SETTING UP THE SERVICE

1. SETTING UP THE SERVICE BY LYNN TOBIN

2. HOW DID WE GET HERE? ABUNDENCE OF EVIDENCE PROVIDING JUSTIFICATION FOR BOWEL CANCER SCREENING

3. BOWEL CANCER-THE FACTS • THIRD MOST COMMON FORM OF CANCER • SECOND LEADING CAUSE OF CANCER RELATED DEATHS IN THE WEST • USUALLY ASYMPOTOMATIC IN EARLY STAGES • 95% OF COLO-RECTAL CANCERS ARISE FROM ADENOMATOUS POLYPS

4. BOWEL CANCER- THE FACTS IN THE UK 1 IN 20 FEMALES AND 1 IN 18 MALES WILL DEVELOP BOWEL CANCER IN THEIR LIFETIME EVERY DAY 50 PEOPLE DIE FROM BOWEL CANCER THIS EQUATES TO 18,000 DEATHS PER YEAR

5. SYMPTOMATIC PATIENTS DUKES STAGES • DUKES A = 13% • DUKES B = 38% • DUKES C = 49%

6. SCREENING PATIENTS DUKES STAGES • DUKES A = 48% • DUKES B = 25% • DUKES C = 27%

7. C & M DUKES STAGES • DUKES A = 53% • DUKES B = 21.4% • DUKES C = 21.4% • DUKES D = 4.2% • THESE STATS ARE BASED UPON THE FIRST 115 PATIENTS IN THE PROGRAMME BUT WE HAVE HAD 247 CANCERS TO DATE

8. BOWEL CANCER SCREENING PROGRAMME PATIENT JOURNEY 1st nurse clinic appointment letter sent to patient from Rugby Rugby rebook 1st nurse clinic appointment 1st appointment nurse clinic Pre appointment Administrator to phone patient and offer new appointment DNA Attended Cancelled Day of appointment Administrator to phone patient and offer new appointment Patient refuses colonoscopy Listed for colonoscopy Unfit for colonoscopy Nurse to discuss assessment with BCSP clinician Referral for CT ACE Disclaimer Routine screening 2 year FOBT invitation DNA NAD Incomplete colonoscopy Polyps Suspected tumour Other Nurse telephone Clinic Surveillance colonoscopy Colonoscopy GP information fax Referral to local MDT for CT staging. Histology within 1 week. Ba Enema within 2 weeks Referral back to local speciality Screening centre to offer 2nd appointment Routine screening 2 year FOBT Invitation Low risk polyps routine screening 2 year FOBT invitation Intermediate risk polyp repeat colonoscopy 3 yearly High risk polyp repeat colonoscopy 1 year NAD Routine screening 2 Year FOBT invitation Abnormal repeat colonoscopy 3 Yearly surveillance until 2 normal examinations 3 Year surveillance until 2 normal examinations SETTING UP THE SERVICE • PUT OVERALL PATHWAY SLIDE IN HERE

9. SETTING UP CLINICS.CONSIDERATIONS; • HOW MANY CLINICS WILL YOU NEED TO FACILITATE YOUR POPULATION? • WHERE WILL YOU HOLD CLINIC? • IF YOU HAVE A SURGE IN FOBT + DO YOU AVAILABILTY FOR EXTRA CLINICS? • DO YOUR PATIENTS HAVE A CHOICE OF WHICH CLINIC THEY WISH TO ATTEND?

10. WHAT MUST BE IN PLACE BEFORE WE SEE A PATIENT • AGREED PATHWAYS/ PROFORMAS • AGREED MANAGEMENT PLANS FOR PATIENTS WITH COMPLEX CO-MORBIDITY • PGD • TCI PATHWAY • ANTI-COAGULATION POLICY (NEW BSG GUIDELINES) • DIABETIC POLICY • NOMINATED LEADS FOR; • CT • X-RAY • PATHOLOGY • PHARMACY

11. WHAT DO I NEED TO BRING TO CLINIC WITH ME? • PATIENT ASSESSMENT FORMS/LAPTOPS • MOBILE PHONES • PATIENT JOURNEY STORY BOOKS • AGREED HEALTH PROMOTION LEAFLETS • CONSENT INFORMATION LEAFLETS • RELEVENT LOCAL HOSPITAL INFORMATION • C&M HAVE CONDENSED THIS INFORMATION INTO BOOKLETS SPECIFIC TO EACH SCREENING SITE

12. WHO IS INELIGABLE? • IBD PATIENTS ALREADY IN SURVEILLANCE PROGRAMME • BARIUM ENEMA WITH FLEXI SIGMOIDOSCOPY OR COLONOSCOPY WITHIN PAST 2 YEARS • CURRENTLY UNDER TREATMENT FOR COLO-RECATL CANCER OR ALREADY IN SURVEILLANCE PROGRAMME • TOTAL COLECTOMY

13. COMMONLY ASKED QUESTIONS/ANSWERS • WHAT IS MY CHANCE OF HAVING; • CANCER = 1 IN 10 (10%) • POLYPS = 1 IN 4 (40%) • NORMAL RESULT = 1IN 5 (50%)

14. COMMONLY ASKED QUESTIONS/ANSWERS • HOW MANY PEOPLE HAVE ABNORMAL FOBT RESULTS? • 2 OUT OF 100 WILL HAVE ABNORMAL RESULTS SO 98 OUT OF 100 WILL BE NORMAL

15. PROS; NON-INVASIVE CAN DO AT HOME REFLECTS COMPLETE COLON CHEAP AND EASY (£5) COLONOSCOPY £424 CONS; POOR SENSITIVITY AND SPECIFICITY - 10% FOR Ca - 40% FOR ADENOMAS SENSITIVITY 55-92% COLORECTAL CANCERS 10-32% ADENOMAS 12-53% ADENOMAS GREATER THAN 1 CM HOW RELIABLE/EFFECTIVE IS THE FOBT TEST KIT?

16. COMMONLY ASKED QUESTIONS/ANSWERS • IF MY COLONOSCOPY IS NORMAL, WILL YOU DO ANY FURTHER INVESTIGATIONS TO LOOK FOR POSSIBLE EXPLANATIONS OF FOBT POSITIVITY?

17. COLONOSCOPY • INVESTIGATION DATASET • CONSENT • MDT PATHWAYS, REFERRAL FORMS AND PATIENT CONTACT LETTERS POST SUSPECTED DIAGNOSIS USEFUL TO HAVE AT EACH SCREENING SITE. • BCSP STAMPS • POST COLONOSCOPY DOCUMENTATION

18. POST COLONOSCOPY/TELEPHONE CLINICS • IT PROFORMAS • POST INVESTIGATION DATASET • SIGNED/DISCUSSED HISTOLOGY • 8 PATIENTS PER CLINIC WITH 20/30 MINUTE SLOTS (DEPENDING UPON EXPERIENCE OF SSP)

19. MALIGNANT POLYPS. WHO TELLS THE PATIENT? • LIAISE WITH SCREENING CONSULTANT RE; MALIGNANT HISTOLOGY • ASSESS SUITABILITY OF SSP GIVING THE RESULT • BRING THE PATIENT INTO FACE TO FACE CLINIC

20. WHAT THE SSP MUST UNDERSTAND BEFORE GIVING MP DIAGNOSIS; • CLINICAL DETAILS • MACROSCOPIC DESCRIPTION • TYPE OF CARCINOMA • DIFFERENTIATION • RESECTION MARGINS • HAGITT STAGE • KIKUCHI STAGE • NO SPECULATION ON PART OF SSP

21. BCSP CHALLENGES • AGE EXTENSION >74 2010-2014 • 62 DAY TARGET DEC 2008 • THIRD WAVE ACTIVITY, WILL LAST FEW SCREENING CENTRES SLIP INTO 2009/2010 • CAREER DEVELOPMENT FOR SSP