What’s New in Colorectal Cancer DiagnosticsOctober 2014

Ed Seward

Consultant Gastroenterologist

ppppp

ppppp

ppppp

ppppp

p

What’s New in Colorectal Cancer DiagnosticsOctober 2014

Ed Seward

Consultant Gastroenterologist

ppppp

ppppp

ppppp

ppppp

p

TOP SECRET!

Key Learning Points Bowel Scope

The rationale The data so far Bringing it to North London

Straight to test Why the need National drivers What it means to you and your patients

Bowel Scope

Atkin WS, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010;357:1624–33

55-64 yrs, n=113,195

Median follow up 11 years

Reduction in colorectal cancer 33%

Reduction in mortality 43%

David Cameron drops a bomb shell on Andrew Marr show October 2010

This was no laughing matter!

Bowel Scope

Jan 2011 Pathfinder sites established

Apr 2011 Flexi sig programme approved

2012/3 First pilot site starts screening

2013/4 First wave sites roll out, 36% coverage by Mar 2014

Mar 2015 Second wave enrolment complete, 2/3 coverage

2016 Roll out complete

Bowel Scope data so far

Invites sent out so far 37,346

Self refer 170

Responded 17,478

Attended for bowel scope 12,295

Number of flexis 12,192

Colonoscopies following flexis 480 (3.94%)

Bowel Scope data so far

Cancers 8

High risk 74(>5 polyps, or 3 plus 1 >1cm)

Intermediate risk 128(>3 polyps, or 1> 1cm)

Low risk 170(1-2 polyps <1cm)

Abnormal, not polyps 4,718

Normal 6,863

i.e. significant

pathology

200/12,000 cases

Bowel Scope: Is it achievable?

1.6% population are 55 years old

For a 500,000 population, that’s 8000 flexis pa

160 flexis per week

This is an additional 8 lists/week (assuming 50% uptake), as well as an additional screening colonoscopy list/wk assuming a 5% referral rate

Bowel Scope: Is it achievable?

Massive workforce implications

Massive infrastructure demands

Massive bureaucratic demands

Bowel Scope: Is it achievable….., maybe?

UCLH on track, just, to roll out March 2015

Slow roll out initially 1 list/week

Building up over 18-24 months

Watch this space!

And now for something completely different…

Straight to test pathway for colorectal symptoms

What the Royal College wants…Beverley Chalmers is a 62-year-old librarian. She is married with two grown up children and three grandchildren. She says her marriage has been going through a particularly ‘difficult patch’ since her husband lost his job two years ago and markedly increased his alcohol consumption. She would like to retire but is concerned over finances. She consults you with symptoms of weakness and fatigue. She has lost 5kg in the last six months with no obvious cause. You ask about Beverley’s gastrointestinal (GI) symptoms: she has had constipation on and off for a number of years, with occasional bloating which she attributes to ‘wind’. She saw you 12 months ago with a single episode of rectal bleeding and you noticed a small external haemorrhoid. The bleeding settled after conservative treatment. Beverley is stressed by changes at her library (a new supervisor is ‘making life difficult’ for her) and by the relationship difficulties in her marriage. She is also concerned about her 12-year-old granddaughter’s behaviour – she is missing school and not telling her parents where she is.Over the last three months Beverley has become a little breathless – she first noticed this when climbing the stairs at work. She has mild rheumatoid arthritis.A locum in the practice recently prescribed a mild diuretic and temazepam (as she was sleeping poorly). She also takes a regular dose of a non-steroidal antiinflammatory drug (NSAID). She has had a normal mammogram within the last 12 months. She has had two invitations, at age 60 and 62, to undertake a faecal occult blood test (FOBT) as part of the screening programme; the first was negative and she declined the second. There is no family history of note. Beverley has never smoked, and drinks only on rare social occasions.On examination she has mild clinical signs of anaemia. Her BP is 130/70, lungs are clear. Abdominal examination is essentially normal. You perform a rectal examination which is also normal, and there is no sign of the haemorrhoid you previously diagnosed.Initial investigations, including an Hb of 7.3 gm/DL, suggest she has iron deficiency anaemia and you commence iron replacement therapy. When you see her on a follow-up visit her tiredness appears to have worsened. She also appears anxious and is very concerned about her poor sleeping. She thinks the iron tablets are making her more constipated. She has lost a further kilogram in weight which she can’t understand. You need to give thought to the next stepsyou will take in investigating and managing Beverley’s symptoms.

What the Royal College wants…Beverley Chalmers is a 62-year-old librarian. She is married with two grown up children and three grandchildren. She says her marriage has been going through a particularly ‘difficult patch’ since her husband lost his job two years ago and markedly increased his alcohol consumption. She would like to retire but is concerned over finances. She consults you with symptoms of weakness and fatigue. She has lost 5kg in the last six months with no obvious cause. You ask about Beverley’s gastrointestinal (GI) symptoms: she has had constipation on and off for a number of years, with occasional bloating which she attributes to ‘wind’. She saw you 12 months ago with a single episode of rectal bleeding and you noticed a small external haemorrhoid. The bleeding settled after conservative treatment. Beverley is stressed by changes at her library (a new supervisor is ‘making life difficult’ for her) and by the relationship difficulties in her marriage. She is also concerned about her 12-year-old granddaughter’s behaviour – she is missing school and not telling her parents where she is.Over the last three months Beverley has become a little breathless – she first noticed this when climbing the stairs at work. She has mild rheumatoid arthritis.A locum in the practice recently prescribed a mild diuretic and temazepam (as she was sleeping poorly). She also takes a regular dose of a non-steroidal antiinflammatory drug (NSAID). She has had a normal mammogram within the last 12 months. She has had two invitations, at age 60 and 62, to undertake a faecal occult blood test (FOBT) as part of the screening programme; the first was negative and she declined the second. There is no family history of note. Beverley has never smoked, and drinks only on rare social occasions.On examination she has mild clinical signs of anaemia. Her BP is 130/70, lungs are clear. Abdominal examination is essentially normal. You perform a rectal examination which is also normal, and there is no sign of the haemorrhoid you previously diagnosed.Initial investigations, including an Hb of 7.3 gm/DL, suggest she has iron deficiency anaemia and you commence iron replacement therapy. When you see her on a follow-up visit her tiredness appears to have worsened. She also appears anxious and is very concerned about her poor sleeping. She thinks the iron tablets are making her more constipated. She has lost a further kilogram in weight which she can’t understand. You need to give thought to the next steps you will take in investigating and managing Beverley’s symptoms.

What the Royal College wants…62lost 5kg

saw you 12 months ago with a single episode of rectal bleeding regular dose of a non-steroidal anti inflammatory drugHb of 7.3

she has iron deficiency anaemia follow-up visit

What real life requires… Do not sit on 2WW criteria Do not ignore rectal bleeding Have a low threshold for referral

4 

ICBP: 5 year relative survival: Coleman et al, Lancet 2011

Future of GI ServicesMassive emphasis on early diagnosis for GI cancers (esp lower GI)



What used to happen

GP referral

Consultant triage

OPD appointment

Colonoscopy appointment

OPD follow up

8 weeks

6 weeks

3 months

Straight to testStraight to test



What now happens

GP referral

Nurse telephone

assessment

Colonoscopy appointment

?OPD review

3 days

2-3 weeks

Straight to testStraight to test



How does it work?

GP makes C&B appointment for any patient with colorectal

symptoms

Telephone assessment by trained nurse for 20 minutes

Proforma and decision algorithm

Options are colonoscopy

flexible sigmoidoscopy

CT pneumocolon

clinic



The Process

Patient assessed by a doctor or specialist nurse

Decision made as to future management

Post procedure

Data entered into database, outcomes tracked

Histology results to GP and patient

Patient satisfaction sought with survey monkey

Weekly and ad hoc debrief



The Data

313 pts, m=f, mean age 57

60% 18WW, 40% 2WW

85% colonoscopy7% flexible sigmoidoscopy8% straight to clinic

3.5% DNA rate (unit average 7%)

4% cancer pick up

6% IBD

43% discharged after endoscopy

The Data

Mean time on pathway for 18WW: 42 days = 57% saving

Mean time on pathway for 2WW: 13.2 days = 50% saving

Other savings…patient benefits..safer..staff redeployment..money saved..improved performance on RTT

To recap… Bowel scope will offer every 55 year old an

opportunity to be screened for polyps and cancer

It’s a huge undertaking, but benefits are evidence based

We owe our patients greater and more timely access to lower GI investigation

New diagnostic pathways are necessary to manage the huge endoscopic requirements

Interested…?

edward.seward@uclh.nhs.uk