What’s New in Colorectal Cancer Diagnostics October 2014

1. What’s New in Colorectal Cancer DiagnosticsOctober 2014 Ed Seward Consultant Gastroenterologist ppppppppppppppppppppp

2. What’s New in Colorectal Cancer DiagnosticsOctober 2014 TOPSECRET! Ed Seward Consultant Gastroenterologist ppppppppppppppppppppp

3. Key Learning Points • Bowel Scope • The rationale • The data so far • Bringing it to North London • Straight to test • Why the need • National drivers • What it means to you and your patients

4. Bowel Scope Atkin WS, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010;357:1624–33 55-64 yrs, n=113,195 Median follow up 11 years Reduction in colorectal cancer 33% Reduction in mortality 43%

5. David Cameron drops a bomb shell on Andrew Marr show October 2010

6. This was no laughing matter!

7. Bowel Scope Jan 2011 Pathfinder sites established Apr 2011 Flexi sig programme approved 2012/3 First pilot site starts screening 2013/4 First wave sites roll out, 36% coverage by Mar 2014 Mar 2015 Second wave enrolment complete, 2/3 coverage 2016 Roll out complete

8. Bowel Scope data so far Invites sent out so far 37,346 Self refer 170 Responded 17,478 Attended for bowel scope 12,295 Number of flexis 12,192 Colonoscopies following flexis 480 (3.94%)

9. Bowel Scope data so far Cancers 8 High risk 74 (>5 polyps, or 3 plus 1 >1cm) Intermediate risk 128 (>3 polyps, or 1> 1cm) Low risk 170 (1-2 polyps <1cm) Abnormal, not polyps 4,718 Normal 6,863 i.e. significant pathology 200/12,000 cases

10. Bowel Scope: Is it achievable? 1.6% population are 55 years old For a 500,000 population, that’s 8000 flexis pa 160 flexis per week This is an additional 8 lists/week (assuming 50% uptake), as well as an additional screening colonoscopy list/wk assuming a 5% referral rate

11. Bowel Scope: Is it achievable? Massive workforce implications Massive infrastructure demands Massive bureaucratic demands

12. Bowel Scope: Is it achievable….., maybe? UCLH on track, just, to roll out March 2015 Slow roll out initially 1 list/week Building up over 18-24 months Watch this space!

13. And now for something completely different… Straight to test pathway for colorectal symptoms

14. What the Royal College wants… Beverley Chalmers is a 62-year-old librarian. She is married with two grown up children and three grandchildren. She says her marriage has been going through a particularly ‘difficult patch’ since her husband lost his job two years ago and markedly increased his alcohol consumption. She would like to retire but is concerned over finances. She consults you with symptoms of weakness and fatigue. She has lost 5kg in the last six months with no obvious cause. You ask about Beverley’s gastrointestinal (GI) symptoms: she has had constipation on and off for a number of years, with occasional bloating which she attributes to ‘wind’. She saw you 12 months ago with a single episode of rectal bleeding and you noticed a small external haemorrhoid. The bleeding settled after conservative treatment. Beverley is stressed by changes at her library (a new supervisor is ‘making life difficult’ for her) and by the relationship difficulties in her marriage. She is also concerned about her 12-year-old granddaughter’s behaviour – she is missing school and not telling her parents where she is. Over the last three months Beverley has become a little breathless – she first noticed this when climbing the stairs at work. She has mild rheumatoid arthritis. A locum in the practice recently prescribed a mild diuretic and temazepam (as she was sleeping poorly). She also takes a regular dose of a non-steroidal antiinflammatory drug (NSAID). She has had a normal mammogram within the last 12 months. She has had two invitations, at age 60 and 62, to undertake a faecal occult blood test (FOBT) as part of the screening programme; the first was negative and she declined the second. There is no family history of note. Beverley has never smoked, and drinks only on rare social occasions. On examination she has mild clinical signs of anaemia. Her BP is 130/70, lungs are clear. Abdominal examination is essentially normal. You perform a rectal examination which is also normal, and there is no sign of the haemorrhoid you previously diagnosed. Initial investigations, including an Hb of 7.3 gm/DL, suggest she has iron deficiency anaemia and you commence iron replacement therapy. When you see her on a follow-up visit her tiredness appears to have worsened. She also appears anxious and is very concerned about her poor sleeping. She thinks the iron tablets are making her more constipated. She has lost a further kilogram in weight which she can’t understand. You need to give thought to the next stepsyou will take in investigating and managing Beverley’s symptoms.

15. What the Royal College wants… Beverley Chalmers is a 62-year-old librarian. She is married with two grown up children and three grandchildren. She says her marriage has been going through a particularly ‘difficult patch’ since her husband lost his job two years ago and markedly increased his alcohol consumption. She would like to retire but is concerned over finances. She consults you with symptoms of weakness and fatigue. She has lost 5kg in the last six months with no obvious cause. You ask about Beverley’s gastrointestinal (GI) symptoms: she has had constipation on and off for a number of years, with occasional bloating which she attributes to ‘wind’. She saw you 12 months ago with a single episode of rectal bleeding and you noticed a small external haemorrhoid. The bleeding settled after conservative treatment. Beverley is stressed by changes at her library (a new supervisor is ‘making life difficult’ for her) and by the relationship difficulties in her marriage. She is also concerned about her 12-year-old granddaughter’s behaviour – she is missing school and not telling her parents where she is. Over the last three months Beverley has become a little breathless – she first noticed this when climbing the stairs at work. She has mild rheumatoid arthritis. A locum in the practice recently prescribed a mild diuretic and temazepam (as she was sleeping poorly). She also takes a regular dose of a non-steroidal antiinflammatory drug (NSAID). She has had a normal mammogram within the last 12 months. She has had two invitations, at age 60 and 62, to undertake a faecal occult blood test (FOBT) as part of the screening programme; the first was negative and she declined the second. There is no family history of note. Beverley has never smoked, and drinks only on rare social occasions. On examination she has mild clinical signs of anaemia. Her BP is 130/70, lungs are clear. Abdominal examination is essentially normal. You perform a rectal examination which is also normal, and there is no sign of the haemorrhoid you previously diagnosed. Initial investigations, including an Hb of 7.3 gm/DL, suggest she has iron deficiency anaemia and you commence iron replacement therapy. When you see her on a follow-up visit her tiredness appears to have worsened. She also appears anxious and is very concerned about her poor sleeping. She thinks the iron tablets are making her more constipated. She has lost a further kilogram in weight which she can’t understand. You need to give thought to the next steps you will take in investigating and managing Beverley’s symptoms.

16. What the Royal College wants… 62 lost 5kg saw you 12 months ago with a single episode of rectal bleeding regular dose of a non-steroidal anti inflammatory drug Hb of 7.3 she has iron deficiency anaemia follow-up visit

18. What real life requires… • Do not sit on 2WW criteria • Do not ignore rectal bleeding • Have a low threshold for referral

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21. ICBP: 5 year relative survival: Coleman et al, Lancet 2011

22. Future of GI Services Massive emphasis on early diagnosis for GI cancers (esp lower GI)

23. Straight to test What used to happen GP referral Consultant triage OPD appointment Colonoscopy appointment 8 weeks 6 weeks OPD follow up 3 months 

24. Straight to test What now happens GP referral Nurse telephone assessment Colonoscopy appointment 3 days ?OPD review 2-3 weeks 

25. How does it work? GP makes C&B appointment for any patient with colorectal symptoms Telephone assessment by trained nurse for 20 minutes Proforma and decision algorithm Options are colonoscopy flexible sigmoidoscopy CT pneumocolon clinic 

26. The Process Patient assessed by a doctor or specialist nurse Decision made as to future management Post procedure Data entered into database, outcomes tracked Histology results to GP and patient Patient satisfaction sought with survey monkey Weekly and ad hoc debrief 

27. The Data 313 pts, m=f, mean age 57 60% 18WW, 40% 2WW 85% colonoscopy 7% flexible sigmoidoscopy 8% straight to clinic 3.5% DNA rate (unit average 7%) 4% cancer pick up 6% IBD 43% discharged after endoscopy 

28. The Data Mean time on pathway for 18WW:42 days = 57% saving Mean time on pathway for 2WW: 13.2 days = 50% saving Other savings…patient benefits ..safer ..staff redeployment ..money saved ..improved performance on RTT

29. To recap… • Bowel scope will offer every 55 year old an opportunity to be screened for polyps and cancer • It’s a huge undertaking, but benefits are evidence based • We owe our patients greater and more timely access to lower GI investigation • New diagnostic pathways are necessary to manage the huge endoscopic requirements

30. Interested…? edward.seward@uclh.nhs.uk