NHSBCSP - guidelines

1. NHSBCSP - guidelines Phil Quirke

2. Why guidelines • To meet the needs of the programme • To improve outcomes • To increase the knowledge base and evolve pathology practice

3. Faecal occult blood screening • To determine the importance of the primary pathology found • Predicting metachronous disease and follow up • Are we missing important groups

4. Haut-Rhin Denis et al 710,000 pop 36% HGD (4.6% in situ) 2.7% invasive 42.9% >1cm 80.3% adenomas 68.7% T 24.6% TV 2.5% V 4.2% Serrated Gut Nov 2007 56 1579-1584 Scottish pilot NHSBCSP 1M pop each 12% HGD (7% Coventry) 43.5% 6+mm 77.2% adenomas FOB Definitely an issue about grading dysplasia more work needs to be done on adenoma types

5. Flexisigmoidoscopy/colonoscopy screening • Primary pathology • Predict synchronous disease • Predict metachronous disease and follow up • Are we missing important groups

7. FS & colonoscopy vs FOB • Flexisigmoidoscopy/colonoscopy find smaller less advanced lesions (UK FS trial) • HGD 1% • >1cm 3-4% • Advanced adenoma rates 3-7% (agrees with German colonoscopy study Brenner Gut 2007 56 1585-9) • FOB larger, more dysplastic lesions • HGD 7-36% • >6mm 43.5% UK NHS >1cm France 43%, Nottingham trial 88%

8. Consistency between programmes • Consistent with F/S guidelines • Generated using groups that overlapped between the pilots and the F/S trial • F/S Williams/Quirke • Pilot FOB Carey/Neubold • Additional experts Shepherd/Warren

9. Consistency with College and other bodies • Involved cancer committee of College and colorectal guidelines and ACGB&I Williams/Quirke • BSG pathology committee Warren • BDIAP Shepherd • Scotland - Carey • Wales - Williams

10. Whats important?

11. Currently • Size - increased risk of malignancy • Type - increased risk of malignancy, further investigation • Dysplasia - increasing aggressiveness • Invasion - prognosis and further treatment

12. Need to: • Determine reproducibility of criteria in routine practice • Is it worth doing? • Can we improve it?

13. Need to: • Collect all data • All screen detected polyps • All screen detected cancers • Computerise • Accumulate follow up • Analyse • Would also want all MDS’s for all CRC’s via registries • ? Mandatory in new cancer plan

14. Looking for: • New features that may be important • Discard old non reproducible ones • Derive new definitions? • Compare conflicting methods • Haggitt • Kikuchi - level of invasion • Ueno - classification by depth microns • Confirm importance of site

15. Mandatory for participants: • Fill out and return pathollogy proforma on each case • Fill out and return College minimum dataset on each screen detected cancer case - 100% • EQA participation

16. Proforma

18. Feedback on: • Polyp form • Ease of use • Issues • IT systems • EQA

19. Organisation • NHSBCSP Julietta Patnick • NHSBCSP pathology committee: • Quirke (Chair),Williams, Carey (QA), Warren, Shepherd (expert opinions),Mapstone (EQA) • Regional leads England 10 including above • Local screening lead • Participating consultants

20. Meetings • Main committee twice a year • Once a year with regional leads • Policy • QA • EQA • Once a year with participants • Proposed changes • EQA discussion

21. Web page

23. Summary • Guidelines needed • Consistent between types of screening • Minimise variability • Invasion • Size • High grade dysplasia • Electronic EQA being tested

24. Summary • Will generate the largest bank of data on screening in the world • Will save lives!

25. Flexisigmoidoscopy detection rates vary between observers

26. Flexisigmoidoscopy adenoma detection rates vary between studies