1. Bowel Cancer and Screening
Dr M T Hendrickse
Clinical Director/ Lead Colonoscopist Lancashire Bowel Screening Centre
Blackpool Teaching Hospitals NHS Foundation Trust

2. Introduction Bowel cancer – basic facts
Screening – development and progress
Results
The future

3. Bowel Cancer – The Facts
16,000 deaths per year from Bowel Cancer
2nd commonest cause cancer death
Over 34,000 new cases/ year
Over 80% occur in over 60s
Lifetime risk 1 in 20

4. Risk Factors
Age
Diet
Obesity
Smoking
Excess alcohol
Family History

5. *
07/16/96
High Risk Groups
Hereditary non Polyposis Colorectal Cancer (Lynch Syndromes I and II )
Familial Adenomatous Polyposis Syndrome
Family History of Colorectal Cancer
History of Polyps or Colorectal Cancer
Inflammatory Bowel Disease * ##

6. Family History of Colorectal Cancer*
07/16/96
Family History of Colorectal Cancer
Screening Controversial
2 or more first degree relatives
1 first degree relative < 50 years
Colonoscopy at 35 – 40 then at 55 years
? Increased pickup of polyps * ## 6

7. Symptoms Changes in bowel habit- particularly to loose stools Bleeding
Anaemia
Abdominal pain
Abdominal mass
* If present - see GP , fast track referral ( not screening)

8. Fast track criteria

9. Staging of colorectal cancer

11. Survival of colorectal cancer
Related to Stage
5 Yr survival Dukes A %
Dukes B %
Dukes C %
Since 85% B/C , overall Survival 40%

12. Stenosing colonic carcinoma

13. Early Bowel Cancer <10 % patients with symptoms
50% of patients picked upon screening
Early cancer cured in 90%

14. Why Screen?
Symptoms occur late years survival for bowel cancer with symptoms 49% Vs >70 % if picked up asymptomatic
16% reduction in mortality from bowel cancer in screening trials
Screening picks up cancers earlier – 48% vs 10% have early curable cancers
Reduction in emergency admissions/ surgery for bowel obstruction

15. Figure 3 Total number of emergency colorectal cancer cases between 1999 (PSY) and 2004 (SY5).
Goodyear, S J et al. Gut 2008;57:
Copyright ©2008 BMJ Publishing Group Ltd.

16. 90 % cancers arise from polyps polyp – cancer 8 – 10 yrs

17. Malignant polyp - Classification

19. National Screening Programme
Started in 2006, rolling out completed end 2009
Based on testing for blood in stools
(FOBt)
60 – 74 yrs, older can request FOB
Test done in own home, a positive test results in a referral to a SSP Clinic with a view to a colonoscopy

20. BCSP – organisation

21. Role of Hub- Rugby To manage call and recall
Provide telephone helpline for participants
Dispatch and process test kits
Send results to participants and GP
Book clinic appointment for abnormal test
Free line –

23. Guaiac FOBt testing kit

24. BCSP - Organisation Centres – (local admin centre Blackpool )
Provide SSP clinics for patients with +ve Fobs, Colonoscopy sites ( Blackpool / Preston, Burnley follow up colonoscopies/ clinics,
Publicise programme locally
Link with Primary care
Link with MDTs

25. Clinic Sites - Current NHS Blackpool & NHS North Lancashire :
Blackpool Victoria Hospital OPD
Lytham Primary Care Centre
Fleetwood Hospital OPD
NHS Central Lancashire:
Healthport, Euxton Hall and Ashurst Health Centre
NHS East Lancashire:
Burnley General Hospital / Clitheroe Hospital
NHS Blackburn with Darwen:
Livesey Clinic - Blackburn
The following sites are now up & running as SSP clinic sites

26. Specialist screening practitioners

28. Colonoscopy Perforation 1/1500 Bleeding 1/200 polypectomy
Death 1/10,000
Only screening test with a mortality
National Office – Best Colonoscopists in the Best centres!!

29. Screening Colonoscopists
> 1000 lifetime experience, caecal intubation rate ( ITT) =>90%, polyp DR > 20 % , minimum 150 per year
Have to pass stringent driving test (failure rate 25 – 40%!) to be accredited.
Committed to min 1 screening list per wk
Six accredited (CG, RH, PSMH, CJS, JS) .

30. Endoscopy Units Accreditation
JAG approval required for screening
Waiting times < 6 weeks
Meet stringent patient centred Clinical quality criteria
( GRS)
BVH started screening first, Preston, Burnley later

31. Lancashire bowel cancer screening centre
Total population – 1.36 million
Aged 60 – 69 initially, age extension to 74 years
8-9 lists per week
Burnley, Preston and Blackpool accredited sites
Estimated 1-2 screen detected cancer / week per MDT

32. National Endoscopy Training Centre at The Mersey School of Endoscopy

33. Transverse colon sessile polyp

34. Post EMR t colon polyp

35. Malignant polyp - Classification

36. Early carcinoma

37. April 2008 – Nov 2011 Total Invites – 269,119
Adequately Screened – 147,637
Definitive Abnormals – 2,950
Definitive Normals ,859
Uptake – 54.81% Positivity – 2.00%

38. NHS BCSP – Lancashire Colonoscopy Uptake - 2010
Jan-Dec
2010
Definitive FOB+ patients
Attended Colonoscopy
Colonoscopy Uptake %
Grand
Totals
930
920
88.49% 1
National Colonoscopy Uptake Rate for 2010 was 84.14%

39. NHS BCSP – Lancashire Caecal Intubation Rate
Jan-Dec
2010
No of Colons
Caecal
Intubation
CIR %
CI with Photo/
Video Evidence
CI with P/V Evidence %
Grand
Totals
984
943
95.83
816
82.93
The National Caecal Intubation Rate (CIR) for 2010 was 96.63%, CIR with Photo / Video Evidence was 91.37%
CIR with Photo / Video Evidence
Standard 90% Target – 97%

40. NHS BCSP – Lancashire Adenoma Detection Rate
Jan-Dec
2010
Index Colons (IC)
IC where Adenomas detected
Adenoma detection %
Adenoma count
Adenoma rate
Grand
Totals
810
394
48.64
872
1.08
The National Adenoma Detection Rate (ADR) for 2010 was 46.69%
The National Adenoma Rate for 2010 was 1.00
Standard: Histologically confirmed adenomas detected in ≥ 35% of screening colonoscopies Target: Histologically confirmed adenomas detected in ≥ 40% of screening colonoscopies

41. NHS BCSP – Lancashire Patient Comfort During Colonoscopy
Jan-Dec Total attended tests = 984
Standard: 100% of colonoscopies with a recorded comfort level
No discomfort 66
Minimal
566
Mild
211
No discomfort min mild %age
85.67 %
Moderate
124
Severe 16
Not entered 1
National Comfort Rate (No discomfort, min mild%) for 2010 was 89.62%

42. April 2008 – to date Test Kits Definitive Abnormals - 2,950
Definitive Normals ,859
Uptake – 54.81% Positivity – 2.00%
Procedures
Total Colonoscopies – ,009
Total Other tests
Cancers Detected – = 8.71%

43. Cancer Staging - April 2008 to April 2011
Jan-Dec
2010
No of Cancers T1
Polyp Cancers A B
C/C1 C2 D
Totals
213 45 58 41 50 8 11
Stages as % of total cancer
21.13
27.23
19.25
23.47
3.76
5.16

44. Challenges Increase uptake in low uptake areas
Impact of age extension/surveillance
Introduction of flexible sigmoidoscopy screening
Increased demand for lower GI endoscopy

45. Flexible sigmoidoscopy
One off flexible sigmoidoscopy at age
53% replied agreed to screening, 71% attended for flexible sigmoidoscopy
Colorectal cancer incidence reduced by 23%, mortality by 31%
? True uptake ? Endoscopy workload
Ongoing pilots, roll out in next 2 – 3 years

46. Expansion of the BCSP and commitments in the Cancer Outcome Strategy mean that there will be additional intensive pressures on endoscopic activity for the next five years
Note: For the historical data the difference between the pink and blue lines largely reflects the current impact of bowel screening on endoscopy

47. Questions?
Thank you