1. Bowel Cancer & Bowel Cancer Screening Education and Awareness Sessions
Men and women have a similar risk of developing Bowel cancer up to the age of 40 but after this rates are higher for men.

2. Bowel Cancer Screening Programme
Maureen Sayer
Health Improvement Practitioner
Cheshire and Merseyside Bowel Cancer
Screening Programme

3. AIMS and Outcomes: Increased awareness of the signs and symptoms of bowel cancer Increased understanding of the Bowel Cancer Screening Programme (BCSP) Increased knowledge on how to support your client group in relation to the BCSP Increased ability of staff to act as health advocates to their client group
Men and women have a similar risk of developing Bowel cancer up to the age of 40 but after this rates are higher for men.

4. Public Health Perspective
Bowel Cancer is the third most common cancer in the UK
Approximately 34,900 new cases p.a
It is is the second largest cause of cancer deaths in the UK (Cancer Research UK, Cancerstats).
Men and women have a similar risk of developing Bowel cancer up to the age of 40 but after this rates are higher for men.

5. Public Health Perspective
In 2004 approximately 16,100 people died from bowel cancer in the UK, 737 deaths within Cheshire & Merseyside
Life time risk of developing Bowel Cancer in the UK is about 1:18 for men and 1:20 for women

6. Who is at risk of developing bowel cancer?
Both men and women
People who-
Take little exercise
Are overweight
Have a diet high in red meat and low in vegetables, fruits and fibre

7. Who is at risk of developing bowel cancer? (continued)
People with a family history (CRC Relatives)
Inflammatory Bowel Disease
Genetics-
Familial Adenomatous Polyposis (FAP)about 1% of cases
Hereditary Non-Polyposis Colorectal Cancer (HNPCC) about 2-5% of cases
Family History Individuals with either one first degree relative diagnosed with Bowel cancer before the age of 45 or two first degree relatives diagnosed at any age. The life time risk increases to 16-25% for men and between 10-15% in women
Diagnoses over 65 can lead to a slightly increased risk
FAP develop 100s or 1000s of polyps in their 20s or 30s and have a 100% chance of developing bowel cancer by their 40s. Prophylactic Colectomy is usually given in their teens or 20s

8. Who is at risk of developing bowel cancer? (continued)
The risk of developing bowel cancer increases with age.
About 80% of people who get Bowel cancer are aged 60 and over

9. Mental Health and Learning Disabilities
Schizophrenia
Recent research shows that people with this condition are at increased risk of developing bowel cancer
Learning Disabilities
Increased risk is linked to obesity, poor diet, lack of physical activity ,exclusion from screening programmes. Mortality is linked to late presentation of symptoms.

10. What are the signs and symptoms of bowel cancer?
Practical Exercise!
Then feedback from groups

11. Bowel Cancer Symptoms
Symptoms lasting 4-6 weeks need to be investigated
Any clients with symptoms should be encouraged to see their GP

12. Bowel Cancer Symptoms Tiredness
Bleeding from the Rectum ( Back passage)
Bright Red or Dark Black blood
Found in or on Bowel Motion ,toilet paper or toilet bowel
Tiredness
Caused by blood loss
Needs investigating

13. Bowel Cancer Symptoms Change of Bowel Habit
Change from your normal pattern
Constipation
Decreased Bowel Motions
Diarrhoea
More frequent Bowel Motions
May alternate

14. Bowel Cancer Symptoms Abdominal or Rectal Pain Abdominal Lump
Needs Investigating

15. Bowel Cancer Symptoms Nausea ( feeling Sick)
Unexplained loss of appetite
Unplanned Weight Loss

16. Bowel Cancer Screening Programme Cheshire and Merseyside NHS North West
Cheshire and Merseyside Consortium are composed of 8 Primary Care Trusts.
Liverpool PCT
Sefton and Southport PCT
Wirral PCT
Knowsley PCT
Halton and St Helens PCT
Warrington PCT
Eastern and Central Cheshire PCT
Western Cheshire PCT
A consortium bid was submitted to the Department of Health in October The Bowel Cancer Screening Local Implementation Group was informed that their bid was successful in April 2006

17. Roll out plan

18. Cancer Reform Strategy Changes
Extending screening from 2010 to year olds
62 day waits to apply – end 2008
Consideration of people in their 50s is next step
Flexi-sig trial results will be available in 2/3 years
Immunological testing and CT colography to be considered in due course

19. Responsibility for the BCSP
Cheshire & Merseyside NHS North West have the lead responsibility for BCSP initially. Thereafter PCT’s will commission the programme.

20. Responsibility of the PCT
Representative identified to attend Primary Care and Health Inequalities Group
Identify suitable venues for the Nurse Led Clinics
Develop a Service Level Agreement with the Bowel Cancer Screening programme at Aintree
Develop Patient Information leaflets

21. Responsibility of the PCT
Publicise Bowel Cancer Screening programme
Identify Groups who may experience Health Inequalities
Hold education sessions for PHCTs
Information provided on PALs telephone service

22. Cheshire & Merseyside BCSP Statistics
Screening population 327,683
Assume 60% uptake based on pilot figures = 196,610 of which,
Approximate 2% will have a positive FOBt = 3,932 of which,
11% of FOBt positive patients will have cancer =433.
35% will have polyps requiring surveillance =1376

23. Duke Staging of CRC on BCSP
Duke A 53% (including malignant polyps)
Duke B %
Duke C 21.4%
Duke D 4.2%
These figures are based upon 115 patients who had undergone surgery at time of audit and had definitive post-operative staging.

24. Bowel Cancer Screening Programme
FOB testing will be offered to all men & women aged yearly.
70+ can request to join the BCSP but have to contact Regional Hub at Rugby on the
FREEPHONE:
Age Extension up to 75 in 2010

25. Organisation in England by March 2007
5 Programme Hubs across England, based on IT Local Service Providers (LSP) undertaking call/recall and lab functions
1 Programme Hub for approx 20 screening centres
Gateshead
Nottingham
Rugby
London
Guildford

26. Role of Midlands and North West Programme Hub
To Manage call and recall for the screening programme
To provide a telephone help line for people invited for screening
To dispatch and process test kits
Send results letters to participants and notify GP
Book the first appointment at a nurse led clinic for patients with an abnormal test result
Coordinate Quality assurance activities

27. Midlands and North West Programme Hub
Invitation letter is sent to participant from Hub.
Participants can opt out of the BCSP by contacting Hub on the free phone –
One week later an FOB screening kit which includes leaflets, sample sticks and a foil lined envelope are dispatched

28. Screening Centres (University Hospital Aintree)
Provide information about the screening programme for the local health community
Promote the screening programme to the
general public in their locality
Provide information and support for local people in completing the FOB test(on referral from the programme hub

29. Screening Centres (University Hospital Aintree)
They will provide nurse led clinics for patients with an abnormal test result.
Arrange colonoscopy appointments for patients with an abnormal test result at either the Royal Liverpool University Hospital ,University Hospital Aintree or Leighton Hospital.
Arrange alternative appointments for patients in whom colonoscopy has failed
Ensure appropriate follow-up or treatment for patients after colonoscopy

30. Faecal Occult Blood Testing Kit
Participants smear the stool sample onto the 2 Squares in the 1st flap indicated on the kit. This is repeated on 2 further days until all 6 Squares are completed
Completed kit is returned by post to Hub within 2 weeks of the 1st sample being smeared on the kit (foil-lined envelope supplied)

31. Results Negative result
Unclear Result (1-4 of the squares are positive)
Spoilt Kit
Technical Failure
Positive ( abnormal) Result

32. Results Patient informed of Faecal Occult Blood Test results by post
Colonoscopy: patient informed of results on
the day
Information about polyps relayed to patient by
telephone clinic or clinic appointment
GP informed of all results, non-responders
and DNAs

33. Screening journey Appointment arranged at Nurse Led Clinic
( Healthy Living Centre Ellesmere Port and St Martins Clinic Chester)
Ellesmere Port) for FOBt positive patients. The patient will receive:
Counselling
A health questionnaire
Information
Consent
Preparation for procedure
BCSP – The Colonoscopy Investigation Leaflet

34. Screening journey (Continued)
Referred to screening provider unit for colonoscopy
Follow-up dependant on procedure results
Normal, sent a BCSP kit in 2 years
Polyps, surveillance by BCSP
Cancer detected cases referred to local Multi Disciplinary Team (local Cancer Team)

35. BCSP Clinical Statistics from September 2006- March 2008
Overall Uptake rate 55%
1268 patients seen in nurse led clinics following FOB positive result
1215 colonoscopies performed
38 patients refused to have colonoscopy (2.6%)
31 patients deemed clinically inappropriate (2.1%)
15 patients had completion barium enema (1%)

36. NEOPLASIA
Total number of adenomatous polyps removed = 1330 (498 patients )
Total number of malignant polyps removed= 21 patients

37. Patient Outcomes
10% patients to have 1 year surveillance (High risk polyps)
18% patients to have 3 year surveillance (Intermediate risk polyps)
60% to return to screening programme with 2 yearly invitation to repeat participation in screening ( Low risk polyps)
12% referred to local MDT for cancer treatment ( 141 patients )

38. Health Inequalities of the BCSP Pilot
Men were less likely to participate in FOBt
Lower uptake in deprived areas.
Black and Racial Minority Communities less likely to participate

39. Potential barriers within BCSP?
Mental Health?
Learning disability?

40. Barriers for patients with Mental Health problems
Lack of awareness about the benefits of screening
Poorer knowledge of health topics
Low self esteem
Lack of motivation
Difficulty in accessing services
Practical issues for completion of the Faecal Occult Blood Test

41. Support individuals with a Mental Health problem to:
How can you help people with Mental Health problem overcome these barriers?
Support individuals with a Mental Health problem to:
Make an appointment with the GP or Practice Nurse at the earliest sign of ill health or disease.
Inform and discuss with the GP or Nurse any signs or symptoms of ill health.
Attend their annual health check at their GP surgery.
Understand what the screening process entails: using easy read format.

42. Barriers for patients with Learning Disabilities/Difficulties
Communication
Recognition of ill health is often difficult .Signs and symptoms for bowel cancer not always recognised
Literacy level
Resources / lack of pictorial easy read information
Practical issues for completion of the Faecal Occult Blood Test

43. Barriers for patients with Learning Disabilities/Difficulties
Lifestyle, behaviours and disengagement
Attitudes of health professionals & NHS administrative procedures . Client group often excluded from screening by Primary Health Care Teams
Perceived difficulty obtaining consent
Family members/carers may not have the skills & knowledge needed about disease

44. How can you help people with LD’s overcome these barriers?
Support individuals with a LD to:
Make an appointment with the GP or Practice Nurse at the earliest sign of ill health or disease.
Inform and discuss with the GP or Nurse any signs or symptoms of ill health.
Attend their annual health check at their GP surgery.
Understand what the screening process entails: using easy read format.
Access support from a LD nurse if required.

45. New Developments
Merseyside and Cheshire Early Detection & Prevention Strategy
Healthy Communities Cancer Collaborative

46. New Developments DVD Developed to meet the needs of
Black and Racial Minorities
Deaf and Hard of Hearing People
Low Literacy
Learning Disabilities

47. New Developments Pictorial Easy Read leaflet
Awareness raising sessions
Anticipatory Care Calendar

48. Purpose of the Anticipatory Care Calendar
Reduce health inequalities.
Provide a sound clinical governance and critical care review mechanism.
Provide care pathways that lead to action.
Improve communication with the multidisciplinary team.
Standardise information/documentation.

49. Purpose of the Anticipatory Care Calendar
Ensure that the legal requirements for documentation are met.
Record patterns in behaviour and symptoms which can be visualised more easily using the monthly chart so that alterations in the client conditions can be viewed on more than one health variable.
Reduce diagnostic overshadowing
Record accurate screening
Provide learning opportunities between teams caring for clients.

51. Any Questions?

52. Contact Details Maureen Sayer Health Improvement Practitioner
Lara Boddy
Cancer Screening Coordinator