The Bowel Cancer Screening Programme in West Herts

The Bowel Cancer Screening Programme in West Herts Alistair King Consultant Gastroenterologist

ANDRÉ PICARD From Saturday's Globe and Mail LONDON — John Dobson prides himself on the healthy lifestyle that has left him lean and fit at 70. He is an avid walker and non-smoker. He eschews the greasy, meaty British diet in favour of one rich in fruits and vegetables. And he lives in one of the most pristine parts of England so he can breathe fresh sea air.

So when he received an invitation from the British National Health Service to participate in a bowelcancer screening program, Mr. Dobson was only too happy to join in. An avid diarist, he noted it in the black, spiral notebook he keeps handy. Little did he know it was the beginning of a life-altering journey.

Luckily for Mr. Dobson, the cancer journey in Britain has a good road map, with clear goals, standards and wait guarantees. Diagnosis and treatment are done quickly, and the quality is excellent all over the country. Mr. Dobson dutifully completed the fecal occult blood test -- which detects minute traces of blood in stool -and mailed it off on Sept. 6. "It's a messy affair, but easily got over, " he says with a laugh.

A week later, a letter arrived, saying test results were "abnormal" and urging Mr. Dobson to undergo a colonoscopy. He met with a nurse to discuss the procedure and booked an appointment. On Sept. 29, he underwent a colonoscopy, watching the test -- in which a flexible, camera-equipped tube is guided into the colon as a means of looking for potentially cancerous polyps -- on a video screen. "Some people would be squirmish, but I was fascinated

Fascination turned to fear when the gastroenterologist, snaking the tube around the bends, arrived at the caecum, the pouch at the beginning of the large intestine, where he detected a large growth. "The good professor said it looked malignant, " Mr. Dobson recalls. "Cancer. "

Laboratory tests confirmed the unexpected diagnosis a few days later. A CT scan (a 3 -D X-ray) showed the cancer had not spread beyond the bowel. On Oct. 12, Mr. Dobson met with the oncology surgery team. After a discussion of his options, he booked a date to go under the knife. On Oct. 23, at Norfolk and Norwich University Hospital, about a third of his bowel was removed.

Leafing through the diary, he notes that the whole process, from simple screening test through to complex cancer surgery, took only six weeks. It is a speediness of care Canadians can only dream of. Moreover, he was accompanied through the entire cancer journey by a single nurse, ensuring coordinated, consistent, quality treatment. Her role was to serve as an educator and an advocate as Mr. Dobson tried to navigate the complex health system. "She guided through every step and answered every question. There was no bull about it, " he says. "I can't fault anything at all in the process. It was brilliant. "

Bowel Cancer Screening Programme n National screening programme n n n 1 st involving men! 60 -69 yr olds sent FOB test every 2 yrs Sent back to ‘hub’ Positives advised to have colonoscopyat screening centre ‘Roll out’ programme- currently 2 nd wave

FOBT n n n We send 60 -69 yrs data to ‘hub’ (Nottingham) with plan for roll out Hub send out explanatory letter 1 week before FOB test 59% kits returned 70+ age group can ask for test kits 2% abnormal – notified within 10 days + booked into our SSP clinics

Specialist Screening Practitioner (SSP) n n n n Specialist nurse Web based booking (from the hub) To see patient within 10 days Counselling + assessing fitness Stays with the patient throughout their ‘journey’ Rings pt 24 hrs post colonoscopy Follows up polyps

Colonoscopy n n n Dedicated lists with accredited screening colonoscopists Details collected by SSP 11% cancers Cancer CNS + MDT 30% polyps follow-up SSP Normal back onto FOBT programme

Benefits of being a centre n n n Prestige Ensures survival of unit Retention of colorectal surgery Waiting lists Money! n n 92 p per head of population x 529, 000 = £ 486, 000 = £ 40, 000 per month

The WHHT bid n n Feb 2007 Set to start 1/9/2007 Hemel as screening site Screening colonoscopists n n n Sue Catnach Bruce Macfarlane Ralph Graham

The screened population West Herts population 529, 011 Eligible population (p) 46, 111 Y 1 invitations (p/2) 23, 056 2% Abnormal Colonoscopy ref Colons/wk 277 Yr 1 Yr 2 5 10

What do we need to do? n Waiting lists n n JAG visit n n Quality, access, training Colonoscopists n n <6 weeks routine <2 weeks urgent ‘Driving test’ Organisation n Implementation Group

Waiting Lists Standard requests OK BUT: (May 2007 - Hemel only) n 243 ‘surveillance’ colonoscopies >6 wk deadline n n Extra Lists (would need 50!) Backfilling Validation

The Validation Exercise n n n Notes reviewed for all ‘recall’ colonoscopies (AK, SC, RH, AA)- FH, polyp f/u, post CRC ‘Validated’ against BSG guidelines 40% cancelled, 19% deferred Patient and GP written to Extremely effective (243 71 pts) BUT Also good medicine

The next step n n Inspection by JAG Oct 2007 Start BCSP before end 2007 n n Hub starts sending out FOBTs Information packs to GPs 1 week before Posters in surgeries etc ‘Discernible, albeit modest’ impact on primary care workload n Paperwork, administration, information to patients

Faecal Occult Bloods n Sensitivity 55 -92% n n n Not for symptomatic patients- Ix on merit False reassurance Specificity n n n 11% CRC even in 60 -69 yr group Obvious bleeding (piles), upper GI, diet etc Often leads to ‘inappropriate’ investigation

BSG 2005

FOBT- individuals v population n No evidence of benefit outside of BCSP n n Pts should be investigated on own merits Good evidence for benefits in BCSP n n n We know we are missing up to 50% cancers! 15% reduction in bowel cancer deaths Overall population benefit