Bowel Cancer and
Screening
Dr M T Hendrickse
Clinical Director/ Lead Colonoscopist
Lancashire Bowel Screening Centre
Blackpool Teaching Hospitals NHS
Foundation Trust
Introduction
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Bowel cancer – basic facts
Screening – development and progress
Results
The future
Bowel Cancer – The Facts
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16,000 deaths per year from Bowel Cancer
2nd commonest cause cancer death
Over 34,000 new cases/ year
Over 80% occur in over 60s
Lifetime risk 1 in 20
Risk Factors
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Age
Diet
Obesity
Smoking
Excess alcohol
Family History
High Risk Groups
• Hereditary non Polyposis Colorectal Cancer
(Lynch Syndromes I and II )
• Familial Adenomatous Polyposis Syndrome
• Family History of Colorectal Cancer
• History of Polyps or Colorectal Cancer
• Inflammatory Bowel Disease
Family History of Colorectal
Cancer
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Screening Controversial
2 or more first degree relatives
1 first degree relative < 50 years
Colonoscopy at 35 – 40 then at 55 years
? Increased pickup of polyps
Symptoms
 Changes in bowel habit- particularly to loose
stools
 Bleeding
 Anaemia
 Abdominal pain
 Abdominal mass
* If present - see GP , fast track referral ( not
screening)
Fast track criteria
Staging of colorectal cancer
Survival of colorectal cancer
Related to Stage
• 5 Yr survival Dukes A
Dukes B
Dukes C
90%
70%
33 %
Since 85% B/C , overall Survival 40%
Stenosing colonic carcinoma
Early Bowel Cancer
• <10 % patients with symptoms
• 50% of patients picked upon screening
• Early cancer cured in 90%
Why Screen?
• Symptoms occur late - 5 years survival for
bowel cancer with symptoms 49% Vs >70 %
if picked up asymptomatic
• 16% reduction in mortality from bowel
cancer in screening trials
• Screening picks up cancers earlier – 48% vs
10% have early curable cancers
• Reduction in emergency admissions/
surgery for bowel obstruction
Figure 3 Total number of emergency colorectal cancer cases between 1999 (PSY)
and 2004 (SY5).
Goodyear, S J et al. Gut 2008;57:218-222
Copyright ©2008 BMJ Publishing Group Ltd.
90 % cancers arise from polyps
polyp – cancer 8 – 10 yrs
Malignant polyp - Classification
National Screening Programme
• Started in 2006, rolling out completed end
2009
• Based on testing for blood in stools
• (FOBt)
• 60 – 74 yrs, older can request FOB
• Test done in own home, a positive test
results in a referral to a SSP Clinic with a
view to a colonoscopy
BCSP – organisation
Role of Hub- Rugby
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To manage call and recall
Provide telephone helpline for participants
Dispatch and process test kits
Send results to participants and GP
Book clinic appointment for abnormal test
Free line – 0800 707 60 60
Guaiac FOBt testing kit
BCSP - Organisation
• Centres – (local admin centre Blackpool )
• Provide SSP clinics for patients with +ve
Fobs, Colonoscopy sites ( Blackpool /
Preston, Burnley follow up colonoscopies/
clinics,
• Publicise programme locally
• Link with Primary care
• Link with MDTs
Clinic Sites - Current
NHS Blackpool & NHS North Lancashire :
• Blackpool Victoria Hospital OPD
• Lytham Primary Care Centre
• Fleetwood Hospital OPD
NHS Central Lancashire:
• Healthport, Euxton Hall and Ashurst Health
Centre
NHS East Lancashire:
• Burnley General Hospital / Clitheroe Hospital
NHS Blackburn with Darwen:
• Livesey Clinic - Blackburn
Specialist screening
practitioners
Colonoscopy
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Perforation 1/1500
Bleeding 1/200 polypectomy
Death 1/10,000
Only screening test with a mortality
National Office – Best Colonoscopists in the
Best centres!!
Screening Colonoscopists
• > 1000 lifetime experience, caecal intubation
rate ( ITT) =>90%, polyp DR > 20 % ,
minimum 150 per year
• Have to pass stringent driving test (failure
rate 25 – 40%!) to be accredited.
• Committed to min 1 screening list per wk
• Six accredited (CG, RH, PSMH, CJS, JS) .
Endoscopy Units Accreditation
• JAG approval required for screening
• Waiting times < 6 weeks
• Meet stringent patient centred Clinical
quality criteria
• ( GRS)
• BVH started screening first, Preston,
Burnley later
Lancashire bowel cancer
screening centre
• Total population – 1.36 million
• Aged 60 – 69 initially, age extension 2010 to
74 years
• 8-9 lists per week
• Burnley, Preston and Blackpool accredited
sites
• Estimated 1-2 screen detected cancer / week
per MDT
National Endoscopy Training Centre at The Mersey School of Endoscopy
Transverse colon sessile polyp
Post EMR t colon polyp
Malignant polyp - Classification
Early carcinoma
April 2008 – Nov 2011
• Total Invites – 269,119
• Adequately Screened – 147,637
• Definitive Abnormals – 2,950
• Definitive Normals - 156,859
• Uptake – 54.81%
Positivity – 2.00%
NHS BCSP – Lancashire
Colonoscopy Uptake - 2010
Jan-Dec
2010
Definitive
FOB+ patients
Grand
Totals
930
Attended
Colonoscopy
Colonoscopy Uptake %
920
88.49%
• National Colonoscopy Uptake Rate for 2010
was 84.14%
NHS BCSP – Lancashire
Caecal Intubation Rate
JanDec
2010
Grand
Totals
No of
Caecal
CIR %
Colons Intubation
984
943
95.83
CI with
Photo/
Video
Evidence
816
CI with P/V
Evidence
%
82.93
• The National Caecal Intubation Rate (CIR) for 2010 was
96.63%, CIR with Photo / Video Evidence was 91.37%
CIR with Photo / Video Evidence
Standard 90% Target – 97%
NHS BCSP – Lancashire
Adenoma Detection Rate
JanDec
2010
Grand
Totals
Index IC where Adenom Adenom
Colon Adenoma
a
a count
s
detectio
s (IC)
detected
n %
810
394
48.64
872
Adenom
a rate
1.08
The National Adenoma Detection Rate (ADR) for 2010 was 46.69%
The National Adenoma Rate for 2010 was 1.00
Standard:
Histologically confirmed adenomas detected in ≥ 35% of
screening colonoscopies
Target:
Histologically confirmed adenomas detected in ≥ 40% of
screening colonoscopies
NHS BCSP – Lancashire
Patient Comfort During Colonoscopy
Jan-Dec 2010 - Total attended tests = 984
Standard: 100% of colonoscopies with a recorded comfort level
No discomfort
66
Minimal
566
Mild
211
No discomfort min mild %age
85.67 %
Moderate
124
Severe
16
Not entered
1
National Comfort Rate (No discomfort, min mild%) for 2010 was
89.62%
April 2008 – to date
Test Kits
• Definitive Abnormals 2,950
• Definitive Normals - 156,859
• Uptake – 54.81%
Positivity – 2.00%
Procedures
• Total Colonoscopies –
• Total Other tests
• Cancers Detected –
3,009
169
262 = 8.71%
Cancer Staging - April 2008 to
April 2011
JanDec
2010
No of
Cancers
Totals
213
Stages
as %
of
total
cancer
T1
A
B
C/C1
C2
D
45
58
41
50
8
11
21.13
27.23
19.25
23.47
3.76
5.16
Polyp
Cancers
Challenges
• Increase uptake in low uptake areas
• Impact of age extension/surveillance
• Introduction of flexible sigmoidoscopy
screening
• Increased demand for lower GI endoscopy
Flexible sigmoidoscopy
• One off flexible sigmoidoscopy at age 55 - 64
• 53% replied agreed to screening, 71%
attended for flexible sigmoidoscopy
• Colorectal cancer incidence reduced by 23%,
mortality by 31%
• ? True uptake ? Endoscopy workload
• Ongoing pilots, roll out in next 2 – 3 years
Expansion of the BCSP and commitments in the Cancer
Outcome Strategy mean that there will be additional
intensive pressures on endoscopic activity for the next
five years
Note: For the historical data the difference between the pink and blue
lines largely reflects the current impact of bowel screening on
endoscopy
Questions?
Thank you