Bowel Cancer and
Screening
Dr M T Hendrickse
Clinical Director/ Lead Colonoscopist
Lancashire Bowel Screening Centre
Blackpool Fylde and Wyre NHS
Hospitals Foundation Trust
Introduction
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Bowel cancer – basic facts
Screening – development and progress
Results
The future
BOWEL CANCER – THE FACTS
16,000 deaths/ yr 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
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HEREDITARY NON POLYPOSIS COLORECTAL CANCER
(LYNCH SYNDROMES I AND II )
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FAMILIAL ADENOMATOUS POLYPOSIS SYNDROME
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FAMILY HISTORY OF COLORECTAL CANCER
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HISTORY OF POLYPS OR COLORECTAL CANCER
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INFLAMMATORY BOWEL DISEASE
FAMILY HISTORY OF COLORECTAL CANCER
 SCREENING
CONTROVERSIAL
2
OR MORE FIRST DEGREE RELATIVES
1
FIRST DEGREE RELATIVE < 50 YEARS
 COLONOSCOPY
AT 35 – 40 THEN AT 55
YRS
?
INCREASED PICKUP OF POLYPS
Symptoms
Change 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
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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?
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Symptoms occur late - 5yrs 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 to complete
end 2009
 Based on testing for blood in stools
 ( FOBt)
 60 – 69yrs old invited , age extension to 74
April 2010
 Test done in own home, a positive test
results in a referral to a SSP Clinic with a
view to a colonoscopy
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INITIAL PILOT RESULTS
60 % uptake of screening
 2% FOB +ve
 90% had colonoscopy
 Cancer 10%, 35 - 46% polyps
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BCSP – organisation
Guaiac FOBt testing kit
BCSP - organisation
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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 with Public
Health/PCT leads
Link with Primary care
Link with MDTs
Lancashire BCS centre
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Admin centre at Blackpool , strongly supported
by the Trust /Medical Division
Offices, staffing , training and support.
Programme manager, Lead SSP , 4 SSPs, 2
Admin staff
Clinical and colonoscopist lead, screening
colonoscopists, lead radiologist, pathologist
Lancashire bowel cancer screening
centre
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Total population – 1.36 million
Aged 60 – 69 - 142,200
Assuming pilot projections
5.5 colonoscopy lists per week
2 lists Burnley, 1.5 lists Preston and 2 lists
Blackpool; screening started Blackpool April
2008, Preston June 2008, Burnley Jan 2009.
Estimated 1 -2 screen detected cancer/ week per
MDT
Specialist screening practitioners
Clinic Sites - Current
NHS Blackpool & NHS North Lancashire
 Blackpool Victoria Hospital OPD
 Lytham Primary Care Centre
 Fleetwood Hospital OPD
NHS Central Lancs
 Healthport , Euxton Hall & Ashurst Health Centre
NHS East Lancs
 Burnley General Hospital / Clitheroe Hospital
NHS Blackburn with Darwen
 Livesey Clinic -Blackburn
Colonoscopy
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Major advantage : diagnostic and therapeutic
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
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> 1000 lifetime experience, caecal intubation
rate ( ITT) =>90%, polyp DR > 20 % ,
minimum 150 / year
Have to pass stringent driving test ( failure rate
25 – 40%!) to be accredited.
Committed to min 1 screening list/ wk
5 accredited (CG, RH,MH, 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
 Required great teamwork across the trusts
 Required development of a New Unit
 Made possible with huge Trust support
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Colon anatomy
National Endoscopy Training Centre at The Mersey School of Endoscopy
National Endoscopy Training Centre at The Mersey School of Endoscopy
Transverse colon sessile polyp
Post EMR t colon polyp
Ascending colon polyp 2
Post EMR Ascending colon polyp
Results
Results - Uptake and FOB positivity
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Uptake of screening varies between 48 – 57% (
varies with time and PCT ; same as average of
other centres supplied by HUB)
FOBT +ve rate – 1.88– 2..3% ( also varies with
PCT)
Lancashire Uptake Rates
30th September 2009
NHS NORTH LANCASHIRE
57.97%
NHS CENTRAL LANCASHIRE
52.52%
NHS BLACKPOOL
49.58%
NHS BLACKBURN WITH DARWEN
48.17%
NHS EAST LANCASHIRE
53.66%
National Average
51.74%
Midlands & North West HUB
Average
53%
Uptake Trends
March – September 2009
Percentage
uptake rate
North Lancs
Central Lancs
Blackpool
Blackburn with
Darwen
East Lancs
National Average
Hub Average
31.03.09
12.05.09 30.06.09 30.09.09
55.86%
56.87%
56.56%
57.97%
50.92%
51.58%
52.05%
52.52%
48.04%
48.44%
48.90%
49.58%
44.62%
45.56%
47.16%
48.17%
47.43%
51.99%
53.71%
53.66%
52.02%
52.80%
52.51%
51.74%
39.83%
52.40%
52.40%
53.00%
Activity
April 2008 – September 2009
1,246
Positive Kits
=
Negative Kits
= 60,692
Retests
=
6,567
Lancs BCSP Overall FOB Positivity
1.82 %
Activity
April 2008 – September 2009
SSP Appointments
No of 1st positive assessment appointments = 977
DNA’s
(5.5%)
= 53
--------------No of Post investigation appointments
= 35
DNA’s
=
(6%)
2
--------------Telephone clinic - follow ups
---------------
= 957
Colonoscopy data April 2008 –
end Sept 2009
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868 examinations by 5 colonoscopists
Varied 71- 287 per colonoscopists
overall completion rate 96.8% (94- 98)
Average time 29mins , wide range
Polyp detection 66% polyp retrieval 91%
Cancer detection rate 8 – 12% overall 11.3%
Bowel prep quality > 91% excellent/good
Local Results
From 25th April 2008 to 8thApril 2010
> 97% seen in SSPclinics have colonoscopy
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1338 Patients undergone colonoscopy
35% normal or minor diagnosis
( 799) 54% had adenomatous polyps , 529
intermediate/high risk
145 (11%) Cancers found
Cancer Results - staging
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145 Cancers
Staging data incomplete in 32
40%Dukes A,
18%Dukes B
18%Dukes C 2.0% Dukes D
33 polyp cancers found (23 %)
Comparison of screen detected Vs
Symptomatic Cancers at Blackpool
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Between June 2008 – April 2009 , 235
symptomatic and 24 screen detected cancers
higher proportion males and earlier age in
screen cancers
> 70% screen cancers in sigmoid , Symptomatic
cancers throughout colon
T1 cancers 29% in screen detected vs 4%
symptomatic
Conclusion
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Bowel screening well established in Lancashire ;
Age extension to commence shortly
Uptake varies ; scope to improve with co –
ordination with PCTs and Public health
High pick up rate of polyps and cancers ; similar
to clinical trials and Pilot studies
High pick up of early cancers
CHALLENGES
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Publicise / promote the programme in
populations with low uptake
Increase in surveillance / colonoscopy capacity
Increase no of screening colonoscopists
Fluctuations in demand / 62 day targets
2010 – increase the target population to 74 yrs
Change in funding arrangements April 2010
QA requirements/ monitoring
Cancer Targets
BCSP National Office
Targets
14 days till FOBt clinic
14 days SSP clinic to
colonoscopy
DH Cancer Target
62 Day Wait
Best practice 7 – 10
days to ssp clinic
7- 10 days to
colonoscopy
The FUTURE
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? Flexible sigmoidoscopy
Different faecal tests – FIT
Colonoscopy at 60!
Virtual Colonoscopy
No Caption Found
Fenlon, H M et al. Gut 1998;43:806-811
Copyright ©1998 BMJ Publishing Group Ltd.
THANKS TO:
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Executive Team at Blackpool Fylde and Wyre NHS
Hospitals Foundation Trust
Cancer Network ,Medical Division, Clinical Support,
pathology/ radiology, MDTs ,
Endoscopy managers/ teams – Blackpool, Burnley,
Preston
BCS team – Judith, Louise, SSPs Elaine/ Helen
PCTs /Public Health– East Lancs,BlackburnW
Darwen, NHS Blackpool, Central and North Lancs
teams