What’s New in Colorectal Cancer Diagnostics October 2014 Ed Seward Consultant Gastroenterologist...
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Transcript of What’s New in Colorectal Cancer Diagnostics October 2014 Ed Seward Consultant Gastroenterologist...
What’s New in Colorectal Cancer DiagnosticsOctober 2014
Ed Seward
Consultant Gastroenterologist
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What’s New in Colorectal Cancer DiagnosticsOctober 2014
Ed Seward
Consultant Gastroenterologist
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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…?