1. Bowel Cancer Screening Programme Cheshire and Merseyside NHS North West

2. Aims and Objectives To provide information about the BCSP To give a Public Health perspective To raise awareness of health inequalities To increase knowledge of Bowel Cancer symptoms

3. Public Health Perspective Bowel Cancer is the third most common cancer in the UK Bowel Cancer is the third most common cancer in the UK Approximately 34,900 new cases p.a Approximately 34,900 new cases p.a It is is the second largest cause of cancer deaths in the UK (Cancer Research UK, 2005. Cancerstats). It is is the second largest cause of cancer deaths in the UK (Cancer Research UK, 2005. Cancerstats).

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

5. 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

6. Warrington PCT Strategy For Sport, Physical Activity and Health In Warrington 2007-2010 Strategy For Sport, Physical Activity and Health In Warrington 2007-2010 Chair Based Exercise Chair Based Exercise Reach for Health Scheme Reach for Health Scheme Warrington Partnership for Food and Health Initiatives Warrington Partnership for Food and Health Initiatives Healthy Weight Strategy Healthy Weight Strategy Food and Health Plan Food and Health Plan Food and Health Workers Food and Health Workers

7. People with a family history (CRC Relatives) People with a family history (CRC Relatives) Inflammatory Bowel Disease Inflammatory Bowel Disease Genetics- Genetics- – Familial Adenomatous Polyposis (FAP)about 1% of cases – Hereditary Non-Polyposis Colorectal Cancer (HNPCC) about 2-5% of cases Who is at risk of developing bowel cancer? (continued)

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

10. Colorectal Cancer an Important Health Problem www.statistics.gov.uk 35,579 new cases in 1999

11. Colorectal Cancer an Important Health Problem www.statistics.gov.uk 16,152 deaths in 2001

12. A persistent change in bowel habit, or diarrhoea for several weeks A persistent change in bowel habit, or diarrhoea for several weeks Rectal bleeding without any obvious reason Rectal bleeding without any obvious reason Anaemia Anaemia Bowel Cancer Symptoms

13. Abdominal pain, especially if it is severe; and a palpable lump in the abdomen. Abdominal pain, especially if it is severe; and a palpable lump in the abdomen. Increased suspicion if symptoms last for four to six weeks. Increased suspicion if symptoms last for four to six weeks. Nausea, anorexia Nausea, anorexia Weight loss Weight loss Bowel Cancer Symptoms

14. Wilson and Jungner Criteria for Population Screening Is it an important Health problem ? Is it an important Health problem ? Is effective treatment available ? Is effective treatment available ? Does the disease have an early or latent stage ? Does the disease have an early or latent stage ? Is there a suitable screening test ? Is there a suitable screening test ? Are diagnostic and treatment facilities available ? Are diagnostic and treatment facilities available ?

15. Wilson and Jungner Criteria for Population Screening Is the Natural History of the condition known? Is the Natural History of the condition known? Is there agreed criteria for who should be treated ? Is there agreed criteria for who should be treated ? Is the programme a continuing process ? Is the programme a continuing process ? Is the programme economically viable? Is the programme economically viable?

16. Why not increase access for Symptomatic patients? 30% of colorectal cancers present as emergencies 30% of colorectal cancers present as emergencies The 2 week rule has had no impact The 2 week rule has had no impact 5% 2 week rule referrals have colorectal cancers 5% 2 week rule referrals have colorectal cancers As yet there has been no shift in Dukes stage As yet there has been no shift in Dukes stage

17. Natural History Adenoma- Carcinoma Sequence Morson 1960s Normal Mucosa Adenoma High Risk Adenoma Carcinoma Prevalence in 50 yr olds 18%4%0.25%

18. Diagram of the Bowel

19. Dukes Staging Diagram 100% 90% 65% 25% 15% 5 yr survival 11% 33% 33% 23% Proportion A=85-95% B=60-80% C=30-60% D=<10% 5 year survival

20. In 2000 the Bowel Cancer screening Pilot began in Scotland (Dundee) and England (Rugby) In 2000 the Bowel Cancer screening Pilot began in Scotland (Dundee) and England (Rugby) Evidence from pilot studies showed that early detection through regular Bowel Cancer Screening has a significant impact upon overall survival rates Evidence from pilot studies showed that early detection through regular Bowel Cancer Screening has a significant impact upon overall survival rates BCSP can reduce mortality (deaths) by 16% in the population invited for screening BCSP can reduce mortality (deaths) by 16% in the population invited for screening Bowel Cancer Screening Pilot

21. Nottingham study Stage shift Dukes stage ABCD Screen20%33%24%21% Controls11%32%31%22% Hardcastle, 1996

22. Health Inequalities of the BCSP Pilot Men were less likely to participate in FOBt Lower uptake in deprived areas. Poor uptake in Black and Ethnic Minority groups particularly Muslims. Ethnic groups more likely to DNA before colonoscopy.

23. Other groups who may experience inequalities – – Learning disabilities/ difficulties – – Blind and Visual impairment – – Deaf – – People with mobility problems – – Illiterate – – Mental illness – – Travellers – – Homeless – – Prison population Health Inequalities of the BCSP

24. Responsibility for the BCSP Cheshire & Merseyside NHS North West have the lead responsibility for BCSP initially. Thereafter PCT’s will commission the programme. Cheshire & Merseyside NHS North West have the lead responsibility for BCSP initially. Thereafter PCT’s will commission the programme. Central budget £10 million first wave, second wave also funded approximately £461K per 500,000 head of population Central budget £10 million first wave, second wave also funded approximately £461K per 500,000 head of population

25. Agreed Model Consortium Approach Consortium Approach Local Implementation Group Local Implementation Group Key stakeholder consensus reached Key stakeholder consensus reached

27. Operationally driven and managed by 1 host Trust.( Aintree) This is the local BCSP administration centre. Operationally driven and managed by 1 host Trust.( Aintree) This is the local BCSP administration centre. Endoscopy nurse-led screening assessment clinics (community) Endoscopy nurse-led screening assessment clinics (community) Agreed Model

28. Quality Assurance Standards Global Rating Scores (Patient experience) Global Rating Scores (Patient experience) Satisfactory Joint Advisory Group (JAG) assessment & visitation Satisfactory Joint Advisory Group (JAG) assessment & visitation Accreditation of colonoscopists Accreditation of colonoscopists Health Promotion and Health Inequality considerations( Uptake, awareness) Health Promotion and Health Inequality considerations( Uptake, awareness)

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

30. Proposed organisation HUB 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 Overarching Structure:

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

32. BCSP Process FOB testing will be offered to all men & women aged 60-69 - 2 yearly. FOB testing will be offered to all men & women aged 60-69 - 2 yearly.

33. 70+ can request to join the BCSP but have to contact Regional Hub at Rugby. 70+ can request to join the BCSP but have to contact Regional Hub at Rugby. BCSP Process

34. Faecal Occult Blood Testing (FOBT) - Guaiac Testing The participant is instructed to smear the stool onto the spots from 2 separate parts of the specimen on three separate days

35. Model in brief Invitation letter is sent to participant from Rugby dispatch centre (HUB). Invitation letter is sent to participant from Rugby dispatch centre (HUB). Participants can opt out of the BCSP by contacting Rugby. Participants can opt out of the BCSP by contacting Rugby.

36. Rugby

37. Administrative Offices

38. Pathology

39. Laboratory

40. Envelope Prepared

41. FOBt Kits

42. Preparing Kit

43. Preparation of Kit

44. Solution Added To Process Kit

45. Results to be checked

46. Normal result

47. Abnormal Result

48. Data base

49. National hub despatch kit Participants smear the stool sample onto the 2 Squares in the 1 st flap indicated on the kit. This is repeated on 2 further days until all 6 Squares are completed Model in brief

50. Screening Journey Completed kit is returned by post to Rugby within 2 weeks of the 1 st sample being smeared on the kit (foil-lined envelope supplied) Completed kit is returned by post to Rugby within 2 weeks of the 1 st sample being smeared on the kit (foil-lined envelope supplied)

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

52. Screening Centres They will provide nurse led clinics for patients with an abnormal test result They will provide nurse led clinics for patients with an abnormal test result Arrange colonoscopy appointments for patients with an abnormal test result Arrange colonoscopy appointments for patients with an abnormal test result Arrange alternative appointments for patients in whom colonoscopy has failed Arrange alternative appointments for patients in whom colonoscopy has failed Ensure appropriate follow-up or treatment for patients after colonoscopy Ensure appropriate follow-up or treatment for patients after colonoscopy

53. Screening Centres Provide information about the screening programme for the local health community Provide information about the screening programme for the local health community Promote the screening programme to the 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 Provide information and support for local people in completing the FOB test(on referral from the programme hub

54. Appointment arranged at Endoscopy Nurse screening assessment clinic if the FOBt is positive. The participant will receive: Counselling A health questionnaire Information Consent Preparation for the procedure Bowel Cancer Screening-The colonoscopy Investigation (leaflet) Screening Journey

55. 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)

56. Role of Primary Care Encourage members of the public to participate in the BCSP Encourage members of the public to participate in the BCSP Provide general information on the BCSP to participants Provide general information on the BCSP to participants Direct inquiries to the national freephone help-line telephone service Direct inquiries to the national freephone help-line telephone service

57. Role of Primary Care Add results to the GP practice IT systems Add results to the GP practice IT systems Encourage patients to complete the whole BCSP process. Encourage patients to complete the whole BCSP process. GP will be notified if patients DNA or opt out of the programme GP will be notified if patients DNA or opt out of the programme

58. Contact Details Maureen Sayer Maureen Sayer Health Improvement Practitioner maureen.sayer@aintree.nhs.uk