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Cancer Screening

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 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.

NHS Bowel Cancer Screening Southern Programme

The NHS Bowel Cancer Screening Programme (BCSP) in England is commissioned by NHS England (biennial faecal occult blood testing 60-74 years) and Public Health England (once-only flexible sigmoidoscopy at 55 years) and co-ordinated through five regional Hubs. The BCSP Southern Programme Hub (Southern Hub) started work in 2006 and is hosted by the Royal Surrey County and Frimley Park Hospitals. The Southern Hub has premises on the Surrey Research Park in Guildford and is directed by Sally Benton FRCPath. Professor Halloran, our previous director, retired in March 2015.

The BCSP Southern Hub research team includes six clinical scientists, two data analysts and an epidemiology lead. The group has various research collaborations with groups in Imperial College London, University College London, and the Universities of Sheffield, Oxford and Durham, all to improve and develop the screening tests for bowel cancer.

Since its launch in September 2006 in excess of eight million men and women have been invited to be screened; more than 7,000 people have been diagnosed with bowel cancer and another 8,000 with advanced benign tumours. The Southern Hub has grown and is now the largest of five Bowel Cancer Screening Programmes across England.  When the service first launched it sent out just 100 screening invitations in its first daily batch, now it invites about 104,000 people for screening every month.  Screening invitations and test kits are sent every two years to men and women aged 60 to 74 years. The kits are designed to detect small amounts of blood in stool that might be shed from the surface of bowel cancer or its precursor (benign tumours or polyps). These are analysed at the Hub and anyone who tests positive is invited for a follow-up investigation, usually colonoscopy, at one of 18 screening centres, including Royal Surrey.  In 2013, the Hub introduced the BCSP’s bowel scope programme offering 55-year-old men and women a once-only examination of the lower bowel using a flexible sigmoidoscope, which allows doctors to see the lower part of the colon.  As a result of this programme, an additional 350 people, so far, have been diagnosed with bowel cancer or a benign tumour.  In 2014 the Southern Hub was one of two to run a six month pilot to investigate the practicalities of replacing the current test with a superior and simpler version.  Based on the result of that pilot, including a marked increase in uptake of the screening invitation, plans are underway to introduce the faecal immunochemical test, or FIT, across England in 2018.   Paula Head, Chief Executive of Royal Surrey County Hospital, said: “Bowel screening offers a real opportunity to try and detect disease before symptoms develop, making any cancers found easier to treat effectively and giving a better chance of long term survival.  “We are delighted to have hosted the Southern Hub for the past 10 years and looking forward to working together for many more to come.”  The Southern Hub’s Director, Sally Benton, is proud of the Hub’s success – “Since its inception, the conscientious and hard-working team at the Hub has strived to provide the best possible service to our population. We will continue to do so as the Programme enters a new phase with the implementation of FIT.”

Current projects include:

Studies on faecal immunochemical tests for haemoglobin (FIT)

Since 2006, the BCSP has used a guaiac-based faecal occult blood test (gFOBt). The superiority of faecal immunochemical tests for haemoglobin (FIT) over gFOBt is now recognised and the BCSP plans to replace gFOBt with FIT. The BCSP Southern Hub research team is involved in several collaborative studies to investigate FIT in CRC screening and to optimise its use.

  • FIT Pilot study
    Two BCSP Hubs (Southern and Midlands & North West) ran the FIT pilot study for six months during 2014. Screening using a FIT device (rather than gFOBt) was offered in one in 28 BCSP invitations. Colleagues in Queen Mary, University of London (clinical assessment) and Oxford (health economics assessment) will compile the BCSP FIT Pilot study reports, which are expected in 2016. The BCSP Southern Hub is preparing the FIT Pilot Report from the Hubs
  • FIT for Screening
    The World Endoscopy Organization convened an Expert Working Group (EWG) (‘FIT for Screening’) as part of its Colorectal Cancer Screening Committee. Professor Halloran was a founding member of the EWG and leads the group in its efforts to promote the use of FIT in CRC screening. The EWG meets twice a year, bringing together CRC screening experts from around the world, and publishes widely in the scientific literature (http://www.worldendo.org/fit-ewg-publications.html).
  • FIT Evaluation
    The Southern Hub research team has completed an evaluation of quantitative FIT to guide the BCSP FIT procurement process. The report is available on the World Endoscopy Organization’s website: http://www.worldendo.org/assets/downloads/pdf/activities/fit_reports/gmec_fit_evaluation_report.pdf.
  • 'FIT for follow-up' study
    The research team at the BCSP Southern Hub is collaborating with colleagues at University College London and Imperial College London on the NIHR-funded ‘FIT for follow-up’ study (http://www.fit4followup.org.uk/).

The BCSP database

The BCSP database (Bowel Cancer Screening System [BCSS]) provides a rich source of data for studies designed to enhance the performance of the BCSP. The research team at the Southern Hub has access to the screening data for the south of England and can apply for access to data for England on a project-by-project basis. (Usual NHS NIGB Information Governance rules apply and research proposals must be approved by the BCSP Research Committee.) The database is populated with the screening records for all individuals within the target age-range (about 8 million 60-74-year-olds in the gFOBt programme, about 665,000 55-year-olds in the FS programme). Records include screening activity (invitations, reminders, returned test kit details and results etc), data from SSP referrals and consultations, colonoscopy outcomes and pathology reports.

Improving uptake of BCSP gFOBt screening invitations

Uptake of BCSP invitations for gFOBt screening averages about 56% in England and there are clear associations between uptake and age, sex, ethnicity and social deprivation.

Optimisation of Current Algorithm for gFOBt

To comply with the gFOBt screening algorithm used in England, screening participants may be asked to complete up to three kits to reach a definitive test result. The gFOBt test card has three pairs of windows (or ‘spots’) upon which two faecal samples from three consecutive stools are applied. Each spot is tested for the presence of blood. If five or six windows are positive, the result is a ‘strong positive’ and referral for colonoscopy ensues. If between one and four windows is positive, the result is unclear and a second kit is requested. Subjects with any positive spots on the second kit are referred for colonoscopy. If the second kit is normal (all spots negative), a third kit is requested. Subjects with any positive spots on the third kit are referred for colonoscopy. Definitive positive test results that arise from two or more kits are defined as ‘weak positives’.

The majority of BCSP gFOBt screening participants referred for colonoscopy have a weak positive gFOBt result. It is uncertain whether or not the current algorithm involving up to three test kits optimises use of colonoscopic resource and cancer detection. The BCSP Southern Hub research team is collaborating with investigators at the Universities of Sheffield, Oxford and Durham, to address this issue.

Polymer Work

The BCSP Southern Hub research team clinical scientists are working with colleagues at the University of Surrey to develop a matrix that can be used for gFOBt and FIT quality assurance and quality control.

Horizon 2020

The BCSP Southern Hub research team is collaborating with European partners on several Horizon 2020 bids.

Further Information

Equipment and Resources

The BCSP Southern Hub research team has several members of staff with expertise in the use of routine health databases (Clinical Practice Research Database [CPRD], BCSS) and clinical scientists with extensive biochemical laboratory expertise and evaluation experience.

The BCSS database provides a rich source of data for research (subject to usual Information Governance and BCSP Research Committee approval). The database is a dynamic system that at any one time will include the screening records of about 8 million people aged 60-74 year (eligible for gFOBt screening), 665,000 people aged 55 years (eligible for once-only flexible sigmoidoscopy) and self-referrers, as well as the outcomes from about 300,000 diagnostic investigations (since 2006 roll-out) and the pathology records for some 136,000 cancers/adenomas.

Publications

  • Allison JE, Fraser CG, Halloran SP, Young GP.
    Comparing fecal immunochemical tests: improved standardization is needed. Gastroenterology 2012;142(3):422-4. Epub 2012/01/24. Read full article
  • Allison JE, Fraser CG, Halloran SP, Young GP.
    Population screening for colorectal cancer means getting FIT: the past, present, and future of colorectal cancer screening using FIT. Gut and Liver 2014;8:117-30.
    Allison JE, Fraser CG, Halloran SP, Young GP.
    Quality indicators and benchmarks for guideline recommended fecal occult tests for blood: sensitive guaiac fecal occult blood test (sFOBT) and fecal immunochemical test for hemoglobin (FIT). In: Quality indicators and benchmarks for stool based blood tests and programs. Shaukat A & Allen J (eds). Springer (in press). Read full article
  • Bowyer HL, Vart G, Kralj-Hans I, Atkin W, Halloran SP, Pearson S, Seaman HE, Wardle J, von Wagner C.
    Patient attitudes towards faecal immunochemical testing for haemoglobin as an alternative to colonoscopy for surveillance of groups at higher risk of colorectal cancer. Journal of Medical Screening 2013 Sep 17. [Epub ahead of print].
    Carroll M, Piggott C, Pearson S, Seaman HE, Bruce H, Benton SC, Halloran S.
    An evaluation of quantitative faecal immunochemical tests for haemoglobin (FIT). EuroLabFocus, 7-10 October 2014, Liverpool (poster). Read full article
  • Carroll M, Piggott C, Pearson S, Seaman HE, Bruce H, Halloran S.
    PWE-019 An evaluation of quantitative faecal immunochemical tests for haemoglobin. Gut 2014;63(Suppl 1):A129-A30. Read full article
  • Carroll MRR, Piggott C, Pearson S, Seaman HE, Halloran SP.
    Evaluation of quantitative faecal immunochemical tests for haemoglobin. Guildford Medical Device Evaluation Centre (GMEC), Guildford, UK, 2013. View report here
  • Carroll MRR, Seaman HE, Butler P, Snowball J, Halloran SP.
    Do seasonal trends in positivity exist with the guaiac-based faecal occult blood test? 21st United European Gastroenterology (UEG) Week, Berlin, Germany, October 12-16, 2013. United European Gastroenterology Journal 2013: 1 (Supplement 1) ;A533. Read full article
  • Carroll MRR, Seaman HE, Halloran SP.
    Tests and investigations for colorectal cancer screening. Clinical Biochemistry 2014;47(10–11):921-39. Read full article
  • Duffy MJ, van Rossum LG, van Turenhout ST, Malminiemi O, Sturgeon C, Lamerz R, Nicolini A, Haglund C, Holubec L, Fraser CG, Halloran SP.
    Use of faecal markers in screening for colorectal neoplasia: a European group on tumor markers position paper. International Journal of Cancer 2011(Jan);128(1):3-11. Read full article
  • Fraser C, Allison JE, Young GP, Halloran S.
    Newer fecal tests: opportunities for professionals in laboratory medicine. Clinical Chemistry 2012;58(6):963-5. Epub 27 March 2012. Read full article
  • Fraser C, Halloran S, Allison J, Young G. Making colorectal cancer screening FITTER for purpose with quantitative faecal immunochemical tests for haemoglobin (FIT). Clinical Chemistry and Laboratory Medicine 2013;51(11):2065-7. Read full article
  • Fraser CG, Allison JE, Halloran SP, Young GP.
    A proposal to standardize reporting units for fecal immunochemical tests for hemoglobin. Journal of the National Cancer Institute 2012;104(11):810-4. Read full article
  • Fraser CG, Allison JE, Young GP, Halloran SP, Seaman HE.
    A Standard for Faecal Immunochemical Tests for Haemoglobin Evaluation Reporting (FITTER) (Letter). Annals of Clinical Biochemistry 2014;51(2):301-2. Read full article
  • Fraser CG, Allison JE, Young GP, Halloran SP, Seaman HE.
    Improving the reporting of evaluations of faecal immunochemical tests for haemoglobin: the FITTER standard and checklist. European Journal of Cancer Prevention 2014. [Epub ahead of print 2014/02/27.] Read full article
  • Fraser CG, Allison JE, Young GP, Halloran SP.
    Quantitation of hemoglobin improves fecal immunochemical tests for noninvasive screening. Clinical Gastroenterology and Hepatology 2013;11(7):839-40. Read full article
  • Geraghty J, Butler P, Seaman HE, Snowball J, Sarkar S, Blanks R, Halloran SP, Bodger K. Rees C.
    Optimising faecal occult blood screening – lessons from the NHS Bowel Cancer Screening Programme in England. British Journal of Cancer 2014. Epub ahead of print16-09-14. Read full article
  • Geraghty J, Snowball J, Butler P, Sarkar S, Blanks R, Halloran S
    OC-083. Faecal occult blood test analysis in the United Kingdom Bowel Cancer Screening Programme. Gut 2013; 62(Suppl 1):A36 Read full article
  • Grazzini G, Ventura L, Zappa M, Ciatto S, Confortini M, Rapi S, Rubeca T, Visioli CB and Halloran SP.
    Influence of seasonal variations in ambient temperatures on performance of immunochemical faecal occult blood test for colorectal cancer screening: observational study from the Florence district. Gut 2010;59(11):1511-5. Read full article
  • Grazzini G, Zappa M, Halloran SP.
    Limited effect of summer warming on the sensitivity of colorectal cancer screening (letter). Gut 2012;61(1):162 Read full article
  • Grazzini G, Zappa M, Ventura L, Rubeca T, Halloran SP.
    Authors’ Response (letter). Gut 2011;60:1304 doi:10.1136/gut.2010.226241. Read full article
  • Grazzini G, Zappa M, Ventura L, Rubeca T, Halloran SP.
    Authors’ Response (letter). Gut 2011;60:1304 doi:10.1136/gut.2010.226241. Read full article
  • Halloran S, Launoy G, Zappa M.
    Faecal occult blood testing. Chapter 4. In: Segnan N, Patnick J, von Karsa L (eds). European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition. European Commission. Luxembourg: Publications Office of the European Union, 2010. Pp165-206. Read full article
  • Halloran S, Launoy G, Zappa M.
    Faecal occult blood testing. European guidelines for quality assurance in colorectal cancer screening and diagnosis. Endoscopy 2012;44 (S03):SE65-SE87. Read full article
  • Halloran SP..
    Colorectal cancer screening – insights and challenges. Nature Reviews Gastroenterology and Hepatology 2014:11; 586–7. Read full article
  • 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. British Journal of Cancer 2011:105(4);475-80. Read full article
  • Kralj-Hans I, Martin J, Pearson S, Piggott C, Bowyer H, Vart G, et al.
    PWE-023 Could faecal immunochemical tests for haemoglobin (FIT) change surveillance of people with intermediate risk adenomas? Gut 2013;62(Suppl1):A139 Read full article
  • Lo SH, Halloran SP, Snowball J, Seaman HE, Wardle J, von Wagner C.
    Colorectal cancer screening uptake over three biennial invitation rounds in the English Bowel Cancer Screening Programme. Gut 2014 May 7. doi: 10.1136/gutjnl-2013-306144. [Epub ahead of print.] Read full article
  • Lo SH, Halloran SP, Snowball J, Seaman HE, Wardle J, von Wagner C.
    Predictors of repeat participation in the NHS Bowel Cancer Screening Programme. British Journal of Cancer 2014 Nov 27. doi: 10.1038/bjc.2014.569 [Epub head of print.]
    Lo SH, Halloran SP, Snowball J, Seaman HE, Wardle J, von Wagner C. br Lo SH, Halloran SP, Snowball J, Seaman HE, Wardle J, von Wagner C. Previous screening episode predictors of repeat participation in the NHS Bowel Cancer Screening Programme. United European Gastroenterology (UEG) Week, 20-22 October 2014, Vienna, Austria (poster). Read full article
  • Lo SH, Vart G, Snowball J, Halloran S, Wardle J, von Wagner C.
    The impact of media coverage of the flexible sigmoidoscopy trial on English colorectal screening uptake. Journal of Medical Screening 2012;19(2)83-8. Read full article
  • MacRae E, Brenner A, Martin J, Pearson S, Piggott C, Bowyer H, et al.
    OC-042 Sensitivity of annual faecal immunochemical tests for haemoglobin (FIT) for detecting advanced neoplasia in patients undergoing three-yearly surveillance colonoscopy – the FIT for Follow-up Study. Gut 2014;63(Suppl 1):A20-A1. Read full article
  • Massat N, Moss SM, Halloran SP, Duffy SW.
    Screening and primary prevention of colorectal cancer: a review of sex-specific and site-specific differences. Journal of Medical Screening 2013;20(3):125-48. Read full article
  • Morris S, Baio G, Kendall E, Von Wagner C, Wardle J, Atkin W, Halloran S et al.
    Socioeconomic variation in uptake of colonoscopy following a positive faecal occult blood test result: a retrospective analysis of the NHS Bowel Cancer Screening Programme. British Journal of Cancer 2012;107(5):765-71. Read full article
  • Nnoaham KE, Frater A, Roderick P, Moon G, Halloran S.
    Do geodemographic typologies explain variations in uptake in colorectal cancer screening? An assessment using routine screening data in the south of England. Journal of Public Health 2010;32(4):572-81. Read full article
  • Seaman HE, Butler P, Snowball JM, Halloran SP.
    PWE-020: Do seasonal trends in positivity exist with the guaiac-based faecal occult blood test? Gut 2013;62(Suppl 1):A137-A8. Read full article
  • Seaman HE, Snowball JM, Halloran SP.
    Mo1191 An investigation of high gFOBT positivity during the first five days following sample collection. Gastroenterology 2013;144(5):S-603. Read full article
  • Seaman HE, Snowball JM, Halloran SP.
    PWE-021: An investigation into high gFOBt positivity during the first five days following sample collection. Gut 2013;62(Suppl 1):A138. Read full article
  • Seaman HE, Snowball JM, Halloran SP.
    PWE-021: An investigation into high gFOBt positivity during the first five days following sample collection. Gut 2013;62(Suppl 1):A138.
    Snowball J, Seaman H, Halloran SP.
    Can we explain the apparent decline in uptake of invitations for colorectal cancer screening in England? United European Gastroenterology (UEG) Week, 20-22 October 2014, Vienna, Austria (poster). Read full article
  • Snowball J, Seaman H, Halloran SP.
    Workload implications of modifying the BCSP algorithm for referral to colonoscopy. National Cancer Research Institute Cancer Conference, 2-5 November 2014, Liverpool (poster). Read full article
  • von Karsa L, Patnick J, Segnan N, Atkin W, Halloran S, Lansdorp-Vogelaar I, et al.
    European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication. Endoscopy 2013;45(1):51-9. Epub 2012/12/06. Read full article
  • von Wagner C, Baio G, Raine R, Snowball J, Morris S, Atkin W, Obichere A, Handley G, Logan RF, Rainbow S, Smith S, Halloran S, Wardle J.
    Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England. International Journal of Epidemiology 2011;40(3):712-8. Read full article
  • Watson J, Shaw K, MacGregor M, Smith S, Halloran SP, Patnick P, Beral V, Green J.
    on behalf of the Bowel Screening Follow-up Study Investigators. Use of research questionnaires in the NHS Bowel Cancer Screening Programme in England: impact on screening uptake. Journal of Medical Screening 2013;20(4):192-7. Read full article
  • Whyte S, Chilcott J, Halloran S.
    Re-appraisal of the options for colorectal cancer screening in England. Colorectal Disease 2012;14(9):e547-61. Read full article
  • Young GP, Fraser CG, Halloran SP, Cole S.
    Guaiac based faecal occult blood testing for colorectal cancer screening: an obsolete strategy? Gut 2012;61(7):959-60. Read full article
  • Young GP, Symonds E, Cole S, Fraser CG, Halloran SP, Allison JE, Kuipers E, Seaman HE.
    Advances in FOBT – the FIT revolution. Digestive Diseases and Science 2014 December 10, doi: 10.1007/s10620-014-3445-3. [Epub ahead of print.] Read full article