The Bowel Cancer Screening Programme in West Herts

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

2. 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 the fresh sea air.

3. So when he received an invitation from the British National Health Service to participate in a bowel-cancer 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.

4. 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.

5. 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

6. 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."

7. 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.

8. 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 co-ordinated, 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."

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

10. FOBT • We send 60-69yrs 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

11. Specialist Screening Practitioner (SSP) • 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 24hrs post colonoscopy • Follows up polyps

12. Colonoscopy • 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

15. Benefits of being a centre • Prestige • Ensures survival of unit • Retention of colorectal surgery • Waiting lists • Money! • 92p per head of population • x529,000 = £486,000 = £40,000 per month

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

17. The screened population West Herts population 529,011 Eligible population (p) 46,111 Y1 invitations (p/2) 23,056 2% Abnormal Colonoscopy ref 277 Yr 1 Yr 2 Colons/wk 5 10

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

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

21. The Validation Exercise • 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

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

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

24. BSG 2005

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