1. NHSBCSP - guidelines Phil Quirke

2. Why guidelines To meet the needs of the programme To improve outcomes To increase the knowledge base and evolve pathology practice

3. Faecal occult blood screening To determine the importance of the primary pathology found Predicting metachronous disease and follow up Are we missing important groups

4. FOB Haut-Rhin Denis et al 710,000 pop 36% HGD (4.6% in situ) 2.7% invasive 42.9% >1cm 80.3% adenomas 68.7% T 24.6% TV 2.5% V 4.2% Serrated Gut Nov 2007 56 1579-1584 Scottish pilot NHSBCSP 1M pop each 12% HGD (7% Coventry) 43.5% 6+mm 77.2% adenomas Definitely an issue about grading dysplasia more work needs to be done on adenoma types

5. Flexisigmoidoscopy/colonoscopy screening Primary pathology Predict synchronous disease Predict metachronous disease and follow up Are we missing important groups

7. FS & colonoscopy vs FOB Flexisigmoidoscopy/colonoscopy find smaller less advanced lesions (UK FS trial) –HGD 1% –>1cm 3-4% –Advanced adenoma rates 3-7% (agrees with German colonoscopy study Brenner Gut 2007 56 1585-9) FOB larger, more dysplastic lesions –HGD 7-36% –>6mm 43.5% UK NHS >1cm France 43%, Nottingham trial 88%

8. Consistency between programmes Consistent with F/S guidelines Generated using groups that overlapped between the pilots and the F/S trial F/S Williams/Quirke Pilot FOB Carey/Neubold Additional experts Shepherd/Warren

9. Consistency with College and other bodies Involved cancer committee of College and colorectal guidelines and ACGB&I Williams/Quirke BSG pathology committee Warren BDIAP Shepherd Scotland - Carey Wales - Williams

10. Whats important?

11. Currently Size - increased risk of malignancy Type - increased risk of malignancy, further investigation Dysplasia - increasing aggressiveness Invasion - prognosis and further treatment

12. Need to: Determine reproducibility of criteria in routine practice Is it worth doing? Can we improve it?

13. Need to: Collect all data –All screen detected polyps –All screen detected cancers –Computerise –Accumulate follow up –Analyse Would also want all MDS’s for all CRC’s via registries –? Mandatory in new cancer plan

14. Looking for: New features that may be important Discard old non reproducible ones Derive new definitions? Compare conflicting methods –Haggitt –Kikuchi - level of invasion –Ueno - classification by depth microns Confirm importance of site

15. Mandatory for participants: Fill out and return pathollogy proforma on each case Fill out and return College minimum dataset on each screen detected cancer case - 100% EQA participation

16. Proforma

18. Feedback on: Polyp form –Ease of use –Issues IT systems EQA

19. Organisation NHSBCSP Julietta Patnick NHSBCSP pathology committee: –Quirke (Chair),Williams, Carey (QA), Warren, Shepherd (expert opinions),Mapstone (EQA) Regional leads England 10 including above Local screening lead Participating consultants

20. Meetings Main committee twice a year Once a year with regional leads –Policy –QA –EQA Once a year with participants –Proposed changes –EQA discussion

21. Web page

23. Summary Guidelines needed Consistent between types of screening Minimise variability –Invasion –Size –High grade dysplasia Electronic EQA being tested

24. Summary Will generate the largest bank of data on screening in the world Will save lives!

25. Flexisigmoidoscopy detection rates vary between observers

26. Flexisigmoidoscopy adenoma detection rates vary between studies