Bowel cancer screening

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Bowel cancer screening

• Roland Valori
• January 2006

www.grs.nhs.uk www.bcsp.nhs.uk
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Learning objectives to understand

• Competing screening methods
• Evidence base for screening
• Outcome of UK Pilots
• Proposed national screening programme
• Expected input and outcomes
• Quality assurance framework

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Screening tools for bowel cancer

• Faecal Occult Blood (FOBT)
• Flexible Sigmoidoscopy (FS)
• CT Colography (CTC)
• Colonoscopy

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Competing methods for bowel cancer screening
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Colon cancer early detection
Three RCTs of screening 15-18 reduction in
death from cancer
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Preventing cancer
Several case control studies Awaiting result of
MRC/ICRF trial
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Effect of FOBT screening on incidence of
colorectal cancer
NEJM 2000 3431603-07
20 less cancer
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CT Colography
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colonoscopy
looking forpolyps
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Effect of FOBT screening on incidence of
colorectal cancer
NEJM 2000 3431603-07
20 less cancer
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FOB screening pilots
Test of effectiveness
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Uptake and positivity invited n 486,355

• Uptake
• 56.8 (259402)
• Positivity rate
• 2.0 (4667)

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Positive Predictive Value
Carcinoma (n552) 10.9

Adenoma 35.0
No neoplasia 54.1
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Stage Distribution of Screen -Detected Cancers

D 1
True A 26
C 26
A 48
B 25
Polyp Cancers 22
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Bowel cancer screening

• Endoscopic workload expressed as procedures per
  year per 1,000,000 population

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Projected endoscopic activity 2003 - 2008 (with
FOB screening)
of population per year
screening colonoscopy for FOBT
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Inputs and outcomes

• For population of 1 million with 60 compliance
• 600 colonoscopies/year
• 65 cancers
• 200 high risk polyps
• 39 lives/year saved

1 million population will generate 500
cancers/year assume 50 mortality (250) and 16
(39) reduction in death/year
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Numbers needed to prevent 1 person dying from
bowel cancer

• 1,282 invited to submit FOB
• 769 FOBs
• 15 colonoscopies

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Numbers needed to prevent 1 person developing
bowel cancer
If every fifth high risk polyp removed was
destined to become cancer, the numbers needed to
prevent one cancer are the same

• 1,282 invited to submit FOB
• 769 FOBs
• 15 colonoscopies

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Screening population of 1 million- effect of
compliance
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Screening population of 1 million- effect of
compliance
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Roll out of National Bowel Cancer Screening
Programme

• NHS Cancer Plan 2000 to introduce bowel cancer
  screening dependent on pilot results
• To commence April 2006 across England and rolled
  out over 3 to 4 years
• Population invited will be aged between 60 and 69
  years
• To be offered guaiac FOB test every 2 years
• Initial areas will prioritise Spearhead PCTs

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Spearhead PCTs
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Criteria for selection of a screening centre

• GRS score with emphasis on waiting times and
  patient experience
• Satisfactory accreditation visit
• Accredited colonoscopists
• Ability to offer all patients a colonoscopy
  within two weeks of nurse positive clinic
  appointment
• Maintenance of workload of colonoscopists at 200
  colonoscopies pa (minimum 150 at entry)

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How will this be done?
Strategic Health Authorities
SHA Clinical Leads
advise on who and when
Ministerial approval
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Proposed organisation
Overarching Structure

• 5 Programme Hubs across England, based on IT
  Local Service Providers (LSP) undertaking
  call/recall and lab functions
• 1 Programme Hub per LSP
• Each Programme Hub will have a number of
  Screening Centres

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Bowel cancer screening programme
Colonoscopy site
treatment
Persons aged 60-69
Colonoscopy site
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Quality Assurance
Agreement, achievement and demonstration of
standards
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Client Satisfaction
Why is QA important?
Growth of theProgramme
JobSatisfaction
Clinical Excellence
Good reputation
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Benefits and risks of high and low quality
screening
Adverse effects of low quality screening
effect
Adverse effects of high quality screening
intensity
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Benefits and risks of high and low quality
screening
Benefits of high quality screening
effect
Benefits of low quality screening
intensity
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Benefits and risks of high and low quality
screening
Harm exceeds benefit
Benefits of high quality screening
Adverse effects of low quality screening
effect
Benefits of low quality screening
Adverse effects of high quality screening
intensity
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Quality assurance - who and what?
individuals
organisations
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Quality assurance
What and how?
standards
processes
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Quality control of individuals
trainee
Certification of competency
all endoscopists
Continuous monitoring of key quality and safety
indicators
competence
performance
established colonoscopist
Revalidation
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Revalidation the driving test

• Submission of audit of practice
• Test day
• MCQ
• observed performing 2 colonoscopies
• Pass/fail

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Tri split video
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Quality control of individuals
Certification of competency
Continuous monitoring of key quality and safety
indicators
performance
Revalidation
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Quality indicators

• Completion rate gt 90
• with photographic evidence
• Adenoma detection rate 35
• Polyp recovery - gt 90 of those excised
• Correct identification of position of tumour gt 95

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Safety indicators

• Perforation rate lt 11000
• Post polypectomy
• bleeding requiring transfusion lt 1100
• perforation lt 1500
• Complication requiring admission lt 31000

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Screening programme monitoring
ERS
monitoring of benefit/harm
ERS
ERS
ERS
Central server
ERS
ERS
ERS
ERS
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Quality assurance - organisations
standards
GRS
processes
Web-based reporting tool accreditation visit
www.grs.nhs.uk
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Patient-centred standards
www.grs.nhs.uk

• Customer care
• equality
• timeliness
• choose and book
• privacy and dignity
• aftercare
• ability to provide feedback to the service

• Quality and safety
• appropriateness
• information/consent
• safety
• comfort
• quality
• timely results

endoscopy global rating scale
Graded D to A
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Standards of GRS for screening

• A for timeliness
• Bs for other items

Standards will gradually rise
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GRS National results
scoring A or B
85 completion
90 completion
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GRS National results
scoring A or B
85 completion
90 completion
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Quality assurance - organisations
standards
GRS
processes
Web-based reporting tool accreditation visit
www.grs.nhs.uk
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Bowel cancer screening Difference between
England and other countries

• England does this sort of thing well
• uptake rates in other countries are low compared
  to pilot sites
• It is possible to quality assure the entire
  programme

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Our goal

• To have the best screening programme in the world
• .and know its the best

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www.bcsp.nhs.ukwww.grs.nhs.uk