SETTING UP THE SERVICE

BYLYNN TOBIN

HOW DID WE GET HERE?

ABUNDENCE OF EVIDENCE PROVIDING JUSTIFICATION FOR BOWEL CANCER SCREENING

BOWEL CANCER-THE FACTS• THIRD MOST COMMON FORM OF

CANCER• SECOND LEADING CAUSE OF CANCER

RELATED DEATHS IN THE WEST• USUALLY ASYMPOTOMATIC IN EARLY

STAGES• 95% OF COLO-RECTAL CANCERS ARISE

FROM ADENOMATOUS POLYPS

BOWEL CANCER- THE FACTSIN THE UK1 IN 20 FEMALES AND 1 IN 18 MALES

WILL DEVELOP BOWEL CANCER IN THEIR LIFETIME

EVERY DAY 50 PEOPLE DIE FROM BOWEL CANCER

THIS EQUATES TO 18,000 DEATHS PER YEAR

SYMPTOMATIC PATIENTS DUKES STAGES

• DUKES A = 13%• DUKES B = 38%• DUKES C = 49%

SCREENING PATIENTS DUKES STAGES

• DUKES A = 48%• DUKES B = 25%• DUKES C = 27%

C & M DUKES STAGES

• DUKES A = 53%• DUKES B = 21.4%• DUKES C = 21.4%• DUKES D = 4.2%• THESE STATS ARE BASED UPON THE

FIRST 115 PATIENTS IN THE PROGRAMME BUT WE HAVE HAD 247 CANCERS TO DATE

SETTING UP THE SERVICE

• PUT OVERALL PATHWAY SLIDE IN HERE

1st nurse clinic appointment letter sent to patient from Rugby

1st appointment nurse clinic

Referral forCT ACE

Patient refuses colonoscopy

Disclaimer

Unfit for colonoscopy

BOWEL CANCER SCREENING PROGRAMME PATIENT JOURNEY

DNA

Nurse to discuss assessmentwith BCSP clinician

Cancelled

NAD Polyps

Nurse telephoneClinic

Incomplete colonoscopy

Administrator to phone patient and offer new appointment

Suspected tumour Other

Referral to local MDT for CT

staging.Histology within 1

week.

Surveillance colonoscopy

Colonoscopy GP information fax

Intermediate risk polyp repeat colonoscopy 3

yearly

Ba Enemawithin 2 weeks

3 Year surveillance until 2 normal examinations

Rugby rebook 1st nurse clinic appointment

Routinescreening

2 year FOBTinvitation

Referral back to local speciality

Pre appointment

Day of appointment

Administrator to phone patient and offer new

appointment

High risk polyp repeat colonoscopy 1 year

Routine screening2 year FOBT

Invitation

Screening centre to offer 2nd

appointment

NAD Routine screening

2 Year FOBT invitation

Abnormal repeat colonoscopy

Low risk polyps routine screening 2 year FOBT

invitation

3 Yearly surveillance until2 normal examinations

Listed for colonoscopy

DNA

Attended

SETTING UP CLINICS.CONSIDERATIONS;• HOW MANY CLINICS WILL YOU NEED TO

FACILITATE YOUR POPULATION?• WHERE WILL YOU HOLD CLINIC?• IF YOU HAVE A SURGE IN FOBT + DO

YOU AVAILABILTY FOR EXTRA CLINICS?• DO YOUR PATIENTS HAVE A CHOICE OF

WHICH CLINIC THEY WISH TO ATTEND?

WHAT MUST BE IN PLACE BEFORE WE SEE A PATIENT• AGREED PATHWAYS/ PROFORMAS• AGREED MANAGEMENT PLANS FOR PATIENTS WITH

COMPLEX CO-MORBIDITY• PGD• TCI PATHWAY• ANTI-COAGULATION POLICY (NEW BSG GUIDELINES)• DIABETIC POLICY• NOMINATED LEADS FOR;• CT• X-RAY• PATHOLOGY• PHARMACY

WHAT DO I NEED TO BRING TO CLINIC WITH ME?

• PATIENT ASSESSMENT FORMS/LAPTOPS• MOBILE PHONES• PATIENT JOURNEY STORY BOOKS• AGREED HEALTH PROMOTION LEAFLETS• CONSENT INFORMATION LEAFLETS• RELEVENT LOCAL HOSPITAL INFORMATION• C&M HAVE CONDENSED THIS INFORMATION

INTO BOOKLETS SPECIFIC TO EACH SCREENING SITE

WHO IS INELIGABLE?

• IBD PATIENTS ALREADY IN SURVEILLANCE PROGRAMME

• BARIUM ENEMA WITH FLEXI SIGMOIDOSCOPY OR COLONOSCOPY WITHIN PAST 2 YEARS

• CURRENTLY UNDER TREATMENT FOR COLO-RECATL CANCER OR ALREADY IN SURVEILLANCE PROGRAMME

• TOTAL COLECTOMY

COMMONLY ASKED QUESTIONS/ANSWERS

• WHAT IS MY CHANCE OF HAVING;• CANCER = 1 IN 10 (10%)• POLYPS = 1 IN 4 (40%)• NORMAL RESULT = 1IN 5 (50%)

COMMONLY ASKED QUESTIONS/ANSWERS

• HOW MANY PEOPLE HAVE ABNORMAL FOBT RESULTS?

• 2 OUT OF 100 WILL HAVE ABNORMAL RESULTS SO 98 OUT OF 100 WILL BE NORMAL

HOW RELIABLE/EFFECTIVE IS THE FOBT TEST KIT?• PROS;• NON-INVASIVE• CAN DO AT HOME• REFLECTS COMPLETE

COLON• CHEAP AND EASY (£5)• COLONOSCOPY £424

• CONS;• POOR SENSITIVITY AND

SPECIFICITY• - 10% FOR Ca• - 40% FOR ADENOMAS• SENSITIVITY• 55-92% COLORECTAL

CANCERS• 10-32% ADENOMAS• 12-53% ADENOMAS

GREATER THAN 1 CM

COMMONLY ASKED QUESTIONS/ANSWERS

• IF MY COLONOSCOPY IS NORMAL, WILL YOU DO ANY FURTHER INVESTIGATIONS TO LOOK FOR POSSIBLE EXPLANATIONS OF FOBT POSITIVITY?

COLONOSCOPY

• INVESTIGATION DATASET• CONSENT• MDT PATHWAYS, REFERRAL FORMS AND

PATIENT CONTACT LETTERS POST SUSPECTED DIAGNOSIS USEFUL TO HAVE AT EACH SCREENING SITE.

• BCSP STAMPS• POST COLONOSCOPY DOCUMENTATION

POST COLONOSCOPY/TELEPHONE CLINICS• IT PROFORMAS• POST INVESTIGATION DATASET• SIGNED/DISCUSSED HISTOLOGY• 8 PATIENTS PER CLINIC WITH 20/30

MINUTE SLOTS (DEPENDING UPON EXPERIENCE OF SSP)

MALIGNANT POLYPS. WHO TELLS THE PATIENT?

• LIAISE WITH SCREENING CONSULTANT RE; MALIGNANT HISTOLOGY

• ASSESS SUITABILITY OF SSP GIVING THE RESULT

• BRING THE PATIENT INTO FACE TO FACE CLINIC

WHAT THE SSP MUST UNDERSTAND BEFORE GIVING MP DIAGNOSIS;• CLINICAL DETAILS• MACROSCOPIC DESCRIPTION• TYPE OF CARCINOMA• DIFFERENTIATION• RESECTION MARGINS• HAGITT STAGE• KIKUCHI STAGE• NO SPECULATION ON PART OF SSP

BCSP CHALLENGES

• AGE EXTENSION >74 2010-2014• 62 DAY TARGET DEC 2008• THIRD WAVE ACTIVITY, WILL LAST

FEW SCREENING CENTRES SLIP INTO 2009/2010

• CAREER DEVELOPMENT FOR SSP