Improving the uptake of bowel cancer screening in East London through targeted GP endorsement
Judith ShanklemanSenior Public Health Strategist
London Borough of Tower Hamlets
Colorectal cancer
Second most common cause of cancer death in UK and in Tower Hamlets• 5 year survival
- 93% for patients diagnosed at stage I - 7% for patients diagnosed at stage 4
• Tower Hamlets - 60 new diagnoses per year- 30 deaths per year
3
Early stage disease(Dukes A and "good" B)
34%
Late stage disease 42%
Metastatic disease24%
Colorectal cancer in Tower Hamlets 2011:
stage at diagnosis (n=56)
Source: Avon, Wiltshire and Somerset Cancer Services Population-based commissioning toolkit for Colorectal Cancer by route to diagnosis and stage of disease (Dukes A-D) August- 2012
09/01/2013
stage 1 stage 2 stage 3 stage 4 unknown0
2
4
6
8
10
12
14
16
18
20
Colorectal cancer in 42 Tower Hamlets residents diagnosed and treated at Barts Hospital 2011
Num
ber o
f pati
ents
NHS Bowel cancer screening programme
• Age 60 – 69 (extending to 74)• Aims to
- identify and remove polyps + surveillance
- identify early bowel cancer• At 60% uptake, population
mortality reduced by 16%• Participants reduce their risk of
dying from bowel cancer by 25%
Lower uptake associated with…
• London• Multiple deprivation• South Asian and Muslim
populations• Low levels of English literacy• Being male
“Intervention generated inequality”
Source: NHS England (London region) N and E London cancer screening team
Tower
Hamlet
s
Newham
City And Hack
ney
Barking A
nd Dagen
ham
Camden
Haringe
y
Islingto
n
Barnet
Waltham
Fores
t
Redbrid
ge
Enfield
Haverin
g 0%
10%
20%
30%
40%
50%
60%
34.92%
55.76%
Bowel screening uptake N & E London Q1 2014/5
Upt
ake
of b
owel
scre
enin
g
National target 60%
Evidence for intervention• Targeted GP endorsement and outreach was effective in
increasing breast screening uptake in Tower Hamlets1 (from 53% to 69%)
• 2011 bowel screening pilot targeted 60 yr olds, invited to health promotion sessions in 12 inner NEL practices
• Targeted endorsement of bowel screening is cost effective and contributes to a reduction in health inequalities2
1 Eilbert et al 2009 British Journal of Cancer2 Ansari et al 2013 University of York
2012 Bowel Screening Project• With Prof Stephen Duffy (QMUL); controlled trial in City &
Hackney, Newham and Tower Hamlets
• PCT commissioners negotiated with NHS BCSP(the Hub) for GPs in NEL to pilot monthly “prior notification lists”
• 18 randomised large practices compared with 28 control practices of similar size
• 9 practices randomised to offer group HP• 9 practices to offer HP over the phone
Protocol• Commissioned community organisation with
trained bilingual advocates
• Data sharing agreements between 18 practices and the Hub; monthly PNLs sent Jan to Dec 2012
• People due to be invited identified by callers using practice registers
• Practices excluded patients with bowel cancer, palliative care needs or opted out
Letter of endorsement and customised national leaflet sent ahead of expected screening invitation
Phone call after anticipated kit dispatch(up to 3 attempts)
In 9 practices, reminder about HP session at practice
In 9 practices scripted explanation and questions answered
Uptake highest for HP over the phone
City & Hackney Newham Tower Hamlets 3 boroughs combined
0%
10%
20%
30%
40%
50%
60%
Control 41.0%
Control 38.4%
Control 36.5%
Control 39.1%
HP session49.6%
HP over phone 50.3% HP over phone
45.3%HP over phone
46.7%
Upta
ke
Bowel screening uptake April to December 2012
All results were highly significant
28 control practices9 intervention
practices - HP over the phone
9 intervention practices HP at group
sessions
BoroughNumber screened
/total invitedUptake
Number screened
/total invitedUptake
Number screened
/total invitedUptake
City & Hackney 560 / 1,337 41.0% 294 / 594 48.9% 289 / 602 49.6%
Newham 810 / 2,049 38.4% 388 / 776 50.3% 295 / 685 42.6%
Tower Hamlets 677 / 1,841 36.5% 292 / 664 45.3% 237 / 565 41.7%
Total 2,047 / 5,227 39.1% 974 / 2,034 46.7% 821 / 1,852 43.8%
Discussion
• Only 50% targeted people reachable by phone
• Practice registers did not always identify bowel cancer patients
• Unusually high DNA rate for colonoscopy in screen +ve patients in NEL
• £6 per person targeted
Next steps
• Tower Hamlets Network service 2014/15 “Detecting cancer earlier in primary care”
• £130k funded by Public Health
• Includes following protocol for targeted endorsement of bowel screening (£40k) to demonstrate ‘proof of concept’
• PNLs for all practices to be negotiated• search identifies 60 year olds due to be invited +
recent DNAs