QA Director’s Update & NHS reforms Dr Linda Garvican QA Director, Cancer Screening Programmes, NHS South East Coast NHS Cancer Screening Programmes

Screening and NHS reforms National Screening Programme Teams  Public Health England Julietta Patnick, Director of Cancer Screening Anne Mackie, Director of UK National Screening Committee [all non-cancer screening programmes, and screening policy] Roles and responsibilities Quality assurance and standards New programme implementation Service specifications Commissioning Screening Programmes Established programmes: National Commissioning Board New programmes: Public Health England NHS Cancer Screening Programmes

Local Public Health involvement in screening No Regional Director of Public Health Director of Public Health in local authority/PHE No longer in NHS Health and Wellbeing Boards Need for some local public health leadership Practical local implementation issues Serious incidents Cancer screening QARC Funded by PHE or fully integrated?

Cervical screening 1 14 day turnaround Sample taking in primary care to result letter posted first class on day 13 98% target set out in Improving Outcomes – a Strategy for Cancer Sustainability in smaller labs… Sussex Pathology Network: centralised hub in Haywards Heath? West Surrey Pathology Network: Merger of ASPH pathology service and Partnership Pathology? Even more laboratory consolidation in Kent and Medway?

Achievement of 14 day turnaround

How sustainable?

Cervical screening 2 Introduction of HPV Testing Triage of low grade abnormalities, from 2011/12 ‘Test of cure’ for treated women from 2012/13 Several automated technologies, using the LBC sample Sentinel sites used Hybrid Capture 2 High volume throughput required for cost effective use of controls

Implications Triage All borderline or mild Result within 14-day turnaround HPV +ve Straight to colposcopy HPV –ve Routine recall in 3/5 years Test of cure Cytology 6/12 post treatment HPV +ve Straight back to colposcopy HPV –ve Routine recall in 3 years No annual follow- up for 10 years

Commissioning HPV testing Announced 15 December 2010 in NHS Operating Framework 2011/12, and in Improving Outcomes: a Strategy for Cancer in January 2011 No details on costs or rules of engagement available Still PCT responsibility to commission screening for 2011/12 No new money… Deadline for PCT’s operating plans for 2011/12 in early January  Missed the boat for new financial year… But There is national funding for 2 years from April 2011: Year 1 - £2 per sample screened Year 2 - £1 per sample screened All within programme samples: GP & community, clinic, hospital, GUM – not just HPV tested ones, not under 25s and not non NHS Pro-rata from start date Includes costs of testing and additional colposcopy

NAT COLP QA Workload changes in Colposcopy After HPV Units seeing pts – 2 mild / 3 borderline = 120 extra colp / 10000 screened Units seeing – 1 mild / 3 borderline = 64 extra colp / 10000 screened Test of cure – expect 20- 26 % HPV +ve at 6/12 Extra 12% workload due to cyto –ve/HPV +ve

Criteria to bid for national funding Laboratory must have a minimum workload of 35000 The programme must continue to comply with 14 day turnaround Colposcopy capacity must be sufficient and sustainable HPV testing must be subject to QA and EQA There must be a Pathway Manager – one lead person for each programme with whom National Office and other parties will liaise Sign off will be by QA and the PCT(s) (not SHA) National Office will contract with each laboratory for HPV testing through an SLA. Labs will be expected to sub- contract for additional services such as colposcopy and virology and pass on the appropriate portion of funding to those services

National ‘to do’ list Evaluation Report, & Advice to the NHS – from DH in May 2011 Implementation Guide Primary Care Pack Patient materials – letters & leaflets Revised NHSCSP guidelines – ABC, Colposcopy & Histopathology Evaluation of different technologies NHS Supply Chain Framework Agreement (Procurement must be subject to the European Procurement Tendering Process)

What we need to do in next few months Formally merge laboratories to reach >35,000… Develop bids Consider technology platforms (but prices won’t be available until September) Address colposcopy capacity issues Re-write local protocols Adopt national template leaflets Educate primary care/sample takers Identify a Pathway Manager in each laboratory Amend laboratory systems to cater for new result & action codes

New DH standard Acute Contract from April 2011- implications for cancer screening Cancer waiting times 62 day target for screen detected cancers must be met in 90% of cases, cf 85% for symptomatic 2WW 31 day targets for First definitive treatment (96%) Second and subsequent treatments Surgery (94%) and drugs (98%) Radiotherapy live from 1 January 2011 (94%) Breaches of all cancer waits will incur below target levels will incur fine to Trust of 2% of ‘Actual Outturn Value of service line revenue’ Staging data: Mandatory inclusion in dataset sent to Cancer Registry Need to ensure recorded at gynae MDM

Training sample takers New training scheme organised by SECQARC Quality-accredited by Universities of Brighton & Surrey More course planned for 2011 On-line update scheme Takes about 1 hour Updates on changes to programme and what to tell women Uptake of e-learning high in Kent & Medway but more work needed to raise awareness in Surrey & Sussex Content reviewed annually - will now need to include HPV testing BMJ Learning: 6 free CPD modules on cancer screening http://learning.bmj.com/learning/modules.html?action=listLatestModules

No news on… Revised protocol for invasive cancer audit Audit of experiences of young women (<30) with cervical cancer Next QADs meeting 5 May

NHSCSP Audit of Invasive Cervical Cancer, National Report, 2007-2010 DRAFT 6,173 cases of cervical cancer and 21,481 controls, 90% overlap with cancer registry data Approximately 80% of all cases within screening age-range (25-64). Peak number in women aged 35-39 23% of cases had no stage recorded in audit 45% of cases in women aged 25-64 are diagnosed with FIGO Stage 1A and 73% of these are treated by cone biopsy. 60% of women > 65 with cervical cancer are FIGO Stage 2 or worse. About three quarters of cervical cancers are of squamous histology.

Attempt to classify women’s screening histories 28% of cases with invasive cervical cancer stage 1A and 28% of those with stage 1B or worse occurred despite apparent adherence to screening guidelines (i.e. their screening history is up to date). Much higher proportion of population controls complied with the screening guidelines (60%) than cases (28%). They were also more likely to have been screened (13% of controls had no screening history compared to 17% of cancers stage 1A and 23% of those stage 1B+).

Colposcopy in ICA Colposcopy data ‘particularly challenging to collect and the variability in the quality of the data included in this Audit has made its interpretation challenging’ Colposcopy data is of particular interest in women who had a cytology test indicating referral to colposcopy more than 4 months before diagnosis, because it suggests a recurrence of a previously treated cervical abnormality or delay in the diagnostic procedure. While 69% of all cervical cancers in the Audit had cytology with an action code of suspend, only in 21% (1290 cases) of them was the cytology taken more than 4 months before diagnosis. Complete colposcopy data on this subset of cases is essential to evaluate colposcopy management as part of the Audit.

Trent Cancer Registry / NCIN / NHSCSP publication Incidence has halved and mortality decreased by 2/3 in 20 years Incidence reduction has levelled off in recent years North/south divide in both incidence and mortality by SHA and cancer network Poorer incidence and mortality associated with deprivation in PCT of residence Some improvement in survival from mid 1980s 82% 86% at 1 yr 62-68% at 5 yrs

Map of incidence by cancer network, 2004-8

Mortality by cancer network, 2004-8

Young women 1 year: 96% at 15-39 cf 52% aged >80 Incidence in women aged 25-29 increased by 77% between 1998 and 2008 Incidence in women aged 30-34 increased by 29%... Mortality in these age groups stabilised… Relative survival much worse in older women: 1 year: 96% at 15-39 cf 52% aged >80 5 year: 86% at 15-39 cf 27% aged >80

Mortality by age