Bowel Cancer Screening

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1 Bowel Cancer Screening Dr John Hancock FRCP Consultant Gastroenterologist University Hospital of North Tees

2 Outline Background Current bowel cancer screening programme Tees Screening Centre Future Flexi Sig screening

3 Brief refresher course

4 Bowel cancer Bowel cancer (colorectal cancer, CRC) is common 2nd most common cancer death (16,000 a year) Lifetime risk CRC is 1 in 20 Greatest risk factor is age 80% occur >age 60

5 Annual UK Workload 480,000 new referrals for?crc ,000 new cases (1 CRC/GP/year)

6 Adenoma carcinoma sequence Vogelstein s s hypothesis: Cancers arise from pre-cancerous growths called polyps (adenomas) Series of cellular mutations

7 How Does Colorectal Cancer Develop? Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.

8 Dukes Classification of CRC DUKE S A DUKE S A DUKE S B DUKE S C DUKE S D

9 Symptomatic CRC is usually advanced Dukes stage Frequency at diagnosis (%) 5y survival (%) A B C D 29 3

10 Delays in diagnosis years 3-4 years Months Weeks Weeks

11 Adenoma polyp to cancer sequence

12 Colonoscopy

13 Bowel Cancer Screening

14 National Bowel Cancer Screening Programme Faecal Occult Blood testing RCT evidence: FOB screening reduces CRC mortality by 16% IMPORTANT: FOB screening will only detect 33 50% of CRC Symptoms trump screening result All year olds invited to participate every 2y Patients over 74 may opt in Home FOB testing kit sent from Hub (5 national Hubs) Those with positive result Tees BCS Centre for COLONOSCOPY

15 Tees BCS Centre >800,000 people Coverslargeareaincluding area Hartlepool, Stockton, Middlesbrough & part of North Yorkshire >900 colonoscopies a year 1st wave site: Feb 2007 See patients in clinic within 2 weeks Perform colonoscopy within 2 weeks Colonoscopists have to be screening accredited See in clinic within 2 weeks with results Manage follow up procedures

16 English BCSP headlines By end of Sep 2012 cohort data 15 million invitations sent FOB uptake rate 55.1% FOB positivity rate 2.1% Uptake of colonoscopy/other test 90.5% 164,000 people have undergone FOB diagnostic colonoscopy 13,876 cancers detected (8.6%) over 250 cases locally Prevalent round 9.9% First incident round 6.2% Cancer stage 71% A or B (compared to 46% for symptomatic service) Adenoma Detection Rate 46%

17 Local Bowel Cancer Screening

18 What have we achieved? Nationally regarded as one of best Screening Centres 1 of only 12 First Wave sites nationally Selected as 1 of only 3 Flexi Sig pathfinder sites Seen nationally as strategic lead for bowel cancer screening Chair the national BCSP Evaluation committee & regional colonoscopy committee, sit on the national Quality in Colonoscopy committee Lead nationally in BCSP research

19 This won t hurt a bit

20 Tees: high quality service In 2011: Colonoscopy success rate 97.35% (cf % nationally) Adenoma Detection Rate 52.31% (cf.45.50% nationally) Comfort score 94.84% (cf % nationally) Half of our patients opt not to have sedation No major complications

21

22 The Future: Flexible Sigmoidoscopy Screening

23 Rational behind Flexible Sigmoidoscopy

24 RCT: per protocol analyses CRC incidence reduced by 33% CRC mortality reduced by 43% One-off FS examination for all 55 year olds Roll-out out over 4 years from April 2013 Complements FOB programme FS = cancer prevention cf. FOB = early detection Atkin. Lancet, 2010

25 FS implementation High volume service 10,000 invitations a year 13 lists per week Nurse endoscopists Large geographical area Satellite sites

26 Summary Bowel cancer is an important disease Bowel cancer screening works We have one of the best Screening Centres Flexible sigmoidoscopy screening is coming