Improving the uptake of bowel cancer screening in East London through targeted GP endorsement

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