Cancer screening can identify early signs of disease before symptoms become apparent and when treatment is more likely to be successful. Screening may also pick up pre-cancerous changes. The UK has an established national screening programmes for breast, cervical and bowel cancer. Screening tests for other cancers such as prostate cancer and ovarian cancer are being investigated but, to date, systematic population screening programmes for prostate cancer or for ovarian cancer are not recommended by the UK National Screening Committee.
The NHS Bowel Cancer Screening Programme (BCSP) in England is commissioned by NHS England (biennial faecal occult blood testing (FOBt) 60-74 years) and Public Health England (once-only flexible sigmoidoscopy (Bowelscope) at 55 years) and co-ordinated through five regional Hubs. Across England, in the last five years in excess of 21 million men and women have been invited to be screened or screened again, sending over 400,000 invites each month.
- Nationally the uptake of the programme is currently approximately 58%, which has increased year-on-year since the start of the screening programme in 2006.
- A small percentage of the returned kits will be abnormal (show the presence of hidden blood), these people will be offered an assessment appointment at a local screening centre (one of 64 – geographically based), and, where appropriate, booked for a diagnostic test – such as a colonoscopy.
- Since 2006 the programme has identified over 32,000 cancers and 200,000 people with adenomas.
- In 2018/19 the qualitative guaiac FOBt (gFOBt) will be replaced by the faecal immunochemical test (FIT), which has a number of advantages including higher sensitivity specificity for human haemoglobin than gFOBt.
- In 2013, the BCSP bowel scope programme was started offering 55-year-old men and women a once-only examination of the lower bowel using a flexible sigmoidoscope.
- Nationally this programme has invited almost 1 million people to participate. Uptake is just under 45%.
- For those people who attend a bowel scope procedure, nearly half have a non-normal outcome, such as findings of polyps, adenomas or cancers, as well as haemorrhoids or diverticular diseases.
Director: Sally C Benton
Manager: Martin Brealey
The BCSP Southern Programme Hub (Southern Hub) started work in 2006 and is hosted by the Royal Surrey County and Frimley Park Hospitals. In 2014 the Southern Hub was one of two to run a six month pilot to investigate the practicalities of replacing the gFOBt with FIT.
Based on the result of that pilot, including a marked increase in uptake of the screening invitation, plans are underway to introduce FIT across England in 2018/2019.
Bowel cancer screening research
Research team: (L-R) Sally C Benton FRCPath (Hub Director); Helen Bruce FRCPath (Deputy Hub Director); Carolyn Piggott FIBMS (Research Scientist); Magdalen Carroll PhD (Clinical Scientist); Cerin John MSc (Research Assistant); Shane O’Driscoll MSc (Research Assistant). Not present: Martin Brealey (Hub Manager).
The BCSP Southern Hub research team includes three clinical scientists, a research scientist and two research assistants. The group has various research collaborations both nationally and internationally, all to improve and develop the screening tests for bowel cancer.
Current research projects:
NICE FIT study: a study to investigate whether the faecal immunochemical test (FIT) can be used as an effective triaging tool in primary care to decide whether patients referred under the two week rule should undergo endoscopic investigation, as recommended in NICE guidelines. The secondary aim is to determine appropriate cut-off levels for subgroups based on age, sex, ethnicity and socioeconomic deprivation. FIT is a cheap, non-invasive test that has been shown in European peer-reviewed studies to exclude colorectal cancer in symptomatic patients, but there is little evidence for use in the UK. The BCSP Southern Hub is collaborating with the research team at Croydon University Hospital to recruit 10,000 patients from 45 hospitals in England; FIT samples are being analysed at the Southern Hub using the HM-JACKarc system manufactured by Kyowa Medex, Japan, and supplied by Alpha Diagnostics, Eastleigh, Hampshire.
Sample stability study: an investigation of the stability of faecal haemoglobin in FIT collection devices. This study will compare the effect on faecal haemoglobin concentration of samples stored at different temperatures.
Effect on faecal haemoglobin concentrations (f-Hb) by overloading FIT devices: We recently published a paper ‘Does the mass of sample loaded affect faecal haemoglobin concentration using the faecal immunochemical test? which concluded that ‘the mass of sample loaded onto the probe did not impact the f-Hb significantly using the four tested devices’. In this first study we loaded small excess masses of faeces into the devices. This second project aims to further investigate if the FIT manufacturers’ claims that the presence of a “collar” in the collection devices means that excess loading of faeces on to the probe does not significantly affect f-Hb, by loading higher masses of faeces into the devices.
Evaluation of FIT analysers: An evaluation of the currently available FIT analytical systems (SENTiFIT 270 (Sentinel Diagnostics, Italy), NS-Prime (Alfresa Pharma, Japan), OC-SENSOR DIANA/PLEDIA (Eiken Chemical Co, Japan), HM-JACKarc (Kyowa Medex, Japan), and a comparison of f-Hb concentration across all four systems.
Hb Variants: A study to investigate haemoglobinopathies and the effect on FIT results. Where the globin structure is abnormal or reduced, it is possible that antibody binding, and thus Hb-detection may be affected. Multiple variants within the globin moiety of human Hb are being examined to determine if abnormal globin chains or reduced globin synthesis affects the efficacy of FIT.
FIT Pilot data analysis: A study to analyse the data from the FIT pilot study, where approximately 41,000 FIT invitations were sent instead of gFOB from the Southern and Midlands & North West Hub over 6 months in 2014. The investigations will include a comparison of FIT and gFOB invitation and sample return intervals, the FIT haemoglobin concentrations in relation to sample return time and subject demographics, the number of and reasons for spoilt kits, and a comparison of analyser performance within and between Hubs.
Practice Endorsed Additional Reminder Letter (PEARL) Health Economics: A Health Economics study to assess the health economic benefits of the PEARL process considering increase in uptake/ cancer detection versus resource required to carry out the process.
Microbiome: A PhD study under Dr Caroline Young at the University of Leeds that will assess the feasibility of using participants’ BCSP gFOBT cards and 16srRNA Next Generation Sequencing (NGS) to acquire microbiome data. The aims of the study are to (a) improve the specificity of gFOBT by defining the microbiome signatures of true positive (colonoscopy positive) and false positive (colonoscopy – negative) gFOBTs, (b) to improve the sensitivity of gFOBT by searching within a gFOBT negative cohort for the microbiome signatures of colonoscopy-positive gFOBTs, (c) to look for panels of ‘biomarker bacteria’ which could be selectively amplified, at reduced cost, and (d) to attempt microbiome data extraction from FIT samples.
FIT Quality Assessment: A study to assess the comparability of different internal quality control (iQC) and External Quality Assurance (EQA) materials using several FIT systems.
- GP participation in increasing uptake in a national bowel cancer screening programme: the PEARL project.Benton SC, Butler P, Allen K, Chesters M, Rickard S, Stanley S, et al. British Journal of Cancer. 2017; 116(12):1551-7.
- Does the mass of sample loaded affect faecal haemoglobin concentration using the faecal immunochemical test?Piggott C, John C, Bruce H, Benton S. Annals of Clinical Biochemistry (23rd May 2018 published online) https://doi.org/10.1177/0004563218778701).
- An assessment of the effect of haemoglobin variants on detection by faecal immunochemical tests.Carroll M, John C, Mantio D, Djedovic N, Benton S. Annals of Clinical Biochemistry (23rd May 2018 published online) doi: 10.1177/0004563218778716.
- Detection capability of quantitative faecal immunochemical tests for haemoglobin (FIT) and reporting of low faecal haemoglobin concentrations. Fraser CG, Benton SC. Clin Chem Lab Med. 2018 Jul 11. pii: /j/cclm.ahead-of-print/cclm-2018-0464/cclm-2018-0464.xml. doi: 10.1515/cclm-2018-0464. [Epub ahead of print] PMID: 29995629
- Does the mass of sample loaded affect faecal haemoglobin concentration using the faecal immunochemical test?Piggott c, John C, Bruce H, Benton S. Annals of Clinical Biochemistry, 2018 Jan 1:4563218778701. doi: 10.1177/0004563218778701. [Epub ahead of print]
- An assessment of the effect of haemoglobin variants on detection by faecal immunochemical tests.Carroll M, John C, Mantio D, Djedovic N, Benton S. Accepted for Annals of Clinical Biochemistry,2018 Jan 1:4563218778716. doi: 10.1177/0004563218778716. [Epub ahead of print]
- Detection capability of quantitative faecal immunochemical tests for haemoglobin (FIT) and reporting of low faecal haemoglobin concentrations.Callum G. Fraser and Sally C. Benton. Clin Chem Lab Med 2018 Jul 11. pii: /j/cclm.ahead-of-print/cclm-2018-0464/cclm-2018-0464.xml. doi: 10.1515/cclm-2018-0464. [Epub ahead of print]
- Setting up a service for a faecal immunochemical test for haemoglobin (FIT): a review of considerations, challenges and constraints.Godber I, Benton S, Fraser C. J Clin Path (accepted Sept 2018 for publication).
- FIT sample stability for haemoglobin-positive faeces using two analytical systems over seven days. Part 1: Piggott C, McDonald P, John C, Bruce H. British Society of Gastroenterology, Liverpool 2016. Part 2: Piggott C, John C, Bruce H. United European Gastroenterology Week Vienna 2016 /Cancer Data and Outcomes Conference, Manchester 2016 (poster).
- GP Participation in increasing uptake in a national cancer screening programme: the PEARL Project. Butler P, Duffy S, Reed K, Chesters M, Stanley S, Rickard S, et al. United European Gastroenterology Week, Vienna 2016 /Cancer Data and Outcomes conference, Manchester 2016 (poster).
- Haemoglobin concentration in faeces from one to 48 hours after sampling using three FIT analytical systems. John C, Piggott C, Bruce H. British Society of Gastroenterology, Liverpool 2016 /Cancer Data and Outcomes Conference, Manchester 2016 (poster).
- Participation, positivity and outcomes in the Nepali community invited for bowel cancer screening – a feasibility study.Seaman HE, Snowball J, Butler P, Underwood J, Bruce H. British Society of Gastroenterology, Liverpool 2016/Cancer Data and Outcomes Conference, Manchester 2016 (poster).
- Do haemoglobin variants affect the detection of haemoglobin by faecal immunochemical tests.Carroll MRR ACB Focus; Leeds 2017 + WEO; Barcelona 2017 (oral presentation).
- Comparison of haemoglobin concentrations on four different faecal immunochemical test (FIT) analysers.John C, Piggott C, Benton S. ACB Focus, Leeds 2017 /IBMS Congress, Birmingham 2017 (poster).
- The effect of different sampling techniques on faecal immunochemical test haemoglobin concentrations.Part 1: John C, Piggott C, Bruce H, Benton C. Cancer Research UK, London 2017. Part 2: Piggott C, John C, Bruce H, Benton S. ACB Focus, Leeds 2017 /IBMS Congress, Birmingham 2017 (poster).
- Evaluation of a new calibrator for the Sentinel FOB Gold faecal immunochemical test.John C, Piggott C, Carroll M, Benton S. ACB Focus, Manchester 2018 (poster).
- Faecal immunochemical testing (FIT) for post-polypectomy surveillance: an accuracy and efficiency study.Robbins E, Wooldrage K, MacRae E, Stenson I, Patel B, Pack K, Piggott C, Pearson S, Snowball J, Duffy SW, Halloran S, Atkin W, Cross AJ. British Society of Gastroenterology Annual Meeting, Liverpool 2018 (oral presentation).