THAMES VALLEY AND

EAST BERKSHIRE CANCER LEAD

CRUK CLINICAL GP

END OF LIFE SPECIALIST GP

Dr Anant Sachdev

GP

Ringmead Medical Practice,

Bracknell

Celebreties ….

The Ones

Diagnosed Starring …

• The cancer screening programmes

• The screening tests and how they work

• National and local uptake/coverage of each programme

• Barriers to participation

• Interventions to improve participation

What we will cover…

Quizzzzzzz

…. FIRST

Which is the most common cancer?

A. Breast

B. Lung

C. Prostate

D. Skin

Which is the most common cancer?

A. Breast

B. Lung

C. Prostate

D. Skin

The most common form of cancer overall in both men and women is skin cancer. Ultraviolet light, is the main cause of skin cancers. There are three main types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and melanoma.

Apart from skin, which are the 3 most common

cancers in order?

A. Breast Lung Prostate

B. Breast Lung Bowel

C. Prostate Breast Bowel

D. Prostate Lung Bowel

Which are the 3 most common cancers?

A. Breast Lung Prostate

B. Breast Lung Bowel

C. Prostate Breast Bowel

D. Prostate Lung Bowel

The 20 Most Commonly Diagnosed Cancers

UK, 2010 (Excluding Non-Melanoma Skin Cancer)

Cancer - UK survival rates

Summary

“The countries of the International Cancer Benchmarking Partnership selected for study have similar wealth, universal health coverage, and high-quality cancer registration.

Survival has continued to improve for each cancer in all six countries, but generally remains higher in Australia, Canada, and Sweden, intermediate in Norway, and lower in Denmark and the UK.

The patterns are consistent with later stage at diagnosis or differences in treatment, particularly in Denmark and the UK and in older patients”

The International Cancer Benchmarking Partnership:

UK Australia Canada Denmark Norway Sweden

Source: The Lancet Volume 377, Issue 9760, pages 127 – 138 8/1/11

One year survival Eurocare 4

WHAT ARE THE CANCER SCREENING PROGRAMMES IN ENGLAND?

Screening programmes for

cancer in UK

Cervical

Bowel Breast

Why is screening important?

Screening reduces the number of people

dying from cancer by:

• Detecting cancer early

63% of cancers detected through

screening are at an early stage

(stage I)

• Preventing cancer Bowel scope screening and

cervical screening can both

prevent cancer

Cancer screening programmes

2

1

Bowel screening

Men and women aged 60 to 74 invites up to 75

Testing kit received in the post.

1 or 6 stool samples needed.

Breast screening

Women aged 50 to 70.

Women over 70 can request screening.

Mammography

Cervical screening

Women aged 25 to 64 in England

Every 3 years up to age 49, then every 5 years

Cytology

National

target

80%

National

target

60%

National

target

80%

Brack

and

Ascot

WAM Slough England

Breast 73.3 74.3 65.6% 72.1

Cervical 75.7 71.9 65.6% 71.7

Bowel 60.8 58.8 43.8% 59.5

Screening Coverage for Berkshire CCGS 17/18

BOWEL SCREENING

BOWEL CANCER FACTS

Bowel cancer is the 4th most common cancer in the UK

There are around 40,000 new cases a year (2014)

& around 16,000 deaths a year

57% of people survive bowel cancer for 10 or more years

More than 50% of bowel cancer cases are linked to major

lifestyle and other risk factors

What kind of foods are linked to colon cancer ?

A. Processed meats

B. Microwavable foods

C. Plastic containers

D. Salt enriched foods

What kind of foods are linked to colon cancer ?

A. Processed meats

B. Microwavable foods

C. Plastic containers

D. Salt enriched foods

Meat processing involves the addition of preservatives like sodium nitrite or products that enhance colour

and flavour. The meat is also sometimes smoked, which may also create compounds (benzene) that

might increase cancer risk. Studies have shown that consuming large amounts of processed meat is

associated with an increased risk of developing colorectal cancer. One potential explanation for this

association is that nitrites are added to many lunch meats, hot dogs, ham products, and other processed

meats.

The English programme uses 2 different types of bowel screening:

• FIT/Faecal Occult Blood Test

(FOBt)

• Bowel Scope

Five Year Forward View #futureNHS

Bowel scope (flexible sigmoidoscopy)

A one-off bowel screening test offered to men and women at 55 years who are registered with a GP. Aims to detect polyps (cancer potential) in the lower part of the bowel with sigmoidoscope For every 220 people screened by bowel scope, 1 less person will die from bowel cancer over 17 years.

Five Year Forward View #futureNHS

Bowel cancer screening: the FOBt

• Men and women aged between 60-74 are invited every 2

years. • Must be registered with a GP practice to receive

invitation

• Anyone over 74 can request a kit by calling

0800 707 6060

• Screening kit is completed at home and sent to the hub

• The screening hub analyses the kit

• The test detects tiny amounts of blood in the sample of poo, which can’t be seen

by the eye

• The FOBt does not diagnose bowel cancer

Fobt: practical tips

• 6 poo samples are needed:

• 2 samples from 3 separate

bowel motions

How to complete the bowel screening test animation:

https://www.youtube.com/watch?v=m2f-wY0C_1Q

WHAT HAPPENS TO THE COMPLETED FOBT KITS?

There are 3 potential outcomes:

• No blood detected (normal result) – person receives letter

informing them no further action is needed

• Result is unclear – test needs to be repeated (programme

sends individual a second kit)

• Blood is detected (abnormal result) – The patient will have an

appointment with a specialist nurse to discuss and arrange a

colonoscopy

The hub/centre/laboratory tests the kit to see whether there are any

traces of blood

For every 1000 people screened with FOBt, 20 will have an abnormal result,

and 2 will have pathology that could lead to/is cancer

FIT for screening Faecal Immunochemical Test

BIG SWITCH UNDER WAY

One sample using a brush

Similar costs

More acceptable

Evidence in GUT 2016

7% increase in overall uptake of screening (from 59% to 66%)

Double that of previous none responders (especially in men)

Fit positivity 7.8% - a negative FIT has a negative predictive value of 98% for cancer and

higher risk adenomas

Increased detection cancer x2 and advanced adenoma x5

Five Year Forward View #futureNHS

Bowel scope (flexible sigmoidoscopy)

A one-off bowel screening test offered to men and

women at 55 years who are registered with a GP.

Aims to detect polyps in the lower part of the bowel

• Uses a thin flexible tube with a tiny camera on

the end

For every 220 people screened by bowel scope, 1 less

person will die from bowel cancer over 17 years.

WHAT ARE THE BENEFITS AND HARMS OF BOWEL CANCER SCREENING?

The benefits of bowel cancer screening

The FOBt kit and bowel scope test save lives

• People taking part in FOBt screening reduce their risk of dying from bowel

cancer by 25%

• People having the bowel scope test have a 40% lower risk of dying from

bowel cancer

• Early diagnosis – 90% survive 5+ years

• Estimates are that by 2025 the programme will save 2000 lives a year

Current uptake is around only 50%, by 2020 hoping to be 65%

Bowel scope can prevent some cancers from developing

• The risk of developing bowel cancer is reduced by a third

• These benefits last for at least 17 years

• Screening can give an abnormal result even though the person doesn't have cancer – a false positive result

• Screening can miss cancer – a false negative result

• People over-interpret a normal result and do not report symptoms they experience in

the future – false reassurance

• A bowel cancer or polyp that would not have caused any harm is diagnosed and

treated - over diagnosis

• Follow up tests from FOBt/FIT, as well as bowel scope itself, have risks such as bleeding,

damage (perforation) to the bowel wall, or (very rarely) death

• Deciding whether to be screened is individual – a person’s attitudes and values shape

their view on the relative benefits and harms

The harms of bowel cancer screening

What are the barriers to participation in the bowel cancer screening programme?

Bowel cancer screening barriers

• Knowledge of screening

• E.g. thinking screening isn’t relevant because they don’t have

symptoms

• Fear and fatalism

• E.g. believing that death is predetermined

• The test itself

• E.g. dislike and social taboo around handling faeces

• Motivation and practical barriers

• E.g. competing demands on time

• Beliefs related to culture, gender, or deprivation

• E.g. screening and preventative tests are not familiar parts of

healthcare

WHAT NEEDS TO BE DONE TO INCREASE UPTAKE?

Improve awareness of bowel cancer screening

Training

- Ensure all staff know about the bowel screening programme and

are familiar with the FOBt - Have a screening lead

- Use the CRUK GP Good Practice Guide

Display screening information - Bowel cancer screening information cards

- Leaflets and posters about bowel cancer and bowel cancer screening

- Animation: how to do the test

Make the most of Bowel Cancer Awareness Month in April

How can you help increase uptake?

Endorse the Bowel Cancer Screening

Programme Contact your local screening hub/ centre to see if they can

provide you with Prior Notification Lists (PNLs) for bowel screening

OR Search for patients approaching their 60th birthday and 60-74

year olds with a non response result in the last 2 years

Consider contacting people via: • Letter (templates are available)

• Telephone (a telephone script is available)

• Opportunistically (Use alerts)

Use READ codes to record any interventions

How can you help increase uptake? (Cont)

Remove barriers to participation

Accessible information

• Screening leaflets and resources are available in a range of languages and pictorial easy read

versions

• Use animation video and CRUK factsheet explain how to complete test

Making reasonable adjustments

• Be ready to offer support to those who ask for it. This includes demonstrating how to use the test

and talking through screening information

• Consider liaising with community health teams to identify people who may benefit from additional

support

• Support people to request replacement kits

HOW CAN YOU HELP INCREASE UPTAKE? (CONT)

BREAST SCREENING

• Breast cancer is the most common cancer in the UK – around 150

cases are diagnosed every day

• Around 55,200 new cases a year in the UK in 2014 and around

11,400 deaths a year

• 78% of women survive breast cancer for 10 or more years

• 27% of breast cancer cases in the UK are linked to major lifestyle

and other risk factors.

Breast cancer facts

Breast Cancer in UK

Breast Cancer Incidence by Age Group, CRUK 2014

• For women aged between 50 and 70 years, who are registered with a GP

• Test is a mammogram – 2 x-rays of each breast

• Carried out at special clinics or mobile breast screening units

• Self-referral over 70

Breast screening: mammography

What happens to women’s mammograms?

• Mammograms are examined and the results are sent to

the woman and her GP within two weeks

• Women may be asked to go to an assessment clinic for

further tests if a potential abnormality is detected at

initial screening

• Women may also be asked to go to an assessment

clinic if their mammograms need repeating (e.g. if an x-

ray was not clear enough)

Every time 100 women are screened:

• 96 women have a normal result

• 4 are called back for more tests

Of those 4 called back:

• 3 are found not to have cancer

• 1 has cancer

BREAST SCREENING RESULTS BREAKDOWN

WHAT ARE THE BENEFITS AND HARMS OF BREAST CANCER SCREENING?

• The current evidence suggests that breast screening reduces the number of deaths from breast cancer by about 1,300 a year in the UK.

• Breast cancers found by screening are generally at an early stage. Early stage breast cancers are more likely to be cured and may need less treatment.

• 99% of women who are diagnosed with breast cancer at the earliest stage (stage I) survive their cancer for 5 years or more

• 80% survive to 10 years

The benefits of breast cancer screening

• Screening doesn't find all breast cancers. So some people with breast cancer will be missed - a false negative result.

• In some women, the test is positive even though there is no breast cancer - a false positive result

• Women over-interpret a normal result and do not report symptoms they experience in the future - false reassurance

• Harms associated with the test e.g. radiation exposure, pain

• A breast cancer is picked up that would not have caused harm – overdiagnosis

The harms of breast cancer screening

• Offer support

• Acknowledge that these are difficult issues, so it’s normal to feel confused or uncertain.

• Explain clearly

• Explain that some cancers didn’t need to be picked up, and would not have caused harm in a woman’s lifetime. This means some women will have treatment they didn’t need, and have to live with the impacts of treatment.

• Don’t push women to take up screening

• Whether to have breast screening is an individual choice and there is no right or wrong answer.

• Use the NHS screening leaflets as a guide https://www.gov.uk/government/publications/breast-screening-helping-women-decide

How can you help women understand the benefits and harms?

CERVICAL SCREENING

• In women, cervical cancer is the 13th most common cancer

• There are around 3,000 new cases in the UK each year and around 900 deaths a year

• 63% of women survive cervical cancer for 10 years or more.

• Earliest stage (1), 96% survive more than 5 years

• Late stage (IV), 5 % survive 5 years

• HPV infection is the main risk factor for cervical cancer (97% association), together with smoking

Cervical cancer facts

14% of cervical cancer cases are identified on cervical screening –

should it be ….?

A. Higher ?

B. Lower ?

C. Same ?

D. Doesn’t matter ?

14% of cervical cancer cases are identified on cervical screening –

should it be ….?

A. Higher ?

B. Lower ?

C. Same ?

D. Doesn’t matter ?

Cervical screening aims to prevent cancer

• It is NOT a test to find cancer. It is a test to detect changes to the cells of the cervix that may develop into cancer in the future

• Women from 25-64, who are registered with a GP are invited for cervical screening

• Women aged 25-49 are invited every 3 years. After that, women are invited every 5 years until the age of 64

• The test collects samples of cells from the cervix

• In England and Wales, the NHS has committed to using an HPV test as the primary test for of cervical screening.

• Screening will be performed in the same way, but the sample taken will be analysed differently. It will be tested to see if the HPV virus is present and only if this test is positive will it be examined for abnormal cell changes (cytology):

HPV +ve Abn smear, 42% chance of CIN3 - colposcopy

HPV +ve smear normal, 5% chance, 1 year follow up

If 1 year smear abn, 25% chance of CIN3 - colposcopy

• HPV primary screening saves more lives than the current test, as those that are HPV positive but who don’t have cell changes will now be identified and monitored.

HPV primary testing

For every 100 women:

• 94 will have a normal result

• 6 will have abnormal cells

Of those 6:

• 2 will have no HPV infection and will return to routine screening

• 4 will be invited for a colposcopy

Results breakdown

• Cervical screening saves at least 2,000 lives each year in the UK.

• The benefit of screening on cervical cancer risk increases with age.

• The cervical screening programme started in the late 1980s and since the early 1990s cervical cancer incidence rates have decreased by almost a quarter in the UK.

The benefits of cervical screening

SUMMARY

• Screening reduces the number of people dying from cancer and in some cases, can prevent cancer from developing

• Informed choice is central to screening, and patients should be given good, balanced information to help them reach a decision

• The uptake of screening can be low in certain areas, particularly for bowel cancer screening

• We can help people to understand and undertake screening by helping them to break some of the common barriers down

• Never underestimate the power we have to help people and the difference we can make

KEY POINTS

Questions?

Thank You

Dr Anant Sachdev

Cancer Lead – TVCA, CRUK, B East anant.sachdev@nhs.net

07976 608871