Local Preparedness for Colorectal Cancer Screening

1. Local Preparedness for Colorectal Cancer Screening Stephen Inns Consultant Gastroenterologist Hutt Valley DHB

2. Relevant Experience • Luminal Gastroenterologist with interest in IBD and therapeutic colonoscopy • No direct involvement with Ministry plans for the introduction of CRC screening in NZ • Senior Fellow at University College Hospital London during implementation of UK CRC screening pilot

4. Local Preparedness for Colorectal Cancer Screening • Likely form of screening in NZ • Administrative preparedness • Endoscopic preparedness • Current local resource • Likely increase in requirements • Current Infrastructure Projects • Approach to skills shortage • Preparedness of Ancillary Services

5. Likely form of Screening in NZ • International experience • FOBT is currently the safest and least expensive screening modality (the best estimate of cost is about NZ$2500 per life year saved). • More significantly, it has led to a reduction in CRC mortality that cannot currently be attained by any other preventative measure.(Goodbrand 2008) • Ministry Statement • The initial screening test used in overseas programmes is a faecal occult blood test (FOBT). This is a test for blood in the bowel motions where a small sample of bowel motion is collected and tested for the presence of blood.(www.nsu.govt.nz)

6. Likely form of Further Assessment • Colonoscopy likely to remain first choice • CT Colonography • Current evidence suggests the sensitivity and specificity of CTC is similar to colonoscopy for adenomas >1cm and cancers • Sensitivity for smaller lesions is less, however evidence developing that these lesions rarely progress to invasive cancer

7. Likely form of Further Assessment • CT Colonography • false positives occur in 15% of individuals, • retained stool being misinterpreted aspolyps • diverticular disease that results in a poorly distensiblecolon • not therapeutic • therefore patients have to undergo a further procedure.

8. Administrative Preparedness • Extensive NZ experience with national screening initiatives • National screening unit infrastructure in existence • FOB screening lends itself to mail out screening allowing centralisation of coordination

10. Administrative Preparedness • Need for national administration of local colonoscopic resources • Need for national reporting architecture • Novel IT solutions to facilitate above • eg. Screening database to interact with endoscopy reporting tools at endoscopic assessment centres

11. Endoscopic Preparedness • Local Resource • Likely increase in requirements • Current infrastructure projects • Approach to skills shortage • Global financial crisis and immigration pressures

12. Local Resource • CCDHB • 1700 colonoscopies per year • Currently up to date with waiting times • HVDHB • 960 colonoscopies per year • Currently behind on waiting times but initiatives in place to reduce this, likely to be able to meet waiting times within 1 year • Private Healthcare • Extensive resource in Wgtn region • Less easily quantified

13. Likely increase in requirements • The percentage of participants in the screening groups who completed at least one round of screening ranged from 60% to 78% • For two of the trials (Funen, Nottingham), the Haemoccult slides were not rehydrated resulting in a low test positivity rate (0.8% to3.8%) the test positivity rate for rehydrated slides (Goteborg and Minnesota) was 1.7% to 15.4% • Around 9 in 10 patients with a positive FOB had further testing. • Little information regarding the rate of adenoma detection in screening groups. Likely about 10% of patients requiring 3 to 5 year follow up for anything upwards of 2 surveillance cycles on average.

14. Likely increase in requirements • Extra surveillance workload likely 20 to 30 patients per year • Dedicated 1 FTE colonoscopist performs 6x7x40=1680 colonoscopies per year • Each half day list requires 0.3 to 0.4 FTE endoscopy nurses • With biennial screening this first round positives will be spread over 2 years • Region will require additional 0.5 to 1 FTE colonoscopists and 1 to 2 endoscopy nurses

15. Current infrastructure projects • CCDHB • Refit of existing endoscopy suite • Increasing capacity at Kenepuru • Private facilities • Rumours of expansion • HVDHB • New endoscopy suite to be commissioned 2011

17. Approach to skills shortage • Endoscopist shortage • Vacancy at WPH recently filled • Hutt Hospital to advertise for 0.5 gastro • Increasing interest from UK gastroenterologists regarding immigration • Nationwide initiatives (NZSGE UK “roadshow”) • Possible increase in local training opportunities • 3-6 year lead-in • Nurse endoscopists • 2 year lead-in once nurse has higher degree

18. Approach to skills shortage • Endoscopy Nurse Shortage • Training time anything from 12 to 18 months • Increasing numbers of applicants recently

19. Preparedness of Ancillary Services • Diagnostics • Surgery • Oncology and Radiotherapy • Genetic services, Cancer Society, GPs, other Allied Groups

20. Preparedness of Ancillary Services • As population screening results in earlier cancer diagnosis, expect an excess of colorectal cancers detected initially in the screening groups (~25% increase over 3 years [Funen]) • All four trials reported more early stage colorectal cancers (Dukes A) and less late stage colorectalcancers (Dukes D or Dukes C and D) in the screening groups • At 10 to 13 years the number of CRCs detected in control group approaches that of screening group

21. Preparedness of Ancillary Services • Screening likely to result in 1 to 2 more perforations per year • There may be a reduction in total colorectal cancer incidence through polyp removal and surveillance

22. Surgery and Staging Diagnostics • Expect an increase in operation rates of 25% over first 3 years • May be operating on less advanced disease on average • Likely to return to baseline rates over 10 years and reduce in long term

23. Oncology • Likely increase in workload in first years but increased apparent incidence will be ameliorated by decreased stage • Likely significant decrease in workload over 10 years

24. Genetic Services, Cancer Society, GPs other Allied Groups • Internationally screening has resulted in increased public interest in CRC • Increased rates of colonoscopy outside screening group • All providers of support and information likely to see an unquantifiable increase in requests

25. Can we prepare locally in time for CRC screening?