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.

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

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.

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). 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.

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

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

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

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

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.

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

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

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

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

Bowel Cancer Symptoms Abdominal or Rectal Pain Abdominal Lump Needs Investigating

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

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 2005 . The Bowel Cancer Screening Local Implementation Group was informed that their bid was successful in April 2006

Roll out plan

Cancer Reform Strategy Changes Extending screening from 2010 to 70-74 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

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

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

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

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

Duke Staging of CRC on BCSP Duke A 53% (including malignant polyps) Duke B 21.4% 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.

Bowel Cancer Screening Programme FOB testing will be offered to all men & women aged 60-69 - 2 yearly. 70+ can request to join the BCSP but have to contact Regional Hub at Rugby on the FREEPHONE: 0800 707 60 60 Age Extension up to 75 in 2010

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

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

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 – 0800 707 60 60 One week later an FOB screening kit which includes leaflets, sample sticks and a foil lined envelope are dispatched

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

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

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)

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

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

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

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)

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%)

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

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 )

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

Potential barriers within BCSP? Mental Health? Learning disability?

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

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.

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

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

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.

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

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

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

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.

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.

Any Questions?

Contact Details Maureen Sayer Health Improvement Practitioner maureen.sayer@aintree.nhs.uk Lara Boddy Cancer Screening Coordinator lara.boddy@knowsley.nhs.uk