Bowel Cancer Screening The Tallaght Experience

Nikki Shearer, RGN, BNS.

Overview

A multi-disciplinary approachOutline of Tallaght Hospital CRC screening programmeImproving public awarenessIdentifying target populationInviting interested individuals for participationProcessing of faecal samplesCoordinating endoscopic examinationsFollow up post colonoscopyEnd of year results 2010Coordinating research activitiesConclusions

Multi-disciplinary approach Screening for Colorectal Cancer

Compliance issues

Approach via health personnel Direct contact

Follow up of participants

•Leaflets: 36.95%

•Media: 9.65%

•Recommendation by GP 58.7%

Multi-disciplinary approach

Faivre J, Eur J Cancer Prev 91

Outline of Tallaght Hospital CRC Screening Programme

Contacting general practitioners in the Dublin 24 Obtaining details for individuals who fit criteriaBuilding relationship with the G.P. / Practice Nurse

The G.P. / Practice Nurse vital to promotion of the programme which helps make it a success

Improving Public Awareness

Organised introductory workshop for area general practitionersPrint mediaOrganised radio shows on CRC screeningColon cancer awareness day at local shopping centre

Identifying Target Population

Inviting suitable individuals for participation-Male, female-50-74 years of age-Dublin 24 Proper instructions to individuals with other co-morbid conditions

Process of invitation

Initial invite letter sent to individuals from G.P’s listFaecal Immunochemical Test (FIT) automatically sent out Accepting or declining the Programme does not impact their relationship with doctor / hospital Barriers: wrong addresses and deceased persons

Reminder letters

If no response to the kit, reminder letter posted outReminder letters have increased our response rateInitially, phone calls were made to encourage uptake, however this proved time consuming and many telephone numbers were incorrect.

Faecal Immunochemical Test

Kits sent by post Information and instructions given with each kit 2 FIT’s are required, samples taken on two consecutive days Samples secured in a small hard plastic tube Samples posted back via free post envelope Samples remain stable at room temperature for 7 days

Faecal Immunochemical Test (contd…)

Faecal Immunochemical Test (contd…)

Samples stored in a fridge at 4 degreesAnalysed in the lab once to twice a week Samples automated through O.C Sensor which gives print out of results The cut off reading for the programme is currently 100ng/ml

Faecal Immunochemical Test (contd…)

FIT Results

Results entered into a database manuallyWith a negative FIT result (under 100ng/ml) a letter will be posted out informing themRepeat the FIT in 2 yearsIf an individual has a positive result, they will be telephoned directly by the Nurse Coordinator

FIT Results (contd…)

A history is taken, if suitable, it will be explained that a colonoscopy is necessary A letter and info on having a colonoscopy will be sentG.P. will also be informed via letter

FIT Results (contd…)

Excluded if:-IBD-Had a colonoscopy in last 5 years-past history of Bowel Cancer

Once counselled by the Nurse-on a waiting list for a colonoscopyWith an available date they will be telephoned for pre-assessment and education given on preparation for the colonoscopy

ColonoscopyColonoscopies carried out on designated Saturdays in AMNCHOut of hours service, using existing facilitiesNot competing with an over burdened service2 consultant and full team2 endoscopy rooms with 2 recovery rooms 20-24 patients colonoscopies per day

Post Colonoscopy

Patients speak to consultant and nurse coordinator prior to dischargePatients are phoned 1-2 weeks post colonoscopy No pathology - a letter is sent to their G.P discharging them back to their careMinor pathology - results examined and the patient is contacted

Post Colonoscopy

Patients may need to be re-scoped in 2-5 years booked through the Endoscopy UnitIf polyps or pathology of concern is identified, the patient is referred to a Gastroenterologist (OPD)After endoscopy, a letter sent to G.P’s regarding results Patients with significant pathology discussed at the MDM

END OF YEAR RESULTS 2010

Participation

9,993 individuals, 99% of target populationOverall participation rate for round one 51%Significant increase in participation rates in year two 63% V 42%Women = 58%

25402523

5063

02000400060008000

10000120001400016000

Year 1 Year 2 Total

Invitees Participants

END OF YEAR RESULTS 2010

FIT Results and Positivity Rates

In all 10% (514) of returned FIT kits in round one were positiveYear one and year two of screening 11% and 9%

END OF YEAR RESULTS 2010

FIT Results and Positivity Rates

Older age group 9% (n=456) of programme participants & 16% of the FIT test positive population

48 43 9 37 46 170

10

20

30

40

50

% of Population Positivity Rate

50 - 59 60 - 69 70 - 74

END OF YEAR RESULTS 2010

Uptake of Colonoscopy

Overall Uptake 87% (419)Caecal Intubation 98% (409)

278

236

514

257

224

481

249

170

419

241

168

409

0 200 400 600

Year 1

Year 2

Total

Completed Colonoscopy

Underwent a Colonoscopy

Offered a Colonoscopy

Positive FIT

END OF YEAR RESULTS 2010Adenoma & Cancer Detection

Adenomatous polyps were detected in 154 (37%) subjectsCancer was found in 38 (9%)Mean age of patients with cancer was 61 yearsCancers were early, stage 1 in 31 (79%)

Number Percentage

All Polyp 206 49%

Hyperplastic polyps 52 12%

Tubular Adenomas 69 16%

Tubulovillous Adenoma 64 15%

High Grade Dysplasia 21 5%

Cancer 17 4%

END OF YEAR RESULTS 2010The Challenges

Increase demand for colonoscopy ~20%

Increased demand for Radiology and Pathology services

Need to target participation in certain sub-groups

NCSS- National Bowel Cancer Screening Programme

Coordinating research activities

Research being carried out in AMNCH with other multinational research centres screening for Colorectal CancerAim to identify new biomarkers for Colorectal CancerConsent obtained from patient prior to their colonoscopyIt requires:-bloods (plasma, serum, DNA,RNA)-stool sample (protein biomarker and DNA)-tissue sample (from adenoma greater than 1cm or lesion)

Conclusions

A patient centred service

Programme currently uses existing services and facilities

Patient satisfaction achieved:-pre-cancerous polypectomy -good nurse-patient relationship

Job satisfaction for staff as more pathology is found

To date no Surgery has refused to participate

Further positive attitude with successful programme

Public response rate increasing with more awareness

A National role-out of screening is likely to save more lives

Thank You