1. What’s new in BCSP pathology?
Professor Neil A Shepherd
Gloucester and Cheltenham, UK

2. Sorry – it’s not just BCSP…..

3. To consider how are we doing?
roll-out of age extension and effect on pathology workload
development of flexible sigmoidoscopy screening and effect on pathology workload
diagnostic pathology issues
QA issues

4. Roll out of the BCSP April 2006: call for first wave bids
July : first invitations go out
March : screening centres
April 2007: second wave begins
March : screening centres
April : call for final wave bids
January 2010: all 58 centres open
August 2010: all 153 PCTs in BCSP
Cancer polyp rate is as found in pilot and in Nottingham trial when looking only at age group 4

5. 58 screening centres First Wave Second Wave Final Wave Wolverhampton
Norwich
South Devon
Cheshire & Merseyside
St Marks
South West London
Gloucestershire
Bolton
Tees
South of Tyne
Humber & Yorkshire Coast
Derbyshire
North East London
Solent and West Sussex
University College London
Second Wave
Heart of England
Coventry and Warwickshire
Bradford & Airedale
West London
Cambridge
County Durham & Darlington
Leicestershire, Northampton & Rutland
South East London
North of Tyne
South Yorkshire
Dorset
West Hertfordshire
East & North Hertfordshire
Nottinghamshire
Hampshire
Cumbria & Westmorland
Sandwell & West Birmingham
Somerset
Final Wave
Pennine
Lancashire
Berkshire
North Staffordshire
South Essex
Surrey
Sussex
Bristol & Weston
North Essex
Bath, Swindon & Wiltshire
Bedfordshire
Cheshire
Calderdale, Kirklees & Wakefield
East Kent
North & East Devon
Harrogate, Leeds & York
Peterborough & Huntingdon
West Kent & Medway
Hereford & Worcester
Buckinghamshire
Cornwall
Shropshire
Manchester
Lincolnshire
Oxford

6. Results of BCSP: up to 31 August 2011
attended SSP Clinic ,542
DNA SSP Clinic ,193
attended diagnostic test 124,830
DNA diagnostic test
people with polyps ,377 (44.5%)
cancers found ,283 (8.95%)
Cancer polyp rate is as found in pilot and in Nottingham trial when looking only at age group
exactly the stage shift in cancer (good pathology all important) in cancer that we would expect from pilots, etc 6

7. Uptake national uptake 54.88% national positivity 2.11%
uptake varies from % to 65.28%
London acceptance rate %
national rate without London %

8. Episode outcomes (after positive FOB): latest data available
all rounds
prevalent
incident
cancers
8445
10.04%
6.06%
high risk adenoma
8632
9.94%
7.24%
intermediate risk adenoma
16,716
18.58%
16.15%
low risk adenoma
15,735
15.87%
20.37%
abnormal not polyps
17,478
17.49%
23.06%
polyps no histology
511
0.48%
0.77%
normal
23,307
25.31%
24.43%
no result
2036
2.28%
1.92%

9. Age expansion of the BCSP
July 2008 age expansion of BCSP from 70 to 74 years from April 2010 announced
Sept 2008 early Implementer sites commenced invites to older population
Jan 2010 first wave of age expansion across screening centres
Oct screening Centres inviting older population
BUT slow-down now in age expansion because of problems with endoscopy capacity

10. Age expansion of the BCSP
Key
 expanded
 partially expanded
 not expanded
We have age expanded and, to be honest, we have seen very little change in workload
What is others’ experience?

11. Further developments: Flexible sigmoidoscopy screening
May 2010 Wendy Atkin publishes ‘Flexiscope’ trial results
Oct 2010 PM announces flexi-sig programme to commence
Jan 2011 ‘Improving Outcomes’ strategy for cancer published
April 2011 National Screening Committee approves FS screening

12. Efficacy of a once-only flexible sigmoidoscopy @ 55
After 11 years of follow-up, in people who had the screening:
cumulative incidence, including prevalent cancers detected at screening, reduced by
50% for distal cancers (rectum and sigmoid colon)
33% for colorectal cancer overall
colorectal cancer mortality was reduced by 43%
no sign of a lessening of effect at longer follow-up times
one life saved per 200 people screened? 12 12

13. Timeline for development
2011/12 development year for Flexi-sig
2012/13 piloting of Flexi-sig
2013/14 first wave roll out of Flexi-sig: 30% open by 31 March 2014
2014/15 second wave roll out of Flexi-sig: 60% open by 31 March
2016 roll out complete

14. Current issues 2011/12 problems with adapting BCSS for FS screening
problems with procurement of enemas
hence ‘development year for Flexi-sig’
for you and me, this means a year to develop pathology
capacity to deal with effects of FS
pilots (likely five sites – one per hub) will start in one year’s time

15. Pathfinder sites
3 screening Centres undertaken ‘pathfinder project’ – South of Tyne, Tees and Derbyshire – just completed
testing organisational issues
3 different invitation processes
initial findings available – evaluation report awaited

16. FS Pathfinder sites: 3 sites combined
Trial
total number invited
4022
57,254
number undergoing flexible sigmoidoscopy
1137 (28%)
40 674
cancer found
2 (0.2%)
131 (0.3%)
number of individuals with
≥ 1 adenoma
111 (10%)
4,931 (12%)
total number adenomas
143
~6,200
colonoscopies generated
30 (2.7%)
2051 (5 %)

17. Best and worst Tees, Derby and South Tyne.
Tees: lots of work for BCSP team and endoscopy units for minimal pathology yield
Derby: workload (particularly admin) more than SC had envisaged. Relatively negative patient feedback. Pathology yield not as expected.
South Tyne: ‘A far cry from the gold standard service we offer in BCSP’

18. Flexible sigmoidoscopy
Three pilot sites: South Tyne, Derby & Tees
surprisingly low take-up
pathology not exactly taxing

19. Pathology breakdown: South Tyne
Number of specimens
Tubular adenoma low grade 53
Tubulovillous adenoma, low grade 4
Villous adenoma
Carcinoma
Hyperplastic polyp 68
Inflammatory polyp 8
Mucosal prolapse
Normal colonic mucosa 11

20. What we didn’t see: South Tyne
no cancers
no high grade dysplasia
no villous adenomas
very little big stuff
nothing weird
nothing especially difficult
(small sample)

21. James Henry (pathologist at Gateshead) on South Tyne FS Pathfinder study
all histology received was relatively simple: we didn’t see any cancers in our part of the pilot.
no big or complex polyps removed at first sigmoidoscopy.
however, sigmoidoscopists had been told not to resect anything bigger than 10mm at screening sigmoidoscopy: hence the bias to lesions less than 10mm in diameter (wish someone had told me this before the meeting!).
nothing big, dangly and difficult from the sigmoid on first screen .
biggest issues: finding enough willing sigmoidoscopists
getting the enemas to the subjects (postal regulations) practical issues about second enemas through the scope etc…. (issues that make me glad I’m a histopathologist).

22. The future of FS in BCSP
Julietta is confident that the detection rates are comparable with the Atkin trial
low uptake because of 3 different invitation strategies
patients need a date, time, place and enema in the post!!!
slow down for one year
the workload for pathology may not be as great as was expected
you have one year more to plan your strategy for increased workload, finance, etc

23. The three big issues in BCSP pathology
the introduction of age expansion and flexible sigmoidoscopy and their implications for pathology workload
continuing diagnostic and management issues with those difficult sigmoid colonic polyps, serrated pathology and polyp cancers
QA visits and their repercussions

24. Expert Board Neil Shepherd, Scott Sanders and Marco Novelli
still controversies and difficulties
105 cases referred to Expert Board
Complete agreement between originating pathologist(s) and EB 26
Original diagnosis equivocal but EB diagnosis certain 41
Diametrically opposite diagnosis: originating pathologist(s) and EB 29
Both epithelial misplacement and cancer 5
Too difficult for EB (little or no agreement) 4

25. What issues have arisen in pathology QA for BCSP?
funding
funding for increased workload (eg age extension)
difficulties in data extraction (your hub should do this)
job planning for leads
leads only leading in their own hospital
attendance at MDTM
high rates of HGD
lack of provision of datasets – feedback from SSPs

26. Current ‘dataset’ for polyps in use in South West

27. BCSP Polyp Datasets POLYP 3: SITE - SIGMOID COLON SIZE - 2MM
TUBULAR ADENOMA
COMPLETENESS OF REMOVAL - N/A
DYSPLASIA - LOW GRADE
ADENOMA WITH CANCER - NO

28. Local excisions

29. Resection specimens

30. What issues have arisen in pathology EQA for BCSP?
polyp measurements
protocol for dealing with difficult cases
communication with other staff, esp SSPs
numbers of pathologists doing BCSP work in centres
complying with EQA and education: BCSP update courses
quality markers of cancer resection data for each BCSP pathologist (last 50 sequential cases):
1. median number of lymph nodes harvested
2. rates of serosal involvement for colonic and rectal cancer
3. rate of extramural venous spread for colorectal cancer
4. range of TNM and Dukes stages

31. Where are we with bowel cancer screening in the UK?
so far, so good
polyp and (early) cancer detection rates high
uptake not bad (could be better in bigger cities)
slow roll-out in some centres has meant we can’t ‘advertise’ on a national basis (we can now and you have seen it)
age extension and FS not a huge problem for pathology
a big thanks to you all from Julietta, Phil and the team (and, I’m sure, from our friends in BSW, SBSP, NIBCS)!