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