1. Direct Access Colonoscopy Service (DACS)
Dr Rob Palmer, C&H CCG Gastro Lead
Dr Ellie Hitchman, C&H Cancer Lead
Dr Nora Thoua, Consultant Gastroenterologist, HUH
A pilot scheme that will be started in April

2. Background
Bowel cancer is the UK's second biggest cancer killer and the fourth most common cancer
Colorectal symptoms are common in the population, and the majority of patients with symptoms do not have colorectal cancer 

3. Nationally, only 6.4% of 2ww referrals lead to a cancer diagnosis
At the Homerton, the 2012/13 data showed that of the colorectal cancers diagnosed
35% were via a 2ww referral
28% were via an A&E presentation
The remaining 37% were via routine referrals

4. Bowel cancer 5 year relative survival rates and percentage of cases by Dukes’ Stage at diagnosis, England (CRUK bowel cancer survival statistics)
Duke's stage at diagnosis
Percentage of cases
Five-year relative survival A
8.7%
93.2% B
24.2%
77.0% C
23.6%
47.7% D
9.2%
6.6%
Unknown
34.3%
35.4%
Relative survival = relative to the rest of the population (takes into account the fact that the person may have died even if they did not have bowel ca)
Bowel ca v treatable if diagnosed early

5. The local picture
City & Hackney has a lower incidence of bowel cancer than the national average (39.3 per 100,000 vs 46.5 per 100,000, NCIN E-atlas)
We have a slightly higher incidence of right sided cancers than the national average
However the proportion of colon and rectal cancers which present at stage 4 (already metastasised) is high

7. If we can influence the stage at diagnosis this may translate into increased survival for our patients
The new service aims to help decrease “routine” waiting time for our “low risk but not no risk” patients

8. Plans to improve early diagnosis
Public health approaches:
awareness campaigns eg Be Clear on Cancer
National screening:
Bowel cancer screening
FOB testing for year olds
Over 75s can request a kit
Bowelscope programme – one off flexi-sig at 55, planned to start at Homerton early 2015
The NHS England: Best Practice Commissioning Pathway for the Early Detection of Colorectal Cancer

9. CRUK are currently piloting approaches aimed at increasing uptake of bowel cancer screening in NE London:
Advertising
A flyer from CRUK with the test kit
An “enhanced” test kit, with more information, gloves etc

10. Approaches aimed at changing GPs’ referral behaviour, to increase rates of investigation at an earlier stage, and to offer colonoscopy sooner
Changing 2ww criteria to widen net (changes to apply to hospitals in the London Cancer area – North and East London)
GP direct access to diagnostic endoscopy “straight to test”

11. New 2ww criteria for Suspected Colorectal Cancer
Rectal bleeding with change of bowel habit towards looser stools of ≥ 3 weeks duration (age 40 and over) [previously >6w]
Rectal bleeding without change in bowel habit with no obvious cause ≥ 3 weeks duration (age 50 years and over) [previously aged >60y with sx >6w]
Change of bowel habit with tendency towards looser stools persisting for 3 weeks or more without bleeding (age 50 years and over) [previously aged >60y with sx >6w]
Abdominal mass thought to be large bowel cancer (any age)
Palpable rectal mass (any age)
Unexplained iron deficiency anaemia
Males of any age with Hb ≤ 110; Ferritin ≤30; MCV ≤ 79
Non menstruating female with Hb ≤ 100; Ferritin ≤30; MCV ≤ 79
Other high clinical suspicion of colorectal cancer
Not yet launched – need final IT stuff to be worked out within the CCGs

12. Transforming Cancer Services for London (part of NHS England)
Recommended increased access to colonoscopy and flexible sigmoidoscopy for “low-risk but not no risk” patients
CCGs to determine most appropriate service provision for their patients
Flexi-sig pathway already available in C&H, so colonoscopy service commissioned to complement this
Age criteria go beyond those initially recommended by TCSL

14. DACS Inclusion Criteria
Aged (essential)
Presents with:
New alteration in bowel habit (towards diarrhoea) >3w
Altered bowel habit and rectal bleeding (any duration)
Rectal bleeding alone if aged >55
Strong family history of colorectal cancer (colonoscopy recommended at age if asymptomatic)*:
CRC in 1 FDR aged <50y
CRC in 2 FDR of any age
A lot of overlap with new 2ww criteria
Go to BSG webiste: colonoscopy in high risk groups for more details

15. Exclusion Criteria Mental health problems or dementia
Recent MI or CVA within 8w
eGFR <30
Obesity (weight >135kg)
Had full colonoscopy within last 2y
CPs at rest
Colonoscopy esp through BCSP

16. Medical Considerations
U&Es within last 3m
esp if comorbidities (CKD, DM, CVD)
Medications:
Iron tablets – stop 7d before
Aspirin – ok to continue
Clopidogrel / warfarin – safe to stop 10d before?
Diabetics on insulin:
Get advice from diabetes centre

17. The GP Consultation Refer for DACS appointment
Directly bookable through C&B
 Diagnostic Endoscopy  Colonoscopy  Homerton
Print and give patient the Patient Information Leaflet on Colonoscopy
Found on City and Hackney CCG website and on Homerton website 
Highlight need for dietary changes in 48hrs prior to procedure and timing of taking bowel prep 
Prescribe Moviprep 2 sachets and  give to patient
instructions on when to take found on patient information leaflet
Tuesday afternoon

18. The GP Consultation Complete City and Hackney DACS Referral Form
ESSENTIAL – REFERRALS WILL BE REJECTED UNLESS REFERRAL FORM COMPLETED (as this acts as checklist that all above measures have been done) 
Advise patient that they need to have an adult available to accompany them home
PREFERABLE – UNABLE TO RECEIVE SEDATION UNLESS ESCORT AVAILABLE

20. On the Day of the Procedure
Patient attends for procedure at appointment time (with relative available to accompany them home after sedation)
Admitted by nursing staff, observations, get changed
Brief history and consent form by Endoscopist
Procedure with sedation
Detailed report to GP, patient and hospital notes
Patient advised not to drive, return to work, use machinery for 24hrs

21. After the Procedure
All patients discharged back to GP care, except if diagnosis of:
colorectal cancer (added to lower GI MDM)
IBD (referred to Gastro clinic)
adenomatous polyps (to be removed at the time and added to polyp surveillance (1, 3 or 5year time)
If biopsies taken, results to be reviewed in a paper clinic 2-3 weeks later and communicated to GP and patient with guidance on appropriate action

22. New 2 week wait forms Look out for these!
We will have new 2ww forms for most cancers
A few have slightly different referral criteria
We will cascade these through the CCG when they are ready to be integrated with EMIS

23. They highlight the different choices of hospitals for the different referrals
For more information on comparing the services at different hospitals go to:

24. CRUK Primary Care Engagement Facilitator
Ben Tunstall has just started as the City & Hackney Primary Care Engagement Facilitator
1 year post
Working closely with GP practices to look at strategies to improve early diagnosis of cancer
Support with risk assessment tools, looking at GP practice profiles, audit and significant event analysis