1. QA Director’s Update & NHS reforms
Dr Linda Garvican
QA Director, Cancer Screening Programmes,
NHS South East Coast
NHS
Cancer Screening Programmes

2. Screening and NHS reforms
National Screening Programme Teams  Public Health England
Julietta Patnick, Director of Cancer Screening
Anne Mackie, Director of UK National Screening Committee [all non-cancer screening programmes, and screening policy]
Roles and responsibilities
Quality assurance and standards
New programme implementation
Service specifications
Commissioning Screening Programmes
Established programmes: National Commissioning Board
New programmes: Public Health England
NHS
Cancer Screening Programmes

3. Local Public Health involvement in screening
No Regional Director of Public Health
Director of Public Health in local authority/PHE
No longer in NHS
Health and Wellbeing Boards
Need for some local public health leadership
Practical local implementation issues
Serious incidents
Cancer screening QARC
Funded by PHE or fully integrated?

4. Cervical screening 1 14 day turnaround
Sample taking in primary care to result letter posted first class on day 13
98% target set out in Improving Outcomes – a Strategy for Cancer
Sustainability in smaller labs…
Sussex Pathology Network: centralised hub in Haywards Heath?
West Surrey Pathology Network: Merger of ASPH pathology service and Partnership Pathology?
Even more laboratory consolidation in Kent and Medway?

5. Achievement of 14 day turnaround

6. How sustainable?

7. Cervical screening 2 Introduction of HPV Testing
Triage of low grade abnormalities, from 2011/12
‘Test of cure’ for treated women from 2012/13
Several automated technologies, using the LBC sample
Sentinel sites used Hybrid Capture 2
High volume throughput required for cost effective use of controls

8. Implications Triage All borderline or mild
Result within 14-day turnaround
HPV +ve
Straight to colposcopy
HPV –ve
Routine recall in 3/5 years
Test of cure
Cytology 6/12 post treatment
HPV +ve
Straight back to colposcopy
HPV –ve
Routine recall in 3 years
No annual follow- up for 10 years

10. Commissioning HPV testing
Announced 15 December 2010 in NHS Operating Framework 2011/12, and in Improving Outcomes: a Strategy for Cancer in January 2011
No details on costs or rules of engagement available
Still PCT responsibility to commission screening for 2011/12
No new money…
Deadline for PCT’s operating plans for 2011/12 in early January 
Missed the boat for new financial year…
But
There is national funding for 2 years from April 2011:
Year 1 - £2 per sample screened
Year 2 - £1 per sample screened
All within programme samples: GP & community, clinic, hospital, GUM – not just HPV tested ones, not under 25s and not non NHS
Pro-rata from start date
Includes costs of testing and additional colposcopy

11. NAT COLP QA Workload changes in Colposcopy After HPV
Units seeing pts – 2 mild / 3 borderline
= 120 extra colp / screened
Units seeing – 1 mild / 3 borderline
= 64 extra colp / screened
Test of cure – expect % HPV +ve at 6/12
Extra 12% workload due to cyto –ve/HPV +ve

12. Criteria to bid for national funding
Laboratory must have a minimum workload of 35000
The programme must continue to comply with 14 day turnaround
Colposcopy capacity must be sufficient and sustainable
HPV testing must be subject to QA and EQA
There must be a Pathway Manager – one lead person for each programme with whom National Office and other parties will liaise
Sign off will be by QA and the PCT(s) (not SHA)
National Office will contract with each laboratory for HPV testing through an SLA. Labs will be expected to sub- contract for additional services such as colposcopy and virology and pass on the appropriate portion of funding to those services

13. National ‘to do’ list
Evaluation Report, & Advice to the NHS – from DH in May 2011
Implementation Guide
Primary Care Pack
Patient materials – letters & leaflets
Revised NHSCSP guidelines – ABC, Colposcopy & Histopathology
Evaluation of different technologies
NHS Supply Chain Framework Agreement (Procurement must be subject to the European Procurement Tendering Process)

14. What we need to do in next few months
Formally merge laboratories to reach >35,000…
Develop bids
Consider technology platforms (but prices won’t be available until September)
Address colposcopy capacity issues
Re-write local protocols
Adopt national template leaflets
Educate primary care/sample takers
Identify a Pathway Manager in each laboratory
Amend laboratory systems to cater for new result & action codes

15. New DH standard Acute Contract from April 2011- implications for cancer screening
Cancer waiting times
62 day target for screen detected cancers must be met in 90% of cases, cf 85% for symptomatic 2WW
31 day targets for
First definitive treatment (96%)
Second and subsequent treatments
Surgery (94%) and drugs (98%)
Radiotherapy live from 1 January 2011 (94%)
Breaches of all cancer waits will incur below target levels will incur fine to Trust of 2% of ‘Actual Outturn Value of service line revenue’
Staging data:
Mandatory inclusion in dataset sent to Cancer Registry
Need to ensure recorded at gynae MDM

16. Training sample takers
New training scheme organised by SECQARC
Quality-accredited by Universities of Brighton & Surrey
More course planned for 2011
On-line update scheme
Takes about 1 hour
Updates on changes to programme and what to tell women
Uptake of e-learning high in Kent & Medway but more work needed to raise awareness in Surrey & Sussex
Content reviewed annually - will now need to include HPV testing
BMJ Learning: 6 free CPD modules on cancer screening

17. No news on… Revised protocol for invasive cancer audit
Audit of experiences of young women (<30) with cervical cancer
Next QADs meeting 5 May

18. NHSCSP Audit of Invasive Cervical Cancer, National Report, 2007-2010 DRAFT
6,173 cases of cervical cancer and 21,481 controls,
90% overlap with cancer registry data
Approximately 80% of all cases within screening age-range (25-64). Peak number in women aged 35-39
23% of cases had no stage recorded in audit
45% of cases in women aged are diagnosed with FIGO Stage 1A and 73% of these are treated by cone biopsy.
60% of women > 65 with cervical cancer are FIGO Stage 2 or worse.
About three quarters of cervical cancers are of squamous histology.

19. Attempt to classify women’s screening histories
28% of cases with invasive cervical cancer stage 1A and 28% of those with stage 1B or worse occurred despite apparent adherence to screening guidelines (i.e. their screening history is up to date).
Much higher proportion of population controls complied with the screening guidelines (60%) than cases (28%). They were also more likely to have been screened (13% of controls had no screening history compared to 17% of cancers stage 1A and 23% of those stage 1B+).

20. Colposcopy in ICA
Colposcopy data ‘particularly challenging to collect and the variability in the quality of the data included in this Audit has made its interpretation challenging’
Colposcopy data is of particular interest in women who had a cytology test indicating referral to colposcopy more than 4 months before diagnosis, because it suggests a recurrence of a previously treated cervical abnormality or delay in the diagnostic procedure.
While 69% of all cervical cancers in the Audit had cytology with an action code of suspend, only in 21% (1290 cases) of them was the cytology taken more than 4 months before diagnosis. Complete colposcopy data on this subset of cases is essential to evaluate colposcopy management as part of the Audit.

21. Trent Cancer Registry / NCIN / NHSCSP publication
Incidence has halved and mortality decreased by 2/3 in 20 years
Incidence reduction has levelled off in recent years
North/south divide in both incidence and mortality by SHA and cancer network
Poorer incidence and mortality associated with deprivation in PCT of residence
Some improvement in survival from mid 1980s
82% 86% at 1 yr
62-68% at 5 yrs

22. Map of incidence by cancer network, 2004-8

24. Mortality by cancer network, 2004-8

25. Young women 1 year: 96% at 15-39 cf 52% aged >80
Incidence in women aged increased by 77% between and 2008
Incidence in women aged increased by 29%...
Mortality in these age groups stabilised…
Relative survival much worse in older women:
1 year: 96% at cf 52% aged >80
5 year: 86% at cf 27% aged >80

27. Mortality by age