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

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

Bowel Cancer – The Facts 16,000 deaths per 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

Risk Factors Age Diet Obesity Smoking Excess alcohol Family History

* 07/16/96 High Risk Groups Hereditary non Polyposis Colorectal Cancer (Lynch Syndromes I and II ) Familial Adenomatous Polyposis Syndrome Family History of Colorectal Cancer History of Polyps or Colorectal Cancer Inflammatory Bowel Disease * ##

Family History of Colorectal Cancer * 07/16/96 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 years ? Increased pickup of polyps * ## 6

Symptoms Changes 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% Dukes B 70% Dukes C 33 % Since 85% B/C , overall Survival 40%

Stenosing colonic carcinoma

Early Bowel Cancer <10 % patients with symptoms 50% of patients picked upon screening Early cancer cured in 90%

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

Figure 3 Total number of emergency colorectal cancer cases between 1999 (PSY) and 2004 (SY5). Goodyear, S J et al. Gut 2008;57:218-222 Copyright ©2008 BMJ Publishing Group Ltd.

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

Malignant polyp - Classification

National Screening Programme Started in 2006, rolling out completed end 2009 Based on testing for blood in stools (FOBt) 60 – 74 yrs, older can request FOB Test done in own home, a positive test results in a referral to a SSP Clinic with a view to a colonoscopy

BCSP – organisation

Role of Hub- Rugby To manage call and recall Provide telephone helpline for participants Dispatch and process test kits Send results to participants and GP Book clinic appointment for abnormal test Free line – 0800 707 60 60

Guaiac FOBt testing kit

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

Clinic Sites - Current NHS Blackpool & NHS North Lancashire : Blackpool Victoria Hospital OPD Lytham Primary Care Centre Fleetwood Hospital OPD NHS Central Lancashire: Healthport, Euxton Hall and Ashurst Health Centre NHS East Lancashire: Burnley General Hospital / Clitheroe Hospital NHS Blackburn with Darwen: Livesey Clinic - Blackburn The following sites are now up & running as SSP clinic sites

Specialist screening practitioners

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

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

Endoscopy Units Accreditation JAG approval required for screening Waiting times < 6 weeks Meet stringent patient centred Clinical quality criteria ( GRS) BVH started screening first, Preston, Burnley later

Lancashire bowel cancer screening centre Total population – 1.36 million Aged 60 – 69 initially, age extension 2010 to 74 years 8-9 lists per week Burnley, Preston and Blackpool accredited sites Estimated 1-2 screen detected cancer / week per MDT

National Endoscopy Training Centre at The Mersey School of Endoscopy

Transverse colon sessile polyp

Post EMR t colon polyp

Malignant polyp - Classification

Early carcinoma

April 2008 – Nov 2011 Total Invites – 269,119 Adequately Screened – 147,637 Definitive Abnormals – 2,950 Definitive Normals - 156,859 Uptake – 54.81% Positivity – 2.00%

NHS BCSP – Lancashire Colonoscopy Uptake - 2010 Jan-Dec 2010 Definitive FOB+ patients Attended Colonoscopy Colonoscopy Uptake % Grand Totals 930 920 88.49% 1 National Colonoscopy Uptake Rate for 2010 was 84.14%

NHS BCSP – Lancashire Caecal Intubation Rate Jan-Dec 2010 No of Colons Caecal Intubation CIR % CI with Photo/ Video Evidence CI with P/V Evidence % Grand Totals 984 943 95.83 816 82.93 The National Caecal Intubation Rate (CIR) for 2010 was 96.63%, CIR with Photo / Video Evidence was 91.37% CIR with Photo / Video Evidence Standard 90% Target – 97%

NHS BCSP – Lancashire Adenoma Detection Rate Jan-Dec 2010 Index Colons (IC) IC where Adenomas detected Adenoma detection % Adenoma count Adenoma rate Grand Totals 810 394 48.64 872 1.08 The National Adenoma Detection Rate (ADR) for 2010 was 46.69% The National Adenoma Rate for 2010 was 1.00 Standard: Histologically confirmed adenomas detected in ≥ 35% of screening colonoscopies Target: Histologically confirmed adenomas detected in ≥ 40% of screening colonoscopies

NHS BCSP – Lancashire Patient Comfort During Colonoscopy Jan-Dec 2010 - Total attended tests = 984 Standard: 100% of colonoscopies with a recorded comfort level No discomfort 66 Minimal 566 Mild 211 No discomfort min mild %age 85.67 % Moderate 124 Severe 16 Not entered 1 National Comfort Rate (No discomfort, min mild%) for 2010 was 89.62%

April 2008 – to date Test Kits Definitive Abnormals - 2,950 Definitive Normals - 156,859 Uptake – 54.81% Positivity – 2.00% Procedures Total Colonoscopies – 3,009 Total Other tests - 169 Cancers Detected – 262 = 8.71%

Cancer Staging - April 2008 to April 2011 Jan-Dec 2010 No of Cancers T1 Polyp Cancers A B C/C1 C2 D Totals 213 45 58 41 50 8 11 Stages as % of total cancer 21.13 27.23 19.25 23.47 3.76 5.16

Challenges Increase uptake in low uptake areas Impact of age extension/surveillance Introduction of flexible sigmoidoscopy screening Increased demand for lower GI endoscopy

Flexible sigmoidoscopy One off flexible sigmoidoscopy at age 55 - 64 53% replied agreed to screening, 71% attended for flexible sigmoidoscopy Colorectal cancer incidence reduced by 23%, mortality by 31% ? True uptake ? Endoscopy workload Ongoing pilots, roll out in next 2 – 3 years

Expansion of the BCSP and commitments in the Cancer Outcome Strategy mean that there will be additional intensive pressures on endoscopic activity for the next five years Note: For the historical data the difference between the pink and blue lines largely reflects the current impact of bowel screening on endoscopy

Questions? Thank you