Perspectives from the Waitemata Bowel Screening Pilot team -The Endoscopic view Paul Frankish Lead Endoscopist

BSP-the endoscopy perspective Can colonoscopy be provided safely and efficiently in a screening programme? What is the impact of the BSP on an existing endoscopy service? What are the particular characteristics of BSP colonoscopies? Conclusions and recommendations

Colonoscopy in BSP -organisational aspects Colonoscopists needed audited completion rates of >90% with mean withdrawal times of >6minutes to enter programme with 100 procedures in prior 12 months No two- tier system of endoscopists Dedicated screening unit with separate governance Programme aims for a minimum 95% colonoscopy completion rate. Failed colonoscopies undergo CT colonography Lead endoscopist provides 3 monthly feedback to endoscopists Fortnightly quality meeting to review complications (patients admitted within 30 days of colonoscopy)

Total procedures to date 6522 Procedures per endoscopist N=28

Percentage of complete colonoscopies per endoscopist

Mean withdrawal time for each endoscopist-standard >6 minutes

% Polyp detection rate for each colonoscopist Mean=76%

BSP colonoscopies 5 colonoscopies per session Aim to complete all therapeutics at the index procedure Mean 3.1 polyps per patient High rate of pathology-adenomas 55% advanced adenomas 30%,cancer 4%

Colonoscopies at WDHB Total BSP colonoscopies 6522 Total non-BSP colonoscopies 8353 Total colonoscopies performed ie 44% of all colonoscopies performed were BSP 18% of all WDHB colonoscopies were outsourced 30% of BSP colonoscopies performed by non- WDHB endoscopists

Number of non-BSP colonoscopies at WDHB

Other Monitoring Indicators Time to colonoscopy <11 weeks=99.3%(95%) Percentage undergoing colonoscopy or CTC =95.8 and 94% in round 2 (>90%)

Endoscopy adverse events 85 patients admitted in the first 3.5 years of BSP (1.2% of total colonoscopies) The most frequent complications included bleeding, perforation, pain and hypotension

Bleeding 49 patients admitted with bleeding 13 were transfused 3 required surgery 6 were rescoped Bleeding rates reduced after 22 cases in year 1

Perforation 7 perforations 2 required surgery 22 patients admitted with pain and no evidence of free perforation on CT etc

Miscellaneous complications Anaphylaxis-1 Hypotension /syncope-3 Vomiting-1 Falls-2

Failed colonoscopies and CTC evaluation in first screening round 20 had CTC as primary investigation-polyp detection rate PDR was only 30% cf 76% in colonoscopy cohort 68 had CTC for failed colonoscopy-PDR was 23.5% increasing to 35% in those with prior colonoscopic polyp removal. In 18 subjects with prior failed colonoscopy who had positive findings on CTC colonoscopy was successful in 17 who had propofol assisted colonoscopy

Conclusions The pilot has met acceptable standards for colonoscopy BSP colonoscopy has a high rate of positive findings and need for therapeutics The role of CTC in a screening programme requires further evaluation It is possible to organise a programme largely within the existing resources of an endoscopy unit Screening colonoscopy in a fully rolled out programme has major resource implications (but at least we “sort of” know what they are)

Recommendations Governance guidelines for a national programme need to be developed to ensure integrity and quality of the programme eg underperforming endoscopists. Registry needs to incorporate individual endoscopist data eg adenoma detection rate plus accurate data on surveillance The programme works well when tasks are entrusted to a defined number of key individuals who decide on endoscopy management eg suitability for screening, consistency of surveillance recommendations and maintenance of endoscopy standards and this should be incorporated in a national programme