screening Cancers Detected at Early Stage Promotion of the BCSP is important to improve uptake Target low uptake areas – deprived areas BCSP develops according to research

Lancashire BCSP Team