Bowel Cancer Screening Programme Cheshire and Merseyside NHS North West

1. Bowel Cancer Screening ProgrammeCheshire 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 • 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).

4. 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

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 • Chair Based Exercise • Reach for Health Scheme • Warrington Partnership for Food and Health Initiatives • Healthy Weight Strategy • Food and Health Plan • Food and Health Workers

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

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

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

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

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

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

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

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

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

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

18. Diagram of the Bowel

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

20. Bowel Cancer Screening Pilot • 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 • BCSP can reduce mortality (deaths) by 16% in the population invited for screening

21. Nottingham studyStage shift Hardcastle, 1996

22. Health Inequalities of the BCSPPilot • 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. Health Inequalities of the BCSP • 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

24. Responsibility for the BCSP • 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

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

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

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

29. SHA 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

30. HUB HUB HUB HUB HUB Proposed organisation Overarching Structure: • 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

31. Role of 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

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

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

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). • 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. Model in brief • National hub despatch 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

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