Bowel Cancer & Bowel Cancer Screening Education and Awareness Sessions

Bowel Cancer & Bowel Cancer Bowel Cancer & Bowel Cancer Screening Screening

Education and Awareness Education and Awareness SessionsSessions

Bowel Cancer Screening Bowel Cancer Screening ProgrammeProgramme

Maureen SayerMaureen Sayer

Health Improvement PractitionerHealth Improvement Practitioner

Cheshire and Merseyside Bowel Cancer Cheshire and Merseyside Bowel Cancer

Screening ProgrammeScreening Programme

AIMS and AIMS and Outcomes:Outcomes:

Increased awareness of the signs and symptoms of Increased awareness of the signs and symptoms of bowel cancerbowel cancer

Increased understanding of the Bowel Cancer Screening Increased understanding of the Bowel Cancer Screening Programme (BCSP)Programme (BCSP)

Increased knowledge on how to support your client Increased knowledge on how to support your client group in relation to the BCSPgroup in relation to the BCSP

Increased ability of staff to act as health advocates to Increased ability of staff to act as health advocates to their client grouptheir client group

Public Health PerspectivePublic Health Perspective

• Bowel Cancer is the third most Bowel Cancer is the third most common cancer in the UKcommon cancer in the UK

• Approximately 34,900 new cases p.aApproximately 34,900 new cases p.a

• It is is the second largest cause of It is is the second largest cause of cancer deaths in the UK cancer deaths in the UK (Cancer Research UK, (Cancer Research UK,

2005. Cancerstats).2005. Cancerstats).

• In 2004 approximately 16,100 people In 2004 approximately 16,100 people died from bowel cancer in the UK, 737 died from bowel cancer in the UK, 737 deaths within Cheshire & Merseysidedeaths within Cheshire & Merseyside

• Life time risk of developing Bowel Life time risk of developing Bowel Cancer in the UK is about 1:18 for men Cancer in the UK is about 1:18 for men and 1:20 for womenand 1:20 for women

Public Health PerspectivePublic Health Perspective

Who is at risk of developing bowel Who is at risk of developing bowel cancer?cancer?

• Both men and women

• People who-

– Take little exercise

– Are overweight

– Have a diet high in red meat and low in vegetables, fruits and fibre

• People with a family history (CRC People with a family history (CRC Relatives)Relatives)

• Inflammatory Bowel DiseaseInflammatory Bowel Disease• Genetics-Genetics-

– Familial Adenomatous Polyposis Familial Adenomatous Polyposis (FAP)about 1% of cases(FAP)about 1% of cases

– Hereditary Non-Polyposis Colorectal Hereditary Non-Polyposis Colorectal Cancer (HNPCC) about 2-5% of cases Cancer (HNPCC) about 2-5% of cases

Who is at risk of developing bowel Who is at risk of developing bowel cancer? (continued)cancer? (continued)

• The risk of developing bowel cancer The risk of developing bowel cancer increases with age. increases with age.

• About 80% of people who get Bowel About 80% of people who get Bowel cancer are aged 60 and overcancer are aged 60 and over

Who is at risk of developing bowel Who is at risk of developing bowel cancer? (continued)cancer? (continued)

Mental Health and Learning Mental Health and Learning DisabilitiesDisabilities

• SchizophreniaSchizophreniaRecent research shows that people with Recent research shows that people with this condition are at increased risk of this condition are at increased risk of developing bowel cancerdeveloping bowel cancer

• Learning DisabilitiesLearning DisabilitiesIncreased risk is linked to obesity, poor Increased risk is linked to obesity, poor diet, lack of physical activity ,exclusion diet, lack of physical activity ,exclusion from screening programmes. Mortality is from screening programmes. Mortality is linked to late presentation of symptoms.linked to late presentation of symptoms.

Bowel CancerBowel Cancer

What are the signs and symptoms of What are the signs and symptoms of bowel cancer?bowel cancer?

Practical Exercise!Practical Exercise!

Then feedback from groupsThen feedback from groups

Bowel Cancer SymptomsBowel Cancer Symptoms

• Symptoms lasting 4-6 weeks need to be Symptoms lasting 4-6 weeks need to be investigatedinvestigated

• Any clients with symptoms should be Any clients with symptoms should be encouraged to see their GPencouraged to see their GP


• Bleeding from the RectumBleeding from the Rectum ( Back passage) ( Back passage)Bright Red or Dark Black blood Bright Red or Dark Black blood Found in or on Bowel Motion ,toilet paper or toilet Found in or on Bowel Motion ,toilet paper or toilet bowelbowel

• TirednessTirednessCaused by blood lossCaused by blood lossNeeds investigatingNeeds investigating


• Change of Bowel HabitChange of Bowel HabitChange from your normal patternChange from your normal patternConstipationConstipationDecreased Bowel MotionsDecreased Bowel MotionsDiarrhoeaDiarrhoeaMore frequent Bowel MotionsMore frequent Bowel MotionsMay alternateMay alternate


• Abdominal or Rectal PainAbdominal or Rectal Pain

• Abdominal LumpAbdominal Lump

Needs InvestigatingNeeds Investigating


• Nausea ( feeling Sick)Nausea ( feeling Sick)

• Unexplained loss of appetiteUnexplained loss of appetite

• Unplanned Weight LossUnplanned Weight Loss

Bowel Cancer Screening ProgrammeBowel Cancer Screening Programme Cheshire and Merseyside NHS North WestCheshire and Merseyside NHS North West

Roll out planRoll out plan

Cancer Reform Strategy Cancer Reform Strategy ChangesChanges

• Extending screening from 2010 to 70-74 year Extending screening from 2010 to 70-74 year oldsolds

• 62 day waits to apply – end 200862 day waits to apply – end 2008

• Consideration of people in their 50s is next Consideration of people in their 50s is next stepstep– Flexi-sig trial results will be available in 2/3 yearsFlexi-sig trial results will be available in 2/3 years

• Immunological testing and CT colography to Immunological testing and CT colography to be considered in due course be considered in due course

Responsibility for the BCSPResponsibility for the BCSP

• Cheshire & Merseyside NHS North Cheshire & Merseyside NHS North West have the lead responsibility for West have the lead responsibility for BCSP initially. Thereafter PCT’s will BCSP initially. Thereafter PCT’s will commission the programme.commission the programme.

Responsibility of the PCTResponsibility of the PCT

• Representative identified to attend Representative identified to attend Primary Care and Health Inequalities Primary Care and Health Inequalities GroupGroup

• Identify suitable venues for the Nurse Identify suitable venues for the Nurse Led ClinicsLed Clinics

• Develop a Service Level Agreement Develop a Service Level Agreement with the Bowel Cancer Screening with the Bowel Cancer Screening programme at Aintreeprogramme at Aintree

• Develop Patient Information leafletsDevelop Patient Information leaflets

Responsibility of the PCTResponsibility of the PCT

• Publicise Bowel Cancer Screening Publicise Bowel Cancer Screening programmeprogramme

• Identify Groups who may experience Identify Groups who may experience Health InequalitiesHealth Inequalities

• Hold education sessions for PHCTsHold education sessions for PHCTs

• Information provided on PALs Information provided on PALs telephone servicetelephone service

Cheshire & Merseyside BCSP Cheshire & Merseyside BCSP StatisticsStatistics

• Screening population 327,683Screening population 327,683

• Assume 60% uptake based on pilot figures = Assume 60% uptake based on pilot figures = 196,610 of which,196,610 of which,

• Approximate 2% will have a positive FOBt = 3,932 Approximate 2% will have a positive FOBt = 3,932 of which,of which,

• 11% of FOBt positive patients will have cancer 11% of FOBt positive patients will have cancer =433.=433.

• 35% will have polyps requiring surveillance =137635% will have polyps requiring surveillance =1376

Duke Staging of CRC on BCSPDuke Staging of CRC on BCSP

• Duke A 53% (including malignant polyps)Duke A 53% (including malignant polyps)

• Duke B 21.4%Duke B 21.4%

• Duke C Duke C 21.4%21.4%

• Duke D Duke D 4.2%4.2%

• These figures are based upon 115 patients who had These figures are based upon 115 patients who had undergone surgery at time of audit and had definitive undergone surgery at time of audit and had definitive post-operative staging.post-operative staging.

Bowel Cancer Screening Bowel Cancer Screening ProgrammeProgramme

• FOB testing will be offered to all men & FOB testing will be offered to all men & women aged 60-69 - 2 yearly. women aged 60-69 - 2 yearly.

• 70+ can request to join the BCSP but 70+ can request to join the BCSP but have to contact Regional Hub at Rugby have to contact Regional Hub at Rugby on theon the

FREEPHONE: 0800 707 60 60FREEPHONE: 0800 707 60 60

• Age Extension up to 75 in 2010Age Extension up to 75 in 2010

Organisation in England by March 2007

• 5 Programme Hubs across England, based on IT Local Service Providers (LSP) undertaking call/recall and lab functions•1 Programme Hub for approx 20 screening centres

Gateshead

Nottingham

London

Guildford

Rugby

Role ofRole of Midlands and North Midlands and North West Programme HubWest Programme Hub

• To Manage call and recall for the screening To Manage call and recall for the screening programmeprogramme

• To provide a telephone help line for people To provide a telephone help line for people invited for screeninginvited for screening

• To dispatch and process test kitsTo dispatch and process test kits• Send results letters to participants and Send results letters to participants and

notify GPnotify GP• Book the first appointment at a nurse led Book the first appointment at a nurse led

clinic for patients with an abnormal test clinic for patients with an abnormal test resultresult

• Coordinate Quality assurance activitiesCoordinate Quality assurance activities

Midlands and North West Midlands and North West Programme HubProgramme Hub

• Invitation letter is sent to participant Invitation letter is sent to participant from Hub.from Hub.

• Participants can opt out of the BCSP Participants can opt out of the BCSP by contacting Hub on the free phone by contacting Hub on the free phone – 0800 707 60 60– 0800 707 60 60

• One week later an FOB screening kit which includes leaflets, sample sticks and a foil lined envelope are dispatched

Screening CentresScreening Centres (University Hospital Aintree)(University Hospital Aintree)

•Provide information about the screening Provide information about the screening programme for the local health communityprogramme for the local health community

•Promote the screening programme to the Promote the screening programme to the

general public in their localitygeneral public in their locality

•Provide information and support for local Provide information and support for local people in completing the FOB test(on referral people in completing the FOB test(on referral from the programme hubfrom the programme hub

Screening CentresScreening Centres(University Hospital Aintree(University Hospital Aintree))

•They will provide nurse led clinics for patients They will provide nurse led clinics for patients with an abnormal test result.with an abnormal test result.

•Arrange colonoscopy appointments for patients Arrange colonoscopy appointments for patients with an abnormal test result at either the Royal with an abnormal test result at either the Royal Liverpool University Hospital ,University Hospital Liverpool University Hospital ,University Hospital Aintree or Leighton Hospital.Aintree or Leighton Hospital.

•Arrange alternative appointments for patients in Arrange alternative appointments for patients in whom colonoscopy has failedwhom colonoscopy has failed

•Ensure appropriate follow-up or treatment for Ensure appropriate follow-up or treatment for patients after colonoscopypatients after colonoscopy

Faecal Occult Blood Testing KitFaecal Occult Blood Testing Kit

• Participants smear the stool sample onto the 2 Squares in the 1st flap indicated on the kit. This is repeated on 2 further days until all 6 Squares are completed

• Completed kit is returned by post to Hub Completed kit is returned by post to Hub within 2 weeks of the 1within 2 weeks of the 1stst sample being sample being smeared on the kit (foil-lined envelope smeared on the kit (foil-lined envelope supplied)supplied)

ResultsResults Negative resultNegative result

Unclear Result (1-4 of the squares are Unclear Result (1-4 of the squares are positive)positive)

Spoilt KitSpoilt Kit

Technical FailureTechnical Failure

Positive ( abnormal) ResultPositive ( abnormal) Result

ResultsResults

• Patient informed of Faecal Occult Blood Test Patient informed of Faecal Occult Blood Test results by postresults by post • Colonoscopy: patient informed of results on Colonoscopy: patient informed of results on the daythe day

• Information about polyps relayed to patient by Information about polyps relayed to patient by telephone clinic or clinic appointment telephone clinic or clinic appointment

• GP informed of all results, non-responders GP informed of all results, non-responders and DNAsand DNAs

Screening journeyScreening journey• Appointment arranged at Nurse Led Clinic ( Healthy Living Centre Ellesmere Port and St

Martins Clinic Chester)• Ellesmere Port) for FOBt positive patients. The

patient will receive:• Counselling• A health questionnaire• Information• Consent• Preparation for procedure• BCSP – The Colonoscopy Investigation Leaflet

Screening journey Screening journey ((Continued)Continued)

• Referred to screening provider unit for colonoscopy

• Follow-up dependant on procedure results – Normal, sent a BCSP kit in 2 years– Polyps, surveillance by BCSP– Cancer detected cases referred to local

Multi Disciplinary Team (local Cancer Team)

BCSP Clinical Statistics fromBCSP Clinical Statistics fromSeptember 2006- March 2008September 2006- March 2008

• Overall Uptake rate 55%Overall Uptake rate 55%

• 1268 patients seen in nurse led clinics following FOB positive 1268 patients seen in nurse led clinics following FOB positive resultresult

• 1215 colonoscopies performed 1215 colonoscopies performed

• 38 patients refused to have colonoscopy (2.6%)38 patients refused to have colonoscopy (2.6%)

• 31 patients deemed clinically inappropriate (2.1%)31 patients deemed clinically inappropriate (2.1%)

• 15 patients had completion barium enema (1%)15 patients had completion barium enema (1%)

NEOPLASIANEOPLASIA

• Total number of adenomatous polyps Total number of adenomatous polyps removed = 1330 (498 patients )removed = 1330 (498 patients )

• Total number of malignant polyps Total number of malignant polyps removed= 21 patientsremoved= 21 patients

Patient OutcomesPatient Outcomes

• 10% patients to have 1 year surveillance (High risk 10% patients to have 1 year surveillance (High risk polyps)polyps)

• 18% patients to have 3 year surveillance (Intermediate 18% patients to have 3 year surveillance (Intermediate risk polyps)risk polyps)

• 60% to return to screening programme with 2 yearly 60% to return to screening programme with 2 yearly invitation to repeat participation in screening ( Low invitation to repeat participation in screening ( Low risk polyps)risk polyps)

• 12% referred to local MDT for cancer treatment ( 141 12% referred to local MDT for cancer treatment ( 141 patients )patients )

Health Inequalities of the BCSPHealth Inequalities of the BCSPPilotPilot

• Men were less likely to participate in FOBt

• Lower uptake in deprived areas.

• Black and Racial Minority Communities less likely to participate

Potential barriers within BCSP?Potential barriers within BCSP?

• Mental Health?Mental Health?

• Learning disability?Learning disability?

Barriers for patients with Mental Barriers for patients with Mental Health problemsHealth problems

• Lack of awareness about the Lack of awareness about the benefits of screeningbenefits of screening

• Poorer knowledge of health topicsPoorer knowledge of health topics

• Low self esteemLow self esteem

• Lack of motivationLack of motivation

• Difficulty in accessing servicesDifficulty in accessing services

• Practical issues for completion of Practical issues for completion of the Faecal Occult Blood Testthe Faecal Occult Blood Test

• Support individuals with a Mental Health Support individuals with a Mental Health problem to:problem to:– Make an appointment with the GP or Practice Nurse Make an appointment with the GP or Practice Nurse

at the earliest sign of ill health or disease.at the earliest sign of ill health or disease.– Inform and discuss with the GP or Nurse any signs Inform and discuss with the GP or Nurse any signs

or symptoms of ill health. or symptoms of ill health. – Attend their annual health check at their GP Attend their annual health check at their GP

surgery.surgery.– Understand what the screening process entails: Understand what the screening process entails:

using easy read format.using easy read format.

How can you help people with Mental How can you help people with Mental Health problem overcome these barriers?Health problem overcome these barriers?

Barriers for patients with Barriers for patients with Learning Disabilities/DifficultiesLearning Disabilities/Difficulties

• CommunicationCommunication

• Recognition of ill health is often Recognition of ill health is often difficult .difficult .Signs and symptoms for bowel Signs and symptoms for bowel cancer not always recognisedcancer not always recognised

• Literacy level Literacy level

• Resources / lack of pictorial easy read Resources / lack of pictorial easy read informationinformation

• Practical issues for completion of the Practical issues for completion of the Faecal Occult Blood TestFaecal Occult Blood Test

Barriers for patients with Barriers for patients with Learning Disabilities/DifficultiesLearning Disabilities/Difficulties

• Lifestyle, behaviours and disengagementLifestyle, behaviours and disengagement

• Attitudes of health professionals & NHS Attitudes of health professionals & NHS administrative procedures . Client group often administrative procedures . Client group often excluded from screening by Primary Health Care excluded from screening by Primary Health Care TeamsTeams

• Perceived difficulty obtaining consentPerceived difficulty obtaining consent

• Family members/carers may not have the skills & Family members/carers may not have the skills & knowledge needed about diseaseknowledge needed about disease

• Support individuals with a LD to:Support individuals with a LD to:– Make an appointment with the GP or Practice Nurse Make an appointment with the GP or Practice Nurse

at the earliest sign of ill health or disease.at the earliest sign of ill health or disease.– Inform and discuss with the GP or Nurse any signs Inform and discuss with the GP or Nurse any signs

or symptoms of ill health. or symptoms of ill health. – Attend their annual health check at their GP Attend their annual health check at their GP

surgery.surgery.– Understand what the screening process entails: Understand what the screening process entails:

using easy read format.using easy read format.– Access support from a LD nurse if required. Access support from a LD nurse if required.

How can you help people with LD’s How can you help people with LD’s overcome these barriers?overcome these barriers?

• Merseyside and Cheshire Early Detection & Prevention Strategy

• Healthy Communities Cancer Collaborative

New DevelopmentsNew Developments


DVDDVDDeveloped to meet the needs of Developed to meet the needs of

• Black and Racial MinoritiesBlack and Racial Minorities

• Deaf and Hard of Hearing PeopleDeaf and Hard of Hearing People

• Low LiteracyLow Literacy

• Learning DisabilitiesLearning Disabilities


• Pictorial Easy Read leaflet

• Awareness raising sessions

• Anticipatory Care Calendar

• Reduce health inequalities.Reduce health inequalities.

• Provide a sound clinical governance and critical Provide a sound clinical governance and critical care review mechanism.care review mechanism.

• Provide care pathways that lead to action.Provide care pathways that lead to action.

• Improve communication with the Improve communication with the multidisciplinary team.multidisciplinary team.

• Standardise information/documentation.Standardise information/documentation.

Purpose of the Anticipatory Care Purpose of the Anticipatory Care CalendarCalendar

• Ensure that the legal requirements for documentation are Ensure that the legal requirements for documentation are met.met.

• Record patterns in behaviour and symptoms which can be Record patterns in behaviour and symptoms which can be visualised more easily using the monthly chart so that visualised more easily using the monthly chart so that alterations in the client conditions can be viewed on more alterations in the client conditions can be viewed on more than one health variable.than one health variable.

• Reduce diagnostic overshadowingReduce diagnostic overshadowing

• Record accurate screeningRecord accurate screening

• Provide learning opportunities between teams caring for Provide learning opportunities between teams caring for clients. clients.

Purpose of the Anticipatory Purpose of the Anticipatory Care CalendarCare Calendar

Any Questions?Any Questions?

Contact DetailsContact Details

• Maureen Sayer Maureen Sayer

Health Improvement PractitionerHealth Improvement Practitioner

[email protected]@aintree.nhs.uk

• Lara Boddy Lara Boddy

Cancer Screening CoordinatorCancer Screening Coordinator

[email protected]@knowsley.nhs.uk

mailto:[email protected]

mailto:[email protected]

Documents

Bowel Cancer & Bowel Cancer Screening Education and Awareness Sessions