05/07/2018. Organisation. The English screening programme what is happening? Organisation. Bowel cancer screening in the UK is:

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1 Organisation The English screening programme what is happening? Phil Quirke Lead Pathologist Bowel Cancer Screening PHE England Bowel Cancer Screening Pathology Committee Started 2006 with roll out 4 devolved countries 60M England 49M guiac FOBT but moving to FIT Bowelscope started 2013 once only at 55 rolling out Wales and Northern Ireland guiac FOBT Scotland guiac FOBT to FIT 20+5 Bowel cancer screening in the UK is: Organisation CHANGING THE SPECTRUM OF DISEASE AND ITS MANAGEMENT Increasing the incidence of colorectal cancer in the population Increasing early stage disease stage I from 11% to 29% Increasing pt1 cancers and local excisions 3 fold to 16.9% Increasing the number of surgically operable patients Reducing stage IV disease Improving endoscopy technique Improving pathology Improving outcomes Overarching Pathology committee with representation and input from Republic of Ireland (Kieran Sheehan) FIT Consistency of definitions and recommendations across Pathology new guidance and TNM8 update EQA across all countries Different levels of quality assurance across programme 1

2 England Uptake and positivity Prevalent first invitation uptake: 51.94% Gateshead Nottingham Rugby London Guildford Five Regional screening hubs Pathology committee responsible for quality Pathology guidance QA visits EQA rounds Expert panel January 2018 Screening round Uptake Positivity Prevalent 35.04% 2.19% Incident 85.69% 1.72% Total 56.61% 1.89% FOBT programme 2006 to May31 st 2018 Diagnostic tests Invitations Self referrals Kits sent Kits returned Definitive normals Definitive abnormals 39,450, ,753 41,865,295 24,494,071 21,817, ,145 2

3 Episode outcomes Bowelscope ,195 controls 57,237 flexisigmoidoscopy 40,674 underwent it Age 60 Incidence 23% (33%) drop Mortality 31% (43%) drop Left sided/rectal cancer 50% incidence drop Distal Proximal Control F/S Control F/S Lesions found 2006-May 2018 Long term effects at 17 years Polyp type Count % Tubular adenoma 354, % Tubulovillous adenoma 94, % Villous adenoma 5, % Serrated adenoma 4, % Mixed HP/adenoma 1, % Hyperplastic 121, % Sessile serrated lesion 4, % Traditional serrated adenoma % Mixed polyp % Sessile serrated lesion with dysplasia % Inflammatory polyp 7, % Other polyp 2, % Lymphoid % Lipoma % Not polyp 36, % Grand total 642, % Adenoma Histology Size Histology size Count % 1-9mm 358, % 10-19mm 77, % 20-29mm 17, % 30-39mm 4, % 40-49mm 1, % 50mm Plus 1, % Not Entered 1, % Grand Total 462, % 3

4 Bowelscope Bowelscope lesions found Importance of removal of lesions developing at 55 rather than 60 or later? Bowelscope uptake and workload What are the tribulations? Bowelscope 395,000 flexisigmoidoscopies and colonoscopies gfobt 450,000 Colonoscopies and flexisigmoidoscopies Over diagnosing pt1 cancer NS Serrated lesions - NS Endoscopy size is unreliable new guidance Incomplete excision does not mean residual disease We are over resecting pt1 cancers and losing patients from operative mortality Interval cancers 4

5 Double reporting Double reporting of all pt1 cancers is required to minimise overdiagnosis of adenocarcinoma. Both reporting pathologists should be BCSP registered and named on the pathology report. If there is any doubt about a diagnosis of cancer, then referral is required for a further opinion. It is recommended that a local opinion is sought first with a further regional opinion or opinion from the national Expert Board should the diagnosis still be in doubt. Main updates 2 Elaboration of standards applicable to pathologists reporting BCSP specimens (section 3.1). Expectations required of endoscopists submitting BCSP specimens for histology (section 3.4). Careful consideration of adenoma sizing, given importance relevant to stratification for colonoscopic surveillance (sections 2 and 5.2.2). Elaboration of descriptors and minimum diagnostic criteria for villousness, in an attempt to improve reproducibility (section 5.2.3). Main updates 1 Reporting to RCPath MDS 2017 TNM8 Reporting of stage pt1 CRC in line with recommendations to include depth and width of invasion (in mm) and separate assessment of lymphatic, neural and venous invasion (section 4.3). [2] Minimum interim standard to perform mismatch repair (MMR) immunohistochemistry in cases of stage pt1 CRC diagnosed in the BCSP setting which demonstrate poor differentiation or other features suggestive of MMR deficiency (section 4.5). NICE recommendation to perform mismatch repair (MMR) immunohistochemistry or microsatellite instability (MSI) testing in all cases of colorectal cancer diagnosed in the BCSP setting [4]. Main updates 3 Assessment of polypectomy margin distinguishing margin involvement by dysplasia from incomplete excision (section 5.2.5). Detailed discussion of epithelial misplacement within adenomas versus adenocarcinoma (section 5.2.6). Update in terminology to be applied to serrated lesions (section 5.2). Minimum criteria for diagnosing adenocarcinoma on endoscopic biopsy specimens (section 4.2). 5

6 Measurement of size Endoscopy size Inaccurate Increased follow up by 10% Terminal digit preference Measuring device Guidance Hierarchy On slide - graticule Cut up Nurse Endoscopy Margin distance There is, however, recent evidence to suggest that for pt1 tumours only tumour present at the true or estimated resection margin, or within the diathermy burn zone, should be considered for further treatment, which may be local re-excision if no other adverse pathology features are identified [34,35,53]. However, it is considered that more substantive evidence is required before a change is made and 1mm or less remains the indicator for incomplete excision until this is forthcoming. If tumour is close to the excision margin, multiple levels (at least three and preferably more) should be examined in the assessment of possible margin involvement, with adjunctive immunohistochemistry if required. Careful follow-up of the local excision site of carcinomas less than 1mm from the margin is recommended if the MDT decide not to undertake a further excision or resection. Margins guidance to NHSBCSP -more work needed Management pt1 Major resection Complications Mortality Surgical team Country Age Health Morbidity Quality of life Stoma Anterior resection syndrome Cost 16,000, stomas No resection/local excision Risk of recurrence and cancer death Currently select by High risk features Sub stage pt1 Lymphovascular invasion Poor differentiation Incomplete excision 10% metastases symptomatic pt1 patients Less in screening patients 6

7 pt1 Conclusions Hagitt/Kikuchi remain for now Ueno et al have proposed that the depth of invasion of tumour beyond the muscularis mucosae and width of the invasive tumour provide more objective measures of potential for lymph node metastasis [46]. Both of these quantitative measurements should also be recorded, in millimetres, in line with the recommendation of the Royal College of Pathologists (UK) dataset [2]. Depth (or thickness) of invasive tumour should be measured from the muscularis mucosae where it is intact and identifiable. If the muscularis mucosae is obscured or destroyed by tumour, tumour thickness should be measured from the surface of intact mucosa or ulcer [47]. Budding is not yet recommended needs studies with the new ITBCC guidance Bowel cancer screening is working in the UK Need to increase the colonoscopy capacity to maximise its benefits Still outstanding issues that need resolution The outstanding issues Thanks to: Increasing screening uptake and increased sensitivity of detection Political Increasing FIT sensitivity vs continuing bowelscope Biomedical scientist reporting Diagnostic pt1 indications for resection Positive margins Role of local treatments Role of MRI in follow up of high risk pt1 s low risk T2 s Biology of serrated lesions Pathology Committee NHSBCSP and Claire Nickerson Eva Morris Julieta Patnick 7

8 Cancer staging per tumour Cancer Stage Tumour Count No cancer detected 1,094 Stage 1 7,376 Stage 2a 3,973 Stage 2b 332 Stage 3a 1,450 Stage 3b 3,642 Stage 3c 1,330 Stage 4 2,063 Incomplete 7,149 Cannot be assessed 3,914 Grand Total 32,323 8

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