1. The Bowel Cancer Screening Programme in West Herts
Alistair King
Consultant Gastroenterologist

2. ANDRÉ PICARD
From Saturday's Globe and Mail
LONDON — John Dobson prides himself on the healthy lifestyle that has left him lean and fit at 70. He is an avid walker and non-smoker. He eschews the greasy, meaty British diet in favour of one rich in fruits and vegetables. And he lives in one of the most pristine parts of England so he can breathe the fresh sea air.

3. So when he received an invitation from the British National Health Service to participate in a bowel-cancer screening program, Mr. Dobson was only too happy to join in. An avid diarist, he noted it in the black, spiral notebook he keeps handy. Little did he know it was the beginning of a life-altering journey.

4. Luckily for Mr. Dobson, the cancer journey in Britain has a good road map, with clear goals, standards and wait guarantees. Diagnosis and treatment are done quickly, and the quality is excellent all over the country.
Mr. Dobson dutifully completed the fecal occult blood test -- which detects minute traces of blood in stool -- and mailed it off on Sept. 6. "It's a messy affair, but easily got over," he says with a laugh.

5. A week later, a letter arrived, saying test results were "abnormal" and urging Mr. Dobson to undergo a colonoscopy. He met with a nurse to discuss the procedure and booked an appointment.
On Sept. 29, he underwent a colonoscopy, watching the test -- in which a flexible, camera-equipped tube is guided into the colon as a means of looking for potentially cancerous polyps -- on a video screen. "Some people would be squirmish, but I was fascinated

6. Fascination turned to fear when the gastroenterologist, snaking the tube around the bends, arrived at the caecum, the pouch at the beginning of the large intestine, where he detected a large growth.
"The good professor said it looked malignant," Mr. Dobson recalls. "Cancer."

7. Laboratory tests confirmed the unexpected diagnosis a few days later
Laboratory tests confirmed the unexpected diagnosis a few days later. A CT scan (a 3-D X-ray) showed the cancer had not spread beyond the bowel.
On Oct. 12, Mr. Dobson met with the oncology surgery team.
After a discussion of his options, he booked a date to go under the knife. On Oct. 23, at Norfolk and Norwich University Hospital, about a third of his bowel was removed.

8. Leafing through the diary, he notes that the whole process, from simple screening test through to complex cancer surgery, took only six weeks. It is a speediness of care Canadians can only dream of.
Moreover, he was accompanied through the entire cancer journey by a single nurse, ensuring co-ordinated, consistent, quality treatment. Her role was to serve as an educator and an advocate as Mr. Dobson tried to navigate the complex health system.
"She guided through every step and answered every question. There was no bull about it," he says. "I can't fault anything at all in the process. It was brilliant."

9. Bowel Cancer Screening Programme
National screening programme
1st involving men!
60-69yr olds sent FOB test every 2 yrs
Sent back to ‘hub’
Positives advised to have colonoscopy- at screening centre
‘Roll out’ programme- currently 2nd wave

10. FOBT
We send 60-69yrs data to ‘hub’ (Nottingham) with plan for roll out
Hub send out explanatory letter 1 week before FOB test
59% kits returned
70+ age group can ask for test kits
2% abnormal – notified within 10 days + booked into our SSP clinics

11. Specialist Screening Practitioner (SSP)
Specialist nurse
Web based booking (from the hub)
To see patient within 10 days
Counselling + assessing fitness
Stays with the patient throughout their ‘journey’
Rings pt 24hrs post colonoscopy
Follows up polyps

12. Colonoscopy Dedicated lists with accredited screening colonoscopists
Details collected by SSP
11% cancers Cancer CNS + MDT
30% polyps follow-up SSP
Normal back onto FOBT programme

15. Benefits of being a centre
Prestige
Ensures survival of unit
Retention of colorectal surgery
Waiting lists
Money!
92p per head of population
x529,000 = £486,000 = £40,000 per month

16. The WHHT bid Feb 2007 Set to start 1/9/2007 Hemel as screening site
Screening colonoscopists
Sue Catnach
Bruce Macfarlane
Ralph Graham

17. The screened population
West Herts population 529,011
Eligible population (p) 46,111
Y1 invitations (p/2) 23,056
2% Abnormal
Colonoscopy ref 277
Yr 1
Yr 2
Colons/wk

19. What do we need to do? Waiting lists JAG visit Colonoscopists
<6weeks routine <2weeks urgent
JAG visit
Quality, access, training
Colonoscopists
‘Driving test’
Organisation
Implementation Group

20. Waiting Lists Standard requests OK BUT: (May 2007- Hemel only)
243 ‘surveillance’ colonoscopies >6 wk deadline
Extra Lists (would need 50!)
Backfilling
Validation

21. The Validation Exercise
Notes reviewed for all ‘recall’ colonoscopies (AK, SC, RH, AA)- FH, polyp f/u, post CRC
‘Validated’ against BSG guidelines
40% cancelled, 19% deferred
Patient and GP written to
Extremely effective (24371 pts) BUT
Also good medicine

22. The next step Inspection by JAG Oct 2007 Start BCSP before end 2007
Hub starts sending out FOBTs
Information packs to GPs 1 week before
Posters in surgeries etc
‘Discernible, albeit modest’ impact on primary care workload
Paperwork, administration, information to patients

23. Faecal Occult Bloods Sensitivity 55-92% Specificity
Not for symptomatic patients- Ix on merit
False reassurance
Specificity
11% CRC even in 60-69yr group
Obvious bleeding (piles), upper GI, diet etc
Often leads to ‘inappropriate’ investigation

24. BSG 2005

25. FOBT- individuals v population
No evidence of benefit outside of BCSP
Pts should be investigated on own merits
Good evidence for benefits in BCSP
We know we are missing up to 50% cancers!
15% reduction in bowel cancer deaths
Overall population benefit