Improving the uptake of bowel
cancer screening in East London
through targeted GP endorsement
Judith Shankleman
Senior Public Health Strategist
London Borough of Tower Hamlets
Colorectal cancer
Second most common cause of cancer death in
UK and in Tower Hamlets
• 5 year survival
- 93% for patients diagnosed at stage I
- 7% for patients diagnosed at stage 4
• Tower Hamlets
- 60 new diagnoses per year
- 30 deaths per year
Colorectal cancer in Tower Hamlets 2011:
stage at diagnosis (n=56)
Metastatic
Early stage
disease
disease
24%
(Dukes A and "good" B)
34%
Late stage
disease
42%
Source: Avon, Wiltshire and Somerset Cancer Services
Population-based commissioning toolkit for Colorectal Cancer by route to diagnosis and stage of disease
(Dukes A-D) August- 2012
09/01/2013
3
Colorectal cancer in 42 Tower Hamlets residents
diagnosed and treated at Barts Hospital 2011
20
18
Number of patients
16
14
12
10
8
6
4
2
0
stage 1
stage 2
stage 3
stage 4
unknown
NHS Bowel cancer screening
programme
• Age 60 – 69 (extending to 74)
• Aims to
- identify and remove polyps +
surveillance
- identify early bowel cancer
• At 60% uptake, population
mortality reduced by 16%
• Participants reduce their risk of
dying from bowel cancer by 25%
Lower uptake associated with…
• London
• Multiple deprivation
• South Asian and Muslim
populations
• Low levels of English literacy
• Being male
“Intervention generated inequality”
Bowel screening uptake
N & E London Q1 2014/5
National target 60%
Uptake of bowel screening
60%
50%
40%
34.92%
30%
20%
10%
0%
Source: NHS England (London region) N and E London cancer screening team
55.76%
Evidence for intervention
• Targeted GP endorsement and outreach was effective in
increasing breast screening uptake in Tower Hamlets1
(from 53% to 69%)
• 2011 bowel screening pilot targeted 60 yr olds, invited
to health promotion sessions in 12 inner NEL practices
• Targeted endorsement of bowel screening is cost
effective and contributes to a reduction in health
inequalities2
1 Eilbert
et al 2009 British Journal of Cancer
2 Ansari et al 2013 University of York
2012 Bowel Screening Project
• With Prof Stephen Duffy (QMUL); controlled trial in City
& Hackney, Newham and Tower Hamlets
• PCT commissioners negotiated with NHS BCSP(the Hub)
for GPs in NEL to pilot monthly “prior notification lists”
• 18 randomised large practices compared with 28
control practices of similar size
• 9 practices randomised to offer group HP
• 9 practices to offer HP over the phone
Protocol
• Commissioned community organisation with
trained bilingual advocates
• Data sharing agreements between 18 practices
and the Hub; monthly PNLs sent Jan to Dec 2012
• People due to be invited identified by callers
using practice registers
• Practices excluded patients with bowel cancer,
palliative care needs or opted out
Letter of endorsement and customised national
leaflet sent ahead of expected screening invitation
Phone call after anticipated kit dispatch
(up to 3 attempts)
In 9 practices,
reminder about HP
session at practice
In 9 practices scripted
explanation and
questions answered
Bowel screening uptake
April to December 2012
60%
50%
Uptake
40%
HP session
HP over phone
49.6%
50.3%
Control
41.0%
Control
38.4%
HP over phone
45.3%
Control
36.5%
HP over phone
46.7%
Control
39.1%
30%
20%
10%
0%
City & Hackney
Newham
Tower Hamlets
3 boroughs
combined
Uptake highest for HP over the phone
All results were highly significant
28 control practices
9 intervention
practices - HP over
the phone
9 intervention
practices HP at group
sessions
Borough
Number
Number
Number
screened
Uptake
screened
Uptake
screened
/total invited
/total invited
/total invited
Uptake
City &
Hackney
560 / 1,337
41.0%
294 / 594
48.9%
289 / 602
49.6%
Newham
810 / 2,049
38.4%
388 / 776
50.3%
295 / 685
42.6%
Tower
Hamlets
677 / 1,841
36.5%
292 / 664
45.3%
237 / 565
41.7%
974 / 2,034
46.7%
821 / 1,852
43.8%
Total
2,047 / 5,227 39.1%
Discussion
• Only 50% targeted people reachable by phone
• Practice registers did not always identify bowel
cancer patients
• Unusually high DNA rate for colonoscopy in
screen +ve patients in NEL
• £6 per person targeted
Next steps
• Tower Hamlets Network service 2014/15 “Detecting
cancer earlier in primary care”
• £130k funded by Public Health
• Includes following protocol for targeted endorsement
of bowel screening (£40k) to demonstrate ‘proof of
concept’
• PNLs for all practices to be negotiated
•
search identifies 60 year olds due to be invited
+ recent DNAs