Bowel Cancer and Screening Dr M T Hendrickse Clinical Director/ Lead Colonoscopist Lancashire Bowel Screening Centre Blackpool Fylde and Wyre NHS Hospitals Foundation Trust

Introduction Bowel cancer – basic facts Screening – development and progress Results The future

BOWEL CANCER – THE FACTS 16,000 deaths/ yr from Bowel cancer 2 nd commonest cause cancer death Over 34,000 new cases/ year Over 80% occur in over 60s Lifetime risk 1 in 20

RISK FACTORS Age Age Diet Diet Obesity Obesity Smoking Smoking Excess alcohol Excess alcohol Family History Family History

HIGH RISK GROUPS HEREDITARY NON POLYPOSIS COLORECTAL CANCER (LYNCH SYNDROMES I AND II ) HEREDITARY NON POLYPOSIS COLORECTAL CANCER (LYNCH SYNDROMES I AND II ) FAMILIAL ADENOMATOUS POLYPOSIS SYNDROME FAMILIAL ADENOMATOUS POLYPOSIS SYNDROME FAMILY HISTORY OF COLORECTAL CANCER FAMILY HISTORY OF COLORECTAL CANCER HISTORY OF POLYPS OR COLORECTAL CANCER HISTORY OF POLYPS OR COLORECTAL CANCER INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE

FAMILY HISTORY OF COLORECTAL CANCER SCREENING CONTROVERSIAL 2 OR MORE FIRST DEGREE RELATIVES 1 FIRST DEGREE RELATIVE < 50 YEARS COLONOSCOPY AT 35 – 40 THEN AT 55 YRS ? INCREASED PICKUP OF POLYPS

Symptoms  Change in bowel habit- particularly to loose stools  Bleeding  Anaemia  Abdominal pain  Abdominal mass * If present - see GP, fast track referral ( not screening)

Fast track criteria

Staging of colorectal cancer

Survival of colorectal cancer Related to Stage 5 Yr survival Dukes A 90% 5 Yr survival Dukes A 90% Dukes B 70% Dukes B 70% Dukes C 33 % Dukes C 33 % Since 85% B/C, overall Survival 40%

Stenosing colonic carcinoma

EARLY BOWEL CANCER <10 % patients with symptoms <10 % patients with symptoms 50% of patients picked upon screening 50% of patients picked upon screening Early cancer cured in 90% Early cancer cured in 90%

Why screen? Symptoms occur late - 5yrs survival for bowel cancer with symptoms 49% Vs >70 % if picked up asymptomatic Symptoms occur late - 5yrs survival for bowel cancer with symptoms 49% Vs >70 % if picked up asymptomatic 16 % reduction in mortality from bowel cancer in screening trials 16 % reduction in mortality from bowel cancer in screening trials Screening picks up cancers earlier – 48% vs 10% have early curable cancers Screening picks up cancers earlier – 48% vs 10% have early curable cancers Reduction in emergency admissions/ surgery for bowel obstruction Reduction in emergency admissions/ surgery for bowel obstruction

Copyright ©2008 BMJ Publishing Group Ltd. Goodyear, S J et al. Gut 2008;57: Figure 3 Total number of emergency colorectal cancer cases between 1999 (PSY) and 2004 (SY5).

 90 % cancers arise from polyps polyp – cancer 8 – 10 yrs

Malignant polyp - Classification

National Screening Programme Started In 2006, rolling out to complete end 2009 Started In 2006, rolling out to complete end 2009 Based on testing for blood in stools Based on testing for blood in stools ( FOBt) ( FOBt) 60 – 69yrs old invited, age extension to 74 April – 69yrs old invited, age extension to 74 April 2010 Test done in own home, a positive test results in a referral to a SSP Clinic with a view to a colonoscopy Test done in own home, a positive test results in a referral to a SSP Clinic with a view to a colonoscopy

INITIAL PILOT RESULTS 60 % uptake of screening 60 % uptake of screening 2% FOB +ve 2% FOB +ve 90% had colonoscopy 90% had colonoscopy Cancer 10%, % polyps Cancer 10%, % polyps

BCSP – organisation

Guaiac FOBt testing kit

BCSP - organisation Centres – (local admin centre Blackpool ) Centres – (local admin centre Blackpool ) Provide SSP clinics for patients with +ve Fobs, Colonoscopy sites ( Blackpool / Preston,Burnley follow up colonoscopies/ clinics, Provide SSP clinics for patients with +ve Fobs, Colonoscopy sites ( Blackpool / Preston,Burnley follow up colonoscopies/ clinics, Publicise programme locally with Public Health/PCT leads Publicise programme locally with Public Health/PCT leads Link with Primary care Link with Primary care Link with MDTs Link with MDTs

Lancashire BCS centre Admin centre at Blackpool, strongly supported by the Trust /Medical Division Admin centre at Blackpool, strongly supported by the Trust /Medical Division Offices, staffing, training and support. Offices, staffing, training and support. Programme manager, Lead SSP, 4 SSPs, 2 Admin staff Programme manager, Lead SSP, 4 SSPs, 2 Admin staff Clinical and colonoscopist lead, screening colonoscopists, lead radiologist, pathologist Clinical and colonoscopist lead, screening colonoscopists, lead radiologist, pathologist

Lancashire bowel cancer screening centre Total population – 1.36 million Total population – 1.36 million Aged 60 – ,200 Aged 60 – ,200 Assuming pilot projections Assuming pilot projections 5.5 colonoscopy lists per week 5.5 colonoscopy lists per week 2 lists Burnley, 1.5 lists Preston and 2 lists Blackpool; screening started Blackpool April 2008, Preston June 2008, Burnley Jan lists Burnley, 1.5 lists Preston and 2 lists Blackpool; screening started Blackpool April 2008, Preston June 2008, Burnley Jan Estimated 1 -2 screen detected cancer/ week per MDT Estimated 1 -2 screen detected cancer/ week per MDT

Specialist screening practitioners

Clinic Sites - Current NHS Blackpool & NHS North Lancashire Blackpool Victoria Hospital OPD Blackpool Victoria Hospital OPD Lytham Primary Care Centre Lytham Primary Care Centre Fleetwood Hospital OPD Fleetwood Hospital OPD NHS Central Lancs Healthport, Euxton Hall & Ashurst Health Centre Healthport, Euxton Hall & Ashurst Health Centre NHS East Lancs Burnley General Hospital / Clitheroe Hospital Burnley General Hospital / Clitheroe Hospital NHS Blackburn with Darwen Livesey Clinic -Blackburn Livesey Clinic -Blackburn

Colonoscopy Major advantage : diagnostic and therapeutic Major advantage : diagnostic and therapeutic Perforation 1/1500 Perforation 1/1500 Bleeding 1/200 polypectomy Bleeding 1/200 polypectomy Death 1/10,000 Death 1/10,000 Only screening test with a mortality Only screening test with a mortality National Office – Best Colonoscopists in the Best centres!! National Office – Best Colonoscopists in the Best centres!!

Screening Colonoscopists > 1000 lifetime experience, caecal intubation rate ( ITT) =>90%, polyp DR > 20 %, minimum 150 / year > 1000 lifetime experience, caecal intubation rate ( ITT) =>90%, polyp DR > 20 %, minimum 150 / year Have to pass stringent driving test ( failure rate 25 – 40%!) to be accredited. Have to pass stringent driving test ( failure rate 25 – 40%!) to be accredited. Committed to min 1 screening list/ wk Committed to min 1 screening list/ wk 5 accredited (CG, RH,MH, CJS, JS). 5 accredited (CG, RH,MH, CJS, JS).

ENDOSCOPY UNITS ACCREDITATION JAG Approval required for screening JAG Approval required for screening Waiting times < 6 weeks Waiting times < 6 weeks Meet stringent patient centred Clinical quality criteria Meet stringent patient centred Clinical quality criteria ( GRS) BVH started screening first, Preston, Burnley later BVH started screening first, Preston, Burnley later Required great teamwork across the trusts Required great teamwork across the trusts Required development of a New Unit Required development of a New Unit Made possible with huge Trust support Made possible with huge Trust support

Colon anatomy

National Endoscopy Training Centre at The Mersey School of Endoscopy

Transverse colon sessile polyp

Post EMR t colon polyp

Ascending colon polyp 2

Post EMR Ascending colon polyp

Results Results

Results - Uptake and FOB positivity Uptake of screening varies between 48 – 57% ( varies with time and PCT ; same as average of other centres supplied by HUB) Uptake of screening varies between 48 – 57% ( varies with time and PCT ; same as average of other centres supplied by HUB) FOBT +ve rate – 1.88– 2..3% ( also varies with PCT) FOBT +ve rate – 1.88– 2..3% ( also varies with PCT)

Lancashire Uptake Rates 30 th September 2009 NHS NORTH LANCASHIRE 57.97% NHS CENTRAL LANCASHIRE 52.52% NHS BLACKPOOL 49.58% NHS BLACKBURN WITH DARWEN 48.17% NHS EAST LANCASHIRE 53.66% National Average Midlands & North West HUB Average 51.74% 53%

Uptake Trends March – September 2009 Percentage uptake rate North Lancs 55.86%56.87%56.56%57.97% Central Lancs 50.92%51.58%52.05%52.52% Blackpool 48.04%48.44%48.90%49.58% Blackburn with Darwen 44.62%45.56%47.16%48.17% East Lancs 47.43%51.99%53.71%53.66% National Average 52.02%52.80%52.51% 51.74% Hub Average 39.83%52.40% 53.00%

Activity April 2008 – September 2009 Positive Kits = 1,246 Negative Kits = 60,692 Retests = 6,567 Lancs BCSP Overall FOB Positivity 1.82 %

Activity April 2008 – September 2009 SSP Appointments No of 1 st positive assessment appointments = 977 DNA’s (5.5%) = No of Post investigation appointments = 35 DNA’s (6%) = Telephone clinic - follow ups =

Colonoscopy data April 2008 – end Sept examinations by 5 colonoscopists 868 examinations by 5 colonoscopists Varied per colonoscopists Varied per colonoscopists overall completion rate 96.8% (94- 98) overall completion rate 96.8% (94- 98) Average time 29mins, wide range Average time 29mins, wide range Polyp detection 66% polyp retrieval 91% Polyp detection 66% polyp retrieval 91% Cancer detection rate 8 – 12% overall 11.3% Cancer detection rate 8 – 12% overall 11.3% Bowel prep quality > 91% excellent/good Bowel prep quality > 91% excellent/good

Local Results From 25 th April 2008 to 8thApril 2010 > 97% seen in SSPclinics have colonoscopy 1338 Patients undergone colonoscopy 1338 Patients undergone colonoscopy 35% normal or minor diagnosis 35% normal or minor diagnosis ( 799) 54% had adenomatous polyps, 529 intermediate/high risk ( 799) 54% had adenomatous polyps, 529 intermediate/high risk 145 (11%) Cancers found 145 (11%) Cancers found

Cancer Results - staging 145 Cancers 145 Cancers Staging data incomplete in 32 Staging data incomplete in 32 40%Dukes A, 40%Dukes A, 18%Dukes B 18%Dukes B 18%Dukes C 2.0% Dukes D 18%Dukes C 2.0% Dukes D 33 polyp cancers found (23 %) 33 polyp cancers found (23 %)

Comparison of screen detected Vs Symptomatic Cancers at Blackpool Between June 2008 – April 2009, 235 symptomatic and 24 screen detected cancers Between June 2008 – April 2009, 235 symptomatic and 24 screen detected cancers higher proportion males and earlier age in screen cancers higher proportion males and earlier age in screen cancers > 70% screen cancers in sigmoid, Symptomatic cancers throughout colon > 70% screen cancers in sigmoid, Symptomatic cancers throughout colon T1 cancers 29% in screen detected vs 4% symptomatic T1 cancers 29% in screen detected vs 4% symptomatic

Conclusion Bowel screening well established in Lancashire ; Age extension to commence shortly Bowel screening well established in Lancashire ; Age extension to commence shortly Uptake varies ; scope to improve with co – ordination with PCTs and Public health Uptake varies ; scope to improve with co – ordination with PCTs and Public health High pick up rate of polyps and cancers ; similar to clinical trials and Pilot studies High pick up rate of polyps and cancers ; similar to clinical trials and Pilot studies High pick up of early cancers High pick up of early cancers

CHALLENGES Publicise / promote the programme in populations with low uptake Publicise / promote the programme in populations with low uptake Increase in surveillance / colonoscopy capacity Increase in surveillance / colonoscopy capacity Increase no of screening colonoscopists Increase no of screening colonoscopists Fluctuations in demand / 62 day targets Fluctuations in demand / 62 day targets 2010 – increase the target population to 74 yrs 2010 – increase the target population to 74 yrs Change in funding arrangements April 2010 Change in funding arrangements April 2010 QA requirements/ monitoring QA requirements/ monitoring

Cancer Targets BCSP National Office Targets 14 days till FOBt clinic 14 days SSP clinic to colonoscopy DH Cancer Target 62 Day Wait Best practice 7 – 10 days to ssp clinic days to colonoscopy

The FUTURE ? Flexible sigmoidoscopy ? Flexible sigmoidoscopy Different faecal tests – FIT Different faecal tests – FIT Colonoscopy at 60! Colonoscopy at 60! Virtual Colonoscopy Virtual Colonoscopy

Copyright ©1998 BMJ Publishing Group Ltd. Fenlon, H M et al. Gut 1998;43: No Caption Found

THANKS TO: Executive Team at Blackpool Fylde and Wyre NHS Hospitals Foundation Trust Executive Team at Blackpool Fylde and Wyre NHS Hospitals Foundation Trust Cancer Network,Medical Division, Clinical Support, pathology/ radiology, MDTs, Cancer Network,Medical Division, Clinical Support, pathology/ radiology, MDTs, Endoscopy managers/ teams – Blackpool, Burnley, Preston Endoscopy managers/ teams – Blackpool, Burnley, Preston BCS team – Judith, Louise, SSPs Elaine/ Helen BCS team – Judith, Louise, SSPs Elaine/ Helen PCTs /Public Health– East Lancs,BlackburnW Darwen, NHS Blackpool, Central and North Lancs teams PCTs /Public Health– East Lancs,BlackburnW Darwen, NHS Blackpool, Central and North Lancs teams