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

Judith Shankleman Senior 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

Colorectal cancer in Tower Hamlets 2011: stage at diagnosis (n=56)

Metastatic disease 24% Early stage disease ( Dukes A and "good" B) 34% Late stage disease 42% 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 3

Colorectal cancer in 42 Tower Hamlets residents diagnosed and treated at Barts Hospital 2011

20 18 16 14 12 10 8 6 4 2 0 stage 1 stage 2 stage 3 stage 4 unknown

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”

60% 50% 40% 30% 20% 10% 0%

34,92% Bowel screening uptake N & E London Q1 2014/5

National target 60%

55,76%

Source: NHS England (London region) N and E London cancer screening team

Evidence for intervention

• • • Targeted GP endorsement and outreach was effective in increasing breast screening uptake in Tower Hamlets 1 (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 inequalities 2 1 Eilbert et al 2009 British Journal of Cancer 2 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

60% 50% 40%

Bowel screening uptake

April to December 2012 Control 41.0% HP session 49.6% HP over phone Control 38.4% 50.3% HP over phone Control 45.3% 36.5% HP over phone Control 46.7% 39.1% 30% 20% 10% 0% City & Hackney Newham Tower Hamlets 3 boroughs combined

Uptake highest for HP over the phone

All results were highly significant

Borough City & Hackney Newham Tower Hamlets Total 28 control practices 9 intervention practices - HP over the phone 9 intervention practices HP at group sessions Number screened /total invited Uptake Number screened /total invited Uptake Number screened /total invited Uptake 560 / 1,337 41.0% 810 / 2,049 38.4% 294 / 594 388 / 776 48.9% 50.3% 289 / 602 295 / 685 49.6% 42.6% 677 / 1,841 36.5% 292 / 664 45.3% 237 / 565 2,047 / 5,227 39.1% 974 / 2,034 46.7% 821 / 1,852 41.7% 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