UK Bowel Cancer screening Dr Voi Shim Wong BsC MD FRCP. Consultant Gastroenterologist Accredited BCSP colonoscopist Whittington + UCL Hospitals

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1 UK Bowel Cancer screening 2017 Dr Voi Shim Wong BsC MD FRCP Consultant Gastroenterologist Accredited BCSP colonoscopist Whittington + UCL Hospitals

2 Bowel Cancer Contents UK Bowel Cancer Screening Programme Bowel cancer screening in private practise

3 Normal Colon Anatomy

4 57F presented with acute large bowel obstruction

5 Prevalance of GI Cancers Liver/biliary 8% Pancreas 16% Oesophagus 16% Bowel/rectum 41% Stomach 19%

6 Distribution of CRC

7 CRC- some facts 2 nd commonest cause of cancer related death in western world 3 rd commonest cancer in UK (35,000 new cases / year, 16,000 deaths/ year) Differing overall survival rates in Europe * UK < France < Germany * ( 45 < 50 < 60 ) % Average 5 yr survival = 55 % 80 % cases are diagnosed at Dukes stages > B

8 N => adenoma => large adenoma => pre-malignant => cancer Normal => LGD => MGD => HGD => cancer

9 EMR of flat colonic polyps

10 Cancer risk in colorectal polyps

11 CRC - No. of New Cases Per Yr & Age-Specific Incidence Rates, UK,

12 Bowel Cancer : Five-Year Net Survival, E & W 5-yr net survival for CRC in men has increased from 25% ( ) to 59% (2011)

13 Colon Cancer : Year Relative Survival, Adults (Aged 15+), European Countries

14 Net Survival up to Ten Years after Diagnosis, (15-99), E & W

15 Bowel Cancer: Five-Year Net Survival by Age, England

16 What screening is testing people for early stages of an illness before they have any symptoms For screening to be useful the tests: must be reliable at picking up the illness must be simple and quick overall must do more good than harm to people taking part

17 CRC Screening Tests Non Invasive FOB x3 CEA Invasive CT Colography Flexible Sigmoidoscopy Colonoscopy Gold standard Colonoscopy

18 Gold standard 90% of adenomas can be seen and removed during colonoscopy

19 NHS Bowel Cancer Screening Current FOB testing Flexible sigmoidoscopy (Bowel Scope) Future? Virtual colonoscopy? Genetic markers in blood / stool / urine (Detection of CRC DNA quantification of exfoliated colonocytes)

20 FOB kit every 2 years FOBT You need to be registered with a GP to receive your screening invitations. In England, men and women years People >74, can request a screening kit by contacting the BCSP

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22 UK Bowel Cancer Screening Programme 2 in 100 will receive an abnormal result colonoscopy. 4 in 100 people may receive an unclear result there was a slight suggestion of blood in the test sample. causes such as hemorrhoids FOB test will need to be repeated. Most people who repeat the test normal For those undergoing colonoscopy 5 in 10 people normal 4 in 10 polyp (s) 1 in 10 ==> cancer

23 Patient Pathway Positive FOBt Seen by Screening Practitioner (SSP) in outpatients Implications of + FOBt explained Colonoscopy offered within next 14 days Declines FOBt kit sent in 2 years Accepts Colonoscopy Biopsy/polypectomy Histology in 3-7 days Normal FOBt kit sent in 2 years Cancer detected Seen by Screening Practitioner For result Non-cancerous For treatment at UCLH SSP gives cancer diagnosis Introduces Colorectal CNS Refers to UCLH MDT For treatment at other hospitals SSP gives cancer diagnosis Refers to relevant MDT Surveillance as per BSCP protocol

24 STAGE UCLH PILOT Data Polyp Cancer (41) 16% 15% Dukes A (64) 25% 25% Dukes B (61) 24% 26% Dukes C (59) 23% 25% Dukes D (30) 12% 9%

25 So far..at UCH Polyp detection rate 33-45% (40%) Cancer detection rate % (10%)

26 NHS Bowel Scope Screening (BSS) Primarily a nurse led programme Running concurrently with FOBT Flexible sigmoidoscopy -55yrs only however, can opt in if under 60 years * Commenced 2013 Complete National roll-out by April 2018

27 NHS Bowel Scope Screening (BSS)

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29 NHS Flexible Sigmoidoscopy Screening trial (UK FSST) Once only (55-64yrs) 190,000 (55%) responded 170,000 randomised (2 : 1) -> 57,000 assigned screening 40,000 (FS) Results 11.3yrs FU * 33% (50) reduction incidence * 43% decrease mortality

30 BOWEL SCOPE AT WHITTINGTON, APRIL 2015 TO APRIL 2017 Total number of Bowel Scopes 789 Colonoscopy 20 (or 2.5% total scopes) Occasions where patient attended but did not complete: 11

31 Result Count Abn - NND only 259 Abn- Polyps & NND Abn- Polyps found Cancer suspected Normal 321 Total 789 1

32 Polyp Class Count Polyp type Count Flat 34 Pedunculated 20 Sessile 226 Grand Total 280 Adenoma 76 Blank 8 Inflammatory polyp 5 Not polyp 32 Other polyp 5 Serrated lesion 83 Grand Total 209

33 Pathology Result Cancer + Polyps 1 High Risk 2 Intermediate Risk 11 Low Risk 5 Polyps to be categorised 1 Grand Total 20

34 Polyp by location and size Polyp location Count Polyp size Count Decending 40 Rectum 151 Sigmoid 84 Transverse 5 Grand Total mm mm mm mm mm 8 >10mm 10 Grand Total 280

35 Poylp Detection rate (PDR) & Adenoma Detection rate (ADR) BSS BoSS with polyp/s PDR % BoSS with adenoma/s ADR % A % % VSW % % Total % %

36 Patient comfort Clinician None Minimal Mild Moderate Severe Total A VSW Total

37 BCS in Private Practice Mirror current NHS programmes: FOBT BSS Those aged 55 missed out on current BSS Those with risk factors FH CRC IBD Genetic factors: e.g Lynch syndrome or FAP, acromegaly

38 Younger people <50 reviewed data on >1 million CRC in National Cancer Database USA No of CRC is rising ~ 1 % a year in < 50 the majority of cases still occur > 50 1: 7 CRC < 50 more likely to have advanced stage cancer but they live slightly longer without a cancer recurrence because they are treated aggressively DDW 2016: Sutton et al + J Cancer 2016

39 Conclusion 70% of CRC detected within the NHS screening programme is early stage disease = potentially curable endoscopically or by surgery NHS bowel cancer screening programme (FOBT & BSS) improved overall survival The challenges will be to increase participation /uptake through improved public awareness and to address socio-economic inequalities

40 Final Word CRC screening should be team work Treat individuals and Not numbers Options for screening be offered and risks explained Consider screening relatives

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