- Email: [email protected]
Survival benefit of increasing colorectal cancer screening uptake in Wolverhampton, UK: An exploratory study
p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) S 4 4 eS 4 6
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Speed Presentations
Survival benefit of increasing colorectal cancer screening uptake in Wolverhampton, UK: An exploratory study V. Anand a,*, J. Gwinnett b, A. Phillips b a b
College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK Wolverhampton City Primary Care Trust, Wolverhampton, UK
article info
summary
Article history:
Background: Colorectal cancer (CRC) is an important cause of morbidity and mortality in the
Available online 5 July 2012
UK. Biennial faecal occult blood test screening has been shown to significantly reduce mortality from CRC. Wolverhampton was the first centre involved in the NHS Bowel Cancer Screening Programme (NHS BCSP) in England. The aim of this study was to assess the life-
Keywords:
year saving by increasing the uptake of CRC screening in Wolverhampton by 20%.
Colorectal cancer
Methods: Using data from the first complete round of the NHS BCSP and 5-year survival
Screening
figures based on the Dukes staging system, a simple model was developed on Microsoft
Survival
Excel using the population of Wolverhampton aged between 60 and 74 years. Results: If uptake of CRC screening in Wolverhampton increased from 50% to 70%, one extra person would be alive at 5 years and the 5-year survival rate would increase by 0.85%. Conclusions: Increasing the uptake of CRC screening by 20% in Wolverhampton would have a modest survival benefit. Further work is needed to determine whether or not this is costeffective. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
As the second most common cause of cancer-related death in the UK, colorectal cancer (CRC) is a significant cause of mortality.1 The NHS Bowel Cancer Screening Programme (NHS BCSP) started in England in July 2006. Screening is undertaken by way of biennial faecal occult blood tests (FOBT), and is targeted at all men and women aged between 60 and 69 years. The age range is currently being extended to 75 years, and this has already been implemented in over half of local screening centres.2 Studies in Denmark and Nottingham have demonstrated significantly higher proportions of Dukes Stage A CRC (tumour confined to intestinal wall) and lower proportions of Dukes Stage C CRC (tumour spread to lymph nodes) in screened populations. This was shown to lead to a reduction in CRC-associated mortality in the screened populations.3,4 Downstaging of CRC towards earlier stage disease has also been demonstrated in the
city of Wolverhampton, the first centre involved in the NHS BCSP.5 However, at present, only 13% of CRC cases in the UK are diagnosed at the earliest stage of the disease.6 According to figures from March 2010, the uptake of CRC screening in Wolverhampton is approximately 51%, ranging from 27% to 61% depending upon the general practice.7 However, the recommended uptake according to European Union guidelines is at least 65%. Although the guidelines say that uptake above 45% is acceptable, uptake above 65% is desirable.8 The aim of the present study was to assess the lifeyear saving if uptake of CRC screening in Wolverhampton increased by 20%, from 50% to 70%. A caseecontrol study compared the CRC stage in the screened population in the first 2 years of the Wolverhampton NHS BCSP with an age-matched population in the 2 years prior
* Corresponding author. Tel.: þ44 07912 618084. E-mail address: [email protected] (V. Anand). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2012.05.022
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Table 1 e Number of colorectal cancers detected and 5-year survival with screening uptake rates of 50% and 70%. Uptake (%) 50 70
Population
17.174 24.044
Number of cancers detected
Number of people alive at 5 years
Screened
Non-screened
Screened
Non-screened
Total
37.15 52.02
95.30 80.44
27.16 38.03
62.44 52.70
89.60 90.73
to the start of the NHS BCSP. One hundred and six cancers were detected in the screened population (55,931), excluding the 152 people with positive FOBT results who declined or were unfit for colonoscopy. Approximately 10% of those undergoing colonoscopy have cancer.5 Therefore, this suggests that there would actually have been 121 cancers in the screened population, giving a cancer detection rate of 0.00216. Data from this study formed the basis of a simple mathematical model that was developed on Microsoft Excel using a decision tree technique. The population of Wolverhampton aged between 60 and 74 years (n ¼ 34,348) was used in the model. An overall cancer rate was calculated by dividing the cancer detection rate by the sensitivity of the FOBT. The sensitivity of the FOBT is between 55% and 57.2%,8 so an average of 56.1% was used. Using the cancer detection rate and the overall cancer rate, the number of cancers in the screened population and the number of cancers not detected were calculated. Five-year survival figures from the Dukes staging system6 were input into the model. Figures from the caseecontrol study regarding the number of people in each of the four Dukes stages in the screened and non-screened populations were used.5 The number of people alive at 5 years with 50% and 70% screening uptake was then calculated. The results of the model indicate that if the uptake of CRC screening increased from 50% to 70% in the population of Wolverhampton aged 60e74 years, the number of people alive at 5 years would increase from 89.60 to 90.73, meaning that an extra 1.13 people would be alive at 5 years. In addition, the 5year survival rate would improve from 67.65% to 68.50%, an improvement of 0.85% (Table 1). This exploratory model has demonstrated the survival benefit of increasing the uptake of CRC screening by 20% in the city of Wolverhampton. Although feasible, a 20% increase in screening uptake would require significant effort. One method of increasing uptake would be to involve primary healthcare teams in promoting the benefits of early CRC detection. It has been shown that a personal letter of endorsement from the patient’s own general practitioner and a procedural leaflet sent with the FOBT kit independently improve screening uptake. The effect of these two interventions is additive, increasing screening uptake by up to 11.5%.9 An advance notification letter has also been shown to significantly increase participation in CRC screening, as have telephone reminders, although these may not be cost-effective.8 Other recommendations into ways of increasing screening uptake include having members of the primary healthcare team remind and encourage patients to participate in screening as part of opportunistic health promotion. This could be done by the computer automatically flagging up patients in the appropriate age group when patients sign in on arrival at the practice. Receptionists would then be able to
Total number of cancers
5-year survival rate (%)
132.5 132.5
67.65 68.50
remind the appropriate patients about screening. It may also be possible to maximize the benefits from those who have had an asymptomatic tumour detected (nudging), using social marketing techniques to change attitudes to FOBT. This study has several limitations. Firstly, calculations were based on a simple exploratory model that had a number of assumptions. For example, it was assumed that the characteristics of the population would be the same when incorporating an extra 20% of people screened. This may not be true, and factors such as socio-economic status have been shown to have an effect on participation in screening.8 Furthermore, statistical significance was not calculated and a sensitivity analysis was not performed. Additional work should be undertaken to create a more robust model which incorporates the detection rate of adenomatous polyps. A cost-effectiveness analysis should also be undertaken to identify whether or not the benefits of increasing screening uptake outweigh the costs of implementation. In conclusion, this exploratory study identified a modest survival benefit from increasing the uptake of CRC screening by 20% in Wolverhampton, with one extra person being alive at 5 years and a 0.85% improvement in 5-year survival rate.
Acknowledgements The authors would like to thank Mr Simon Caldwell for his help with producing the model.
Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. Office for National Statistics. Cancer incidence and mortality in the UK, 2006e2008. Newport: Office for National Statistics; 2011. Available at: http://www.ons.gov.uk [last accessed 02.07.2011]. 2. NHS Cancer Screening Programmes. About bowel cancer screening. Sheffield: NHS Cancer Screening Programmes; 2008. Available at: http://www.cancerscreening.nhs.uk [last accessed 02.07.2011].
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p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) S 4 4 eS 4 6
3. Kronborg O, Fenger C, Olsen J. Randomized study of screening for colorectal cancer with faecal occult blood test. Lancet 1996;348:1467e71. 4. Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW, et al. Randomized controlled trial of faecal occult blood screening for colorectal cancer. Lancet 1996;348:1472e7. 5. Ellul P, Fogden E, Simpson CL, Nickerson CLR, Mckaig BC, Swarbrick ET, et al. Downstaging of colorectal cancer by the national bowel cancer screening programme in England: first round data from the first centre. Colorect Dis 2010;12:420e2. 6. National Cancer Intelligence Network. Colorectal cancer survival by stage e NCIN data briefing. London: National Cancer
Intelligence Network; 2009. Available at: http://www.ncin.org. uk [last accessed 09.07.2011]. 7. Wolverhampton City Primary Care Trust. CRC screening uptake and positivity by GP practice. Wolverhampton: Wolverhampton City Primary Care Trust; 2010. 8. European Commission. European guidelines for quality assurance in colorectal screening and diagnosis. Luxembourg: Publications Office of the European Union; 2010. Available at: http://www. iarc.fr/ [last accessed 09.07.2011]. 9. Hewitson P, Ward AM, Heneghan C, Halloran SP, Mant D. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Br J Cancer 2011; 105:475e80.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Speed Presentations
Survival benefit of increasing colorectal cancer screening uptake in Wolverhampton, UK: An exploratory study V. Anand a,*, J. Gwinnett b, A. Phillips b a b
College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK Wolverhampton City Primary Care Trust, Wolverhampton, UK
article info
summary
Article history:
Background: Colorectal cancer (CRC) is an important cause of morbidity and mortality in the
Available online 5 July 2012
UK. Biennial faecal occult blood test screening has been shown to significantly reduce mortality from CRC. Wolverhampton was the first centre involved in the NHS Bowel Cancer Screening Programme (NHS BCSP) in England. The aim of this study was to assess the life-
Keywords:
year saving by increasing the uptake of CRC screening in Wolverhampton by 20%.
Colorectal cancer
Methods: Using data from the first complete round of the NHS BCSP and 5-year survival
Screening
figures based on the Dukes staging system, a simple model was developed on Microsoft
Survival
Excel using the population of Wolverhampton aged between 60 and 74 years. Results: If uptake of CRC screening in Wolverhampton increased from 50% to 70%, one extra person would be alive at 5 years and the 5-year survival rate would increase by 0.85%. Conclusions: Increasing the uptake of CRC screening by 20% in Wolverhampton would have a modest survival benefit. Further work is needed to determine whether or not this is costeffective. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
As the second most common cause of cancer-related death in the UK, colorectal cancer (CRC) is a significant cause of mortality.1 The NHS Bowel Cancer Screening Programme (NHS BCSP) started in England in July 2006. Screening is undertaken by way of biennial faecal occult blood tests (FOBT), and is targeted at all men and women aged between 60 and 69 years. The age range is currently being extended to 75 years, and this has already been implemented in over half of local screening centres.2 Studies in Denmark and Nottingham have demonstrated significantly higher proportions of Dukes Stage A CRC (tumour confined to intestinal wall) and lower proportions of Dukes Stage C CRC (tumour spread to lymph nodes) in screened populations. This was shown to lead to a reduction in CRC-associated mortality in the screened populations.3,4 Downstaging of CRC towards earlier stage disease has also been demonstrated in the
city of Wolverhampton, the first centre involved in the NHS BCSP.5 However, at present, only 13% of CRC cases in the UK are diagnosed at the earliest stage of the disease.6 According to figures from March 2010, the uptake of CRC screening in Wolverhampton is approximately 51%, ranging from 27% to 61% depending upon the general practice.7 However, the recommended uptake according to European Union guidelines is at least 65%. Although the guidelines say that uptake above 45% is acceptable, uptake above 65% is desirable.8 The aim of the present study was to assess the lifeyear saving if uptake of CRC screening in Wolverhampton increased by 20%, from 50% to 70%. A caseecontrol study compared the CRC stage in the screened population in the first 2 years of the Wolverhampton NHS BCSP with an age-matched population in the 2 years prior
* Corresponding author. Tel.: þ44 07912 618084. E-mail address: [email protected] (V. Anand). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2012.05.022
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p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) S 4 4 eS 4 6
Table 1 e Number of colorectal cancers detected and 5-year survival with screening uptake rates of 50% and 70%. Uptake (%) 50 70
Population
17.174 24.044
Number of cancers detected
Number of people alive at 5 years
Screened
Non-screened
Screened
Non-screened
Total
37.15 52.02
95.30 80.44
27.16 38.03
62.44 52.70
89.60 90.73
to the start of the NHS BCSP. One hundred and six cancers were detected in the screened population (55,931), excluding the 152 people with positive FOBT results who declined or were unfit for colonoscopy. Approximately 10% of those undergoing colonoscopy have cancer.5 Therefore, this suggests that there would actually have been 121 cancers in the screened population, giving a cancer detection rate of 0.00216. Data from this study formed the basis of a simple mathematical model that was developed on Microsoft Excel using a decision tree technique. The population of Wolverhampton aged between 60 and 74 years (n ¼ 34,348) was used in the model. An overall cancer rate was calculated by dividing the cancer detection rate by the sensitivity of the FOBT. The sensitivity of the FOBT is between 55% and 57.2%,8 so an average of 56.1% was used. Using the cancer detection rate and the overall cancer rate, the number of cancers in the screened population and the number of cancers not detected were calculated. Five-year survival figures from the Dukes staging system6 were input into the model. Figures from the caseecontrol study regarding the number of people in each of the four Dukes stages in the screened and non-screened populations were used.5 The number of people alive at 5 years with 50% and 70% screening uptake was then calculated. The results of the model indicate that if the uptake of CRC screening increased from 50% to 70% in the population of Wolverhampton aged 60e74 years, the number of people alive at 5 years would increase from 89.60 to 90.73, meaning that an extra 1.13 people would be alive at 5 years. In addition, the 5year survival rate would improve from 67.65% to 68.50%, an improvement of 0.85% (Table 1). This exploratory model has demonstrated the survival benefit of increasing the uptake of CRC screening by 20% in the city of Wolverhampton. Although feasible, a 20% increase in screening uptake would require significant effort. One method of increasing uptake would be to involve primary healthcare teams in promoting the benefits of early CRC detection. It has been shown that a personal letter of endorsement from the patient’s own general practitioner and a procedural leaflet sent with the FOBT kit independently improve screening uptake. The effect of these two interventions is additive, increasing screening uptake by up to 11.5%.9 An advance notification letter has also been shown to significantly increase participation in CRC screening, as have telephone reminders, although these may not be cost-effective.8 Other recommendations into ways of increasing screening uptake include having members of the primary healthcare team remind and encourage patients to participate in screening as part of opportunistic health promotion. This could be done by the computer automatically flagging up patients in the appropriate age group when patients sign in on arrival at the practice. Receptionists would then be able to
Total number of cancers
5-year survival rate (%)
132.5 132.5
67.65 68.50
remind the appropriate patients about screening. It may also be possible to maximize the benefits from those who have had an asymptomatic tumour detected (nudging), using social marketing techniques to change attitudes to FOBT. This study has several limitations. Firstly, calculations were based on a simple exploratory model that had a number of assumptions. For example, it was assumed that the characteristics of the population would be the same when incorporating an extra 20% of people screened. This may not be true, and factors such as socio-economic status have been shown to have an effect on participation in screening.8 Furthermore, statistical significance was not calculated and a sensitivity analysis was not performed. Additional work should be undertaken to create a more robust model which incorporates the detection rate of adenomatous polyps. A cost-effectiveness analysis should also be undertaken to identify whether or not the benefits of increasing screening uptake outweigh the costs of implementation. In conclusion, this exploratory study identified a modest survival benefit from increasing the uptake of CRC screening by 20% in Wolverhampton, with one extra person being alive at 5 years and a 0.85% improvement in 5-year survival rate.
Acknowledgements The authors would like to thank Mr Simon Caldwell for his help with producing the model.
Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. Office for National Statistics. Cancer incidence and mortality in the UK, 2006e2008. Newport: Office for National Statistics; 2011. Available at: http://www.ons.gov.uk [last accessed 02.07.2011]. 2. NHS Cancer Screening Programmes. About bowel cancer screening. Sheffield: NHS Cancer Screening Programmes; 2008. Available at: http://www.cancerscreening.nhs.uk [last accessed 02.07.2011].
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p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) S 4 4 eS 4 6
3. Kronborg O, Fenger C, Olsen J. Randomized study of screening for colorectal cancer with faecal occult blood test. Lancet 1996;348:1467e71. 4. Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW, et al. Randomized controlled trial of faecal occult blood screening for colorectal cancer. Lancet 1996;348:1472e7. 5. Ellul P, Fogden E, Simpson CL, Nickerson CLR, Mckaig BC, Swarbrick ET, et al. Downstaging of colorectal cancer by the national bowel cancer screening programme in England: first round data from the first centre. Colorect Dis 2010;12:420e2. 6. National Cancer Intelligence Network. Colorectal cancer survival by stage e NCIN data briefing. London: National Cancer
Intelligence Network; 2009. Available at: http://www.ncin.org. uk [last accessed 09.07.2011]. 7. Wolverhampton City Primary Care Trust. CRC screening uptake and positivity by GP practice. Wolverhampton: Wolverhampton City Primary Care Trust; 2010. 8. European Commission. European guidelines for quality assurance in colorectal screening and diagnosis. Luxembourg: Publications Office of the European Union; 2010. Available at: http://www. iarc.fr/ [last accessed 09.07.2011]. 9. Hewitson P, Ward AM, Heneghan C, Halloran SP, Mant D. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Br J Cancer 2011; 105:475e80.