Linda Garvican

Planning for a possible national colorectal cancer screening programme.

This report presents the planning, projected costs, and manpower requirements for a possible national colorectal cancer screening programme. Screening would be offered to all those aged 50–69, who comprise 20% of the United Kingdom population. The initial screening test would be faecal occult blood testing every two years. A local programme, administered by a screening centre serving a population of one million, would be responsible for inviting 100 000 subjects a year. The response rate in Nottingham, the UK trial centre, was below 60%. Good informed compliance would require the active support of primary care. The invitation and test kit would be sent by post, and completed tests returned to the screening centre, for reading and reporting. Those with a positive initial screen (about 2%) would be recalled for assessment. This would result in 60 000 investigations each year across England and Wales, given a screening uptake rate of 60%. Clearly any deviation from this predicted rate would have a major effect on resources. Assessment and any subsequent treatment would be by a multidisciplinary team working at the cancer unit, as recommended in recent NHS executive guidance. The best method for investigation is colonoscopy. When completed successfully this allows visualisation of the whole bowel. However, performance varies widely across the UK, and there is insufficient skilled manpower to undertake this additional workload. Most significantly the technique has a mortality rate of 0.02%, so the programme might expect 12 deaths a year, which would not be acceptable. Alternatively, assessment of screen positive cases could be by a combination of double contrast barium enema and flexible sigmoidoscopy, with a comparable sensitivity. Both procedures have much lower morbidity and mortality rates. Colonoscopy would then only be required for a smaller number of patients, with cancer or suspicious lesions, or after unsatisfactory investigations. Quality assurance should be an integ- ral part of the programme, as in the other NHS cancer screening programmes, involving all professional groups and coordinated by a regional quality assurance reference centre. Cost estimates are over £40 million a year, together with any allowance for general practitioners, with additional capital and training costs at the start of the programme. Given a 60% overall uptake rate, a test sensitivity of 60%, and a recall rate of 2%, about 35% of the cases of colorectal cancer in the eligible population—that is, about 5400 cases, could be detected each year. As this would also depend on maintaining good compliance, a continuing value of 4000 cases is more realistic. Appreciable savings on costs of treatment are unlikely as aggressive curative treatments would be expensive.

Routine invitation of women aged 65-69 for breast cancer screening: results of first year of pilot study.

See p 376 and Editorial by Werneke and McPherson Evidence from Sweden shows that screening for breast cancer is as effective in reducing mortality from the disease in women aged 65-69 as it is in women aged 50-64.1 However, although the British governments Forrest report recognised that older women were more likely to develop breast cancer, it recommended that they should not be routinely invited for screening because of low cost effectiveness from a likely low uptake and shorter life expectancy.2 Instead women over 64 years are entitled to self refer every three years — although few do so.3 A three-centre pilot study was established in which women aged 65-69 are routinely invited for breast screening. This study investigates the problems of extending the programme to this age group, and cost effectiveness. Based on the results a policy decision should be possible. The East Sussex service started inviting …

Cost of quality management and information provision for screening: colorectal cancer screening.

Objective To estimate the costs of a quality management (QM) system as proposed by the Quality Management for Screening report for a future national colorectal cancer screening programme. Methods Estimates of the costs of the QM system, including the associated costs of education and training and information provision, were based on expert opinion, the existing literature, and the experience of the current National Health Service (NHS) breast cancer screening programme (BSP) and the NHS cervical cancer screening programme (CSP). Results The cost of a QM system to support a national colorectal cancer programme in the UK was estimated as approximately £3.8 million a year. Further annual costs related to QM will include £500 000 for education and training and £200 000 for information provision. Adding these additional costs to a previously published UK economic evaluation of colorectal cancer screening increases the cost-utility ratio to approximately £6500 per quality adjusted life year gained (over an eight year follow up period). Conclusions Any new screening programme, or an existing one, must have QM to ensure that the quality of screening is high and to maintain the right balance between benefit and harm. The significant costs of such a QM system should be included in any economic evaluation of a screening programme.

An evaluation of the prevalent round of the breast screening programme in south east Thames, 1988-1993: achievement of quality standards and population impact.

Objective –To evaluate the impact of the prevalent round of the NHS breast screening programme on the whole population of women aged 50–64 during the period 1988–92, by comparing the numbers of cancers detected at screening with those diagnosed symptomatically, in one United Kingdom health region (population 3.5 million). To relate this impact to the achievement of national quality standards and the observed sensitivity and specificity of the programme. Method –The breast screening programme computer systems and the Thames Cancer Registry database were used to diagnose cancers in women aged 50–64 during the period 1988–1992, who were classified into screen detected, interval cases, eligible but not yet invited, non-attenders, and those not registered with the programme. Results –The programme met all national quality assurance targets for uptake, diagnostic process, and detection, but screen detected cases comprised only 48% of those diagnosed during 1991 and 1992 when the breast screening programme was fully operational. As fewer than 40% of breast cancers registered occur in the eligible age range, this limits the impact of the programme to the possible early diagnosis of only 20% of all cases. A surprisingly high proportion occurred in women unknown to the programme, especially in inner London. The high number of interval cancers led to a programme sensitivity of only 73%, but 99.7% of women screening negative were correctly reassured as a result of screening—and for them the breast screening programme is a success. Conclusion –Despite achievement of quality standards, the breast screening programme is apparently having a low impact on the overall diagnosis of breast cancer in South East Thames, so a large mortality reduction due to screening alone is unlikely. Population coverage will need to be improved, and it may be necessary to reduce the screening interval, or extend the age range, or both.

The relationship between the NHS and residential and nursing care for older people: A survey of home owners and managers in East Sussex, Brighton and Hove

In view of the decline in the number of residential and nursing homes over the last few years, East Sussex, Brighton and Hove Health Authority was concerned about optimum usage of places. This project aimed to ascertain the views of home owners and managers on their working relationship with the health authority, local hospitals and social services.Respondents felt that the incoming residents were generally frailer and more dependent than a few years ago, funding allocations were inadequate, given the standards now expected of care homes, and there were delays of up to a year in reaching agreement. Several indicated that they would no longer take publicly funded clients unless the families could top up the payments. Ten percent of the private residential homes surveyed were for sale or due to close. Between 40 and 50 older people were estimated to be awaiting transfer to EMI or nursing homes in East Sussex. Over 35% of homes complained about inappropriate discharges of their residents from hospital, and a poor standard of nursing care. Communication with hospitals was poor and relationships with the health authority and social services needed strengthening. Routine admissions were appropriate, but hospital discharges may have been premature. Home owners/managers were dissatisfied with their relationship with the NHS. Improvements are needed if partnership working is to be developed.

Breast cancer screening: false positive rate is lower in older women.

EDITOR —Werneke and McPherson1 question the detection rates of cancer observed in the breast screening programme in East Sussex, Brighton, and Hove that we reported in our recent paper.2 They suggest that these are the result of a high proportion of false positive screens. It is unfortunate that they did not consult us beforehand. The paper gives results of an ongoing study, but …