Access to colorectal cancer screening varies across the UK. This article describes the various tests and how community pharmacists can promote them

Choglay, S

Kerrison, R

Marshall, S

Prentice, A

Vance, M

Von Wagner, C

English

UCL Discovery

The Pharmaceutical Journal 23 JAN 2019 By Andrew Prentice , Sarah Marshall , Margaret Vance , Sameer Choglay , Christian vonWagner , Robert KerrisonColorectal cancer screening and the role of community pharmacypharmaceutical-journal.com/learning/learning-article/colorectal-cancer-screening-and-the-role-of-community-pharmacy/20205674.articleAccess to colorectal cancer screening varies across the UK. This articledescribes the various tests and how community pharmacists canpromote them.Source: Victor de Schwanberg / Science Photo Library / reproduced with permission from Gut2017;66(9):1631–1Colorectal cancer (CRC), also called bowel cancer, is a leading cause of morbidity andmortality in the UK. In 2012, the disease accounted for nearly 1 in every 10 newlydiagnosed cancer cases and more than 1 in every 12 registered cancer deaths ,making it the fourth most frequently diagnosed cancer and the second leading cause ofcancer-related deaths in that year .In the UK, incidence rates are higher among men than women (58 new cases per 100,000[1],[2][3],[4]1/11In the UK, incidence rates are higher among men than women (58 new cases per 100,000men compared with 38 new cases per 100,000 women) and have steadily increased forboth sexes since the 1970s . Mortality rates are similarly higher among men; however,[5]2/11rates have steadily declined over the past 40 years — in 2012, the mortality rate of CRC inthe UK was 21 deaths per 100,000 men and 13 deaths per 100,000 women (nearly half ofwhat they were in 1971) .This article will discuss the main symptoms of CRC and the different screening testsavailable in the UK, as well as the role of the pharmacist and pharmacy team inpromoting screening.AetiologyOnset of CRC is influenced by a complex interaction between genetic, environmental andlifestyle factors, which include:The likelihood of being diagnosed increases with age; men aged 60–64 years are nearly 14times more likely to be diagnosed with CRC than men aged 40–44 years . The effect ofage is less pronounced in women, although older women (between the ages of 80 and 84years) are also much more likely to develop CRC than younger women (under the age of69 years) .A previous history of bowel polyps , severe ulcerative colitis or Crohn’s disease are allassociated with an increased risk of developing CRC . There are also two knowngenetic syndromes linked to the malignancy: hereditary non-polyposis colon cancer andfamilial adenomatous polyposis. However, syndromes with known genetic defects onlyaccount for 1–5% of all CRCs ; therefore, at present, genetic screening can only make alimited contribution to risk reduction in the general population.SymptomsThere are many symptoms of CRC that pharmacists should be aware of, including :A persistent change in bowel habit;Bleeding from the back passage;Blood in the stool;A lump in the abdomen;Anaemia;[5][17][17][18][19],[20][18][21]3/11Unexplained tiredness;Weight loss;Abdominal pain.The adenoma-carcinoma pathwayMore than 90% of CRCs develop from adenomas (also referred to as adenomatouspolyps), which are benign growths that develop from gland cells that line the bowelwall . Around 33–50% of all adults will develop one or more adenomas duringtheir lifetime  and, while all have the potential to become malignant, fewer than 10%develop into invasive cancer .The likelihood that an adenoma will develop into invasive cancer is highly dependent on anumber of factors, including: the size and histological type of the adenoma; the degree ofepithelial dysplasia (i.e. the extent to which cells appear to be abnormal); and theinvolvement of specific tumour suppressor genes  (see Box).Box: Treatment and survival rates by stage of colorectal cancer at diagnosisChances of survival are strongly contingent on the stage at diagnosis .Stage IPeople with localised disease have the best chances for survival, with 95% surviving forat least five years .Stage IIFor people with colorectal cancer (CRC) that has infiltrated the colon wall, the chance ofsurviving five or more years is reduced to 80%.Stage IIIFor people where the cancer has spread to one or more lymph nodes, the chance ofsurviving for five or more years is reduced to around 63% .Stage IVPeople with distant metastases have the poorest chances of survival, with as few as10% surviving for five or more years .Owing to the extensive preclinical phase of CRC , most people are diagnosed whenthe cancer has spread to the surrounding tissues or lymph nodes (stages III and IV),and the prognosis for survival is generally poor .As well as being associated with a poorer prognosis for survival, late-stage CRC isgenerally associated with more expensive and more invasive treatment regimens. Formost early-stage CRCs, surgery is the main treatment , whereas a combination ofsurgery and chemotherapy or radiotherapy is recommended for late-stage CRCs .Consequently, the lifetime cost per head to treat a CRC can range from £3,337 for a[22],[23],[24][25],[26][24],[27][28][29][29][29][29][30][31][32][33]4/11Consequently, the lifetime cost per head to treat a CRC can range from £3,337 for astage I CRC to £12,519 for a stage IV CRC . Impetus to improve the early diagnosis ofCRC is therefore high, not only because doing so will have improved outcomes for thepatient, but also reduced treatment costs for the NHS.Screening for colorectal cancer in the UKSeveral investigations are capable of testing for CRC and the precancerous lesions fromwhich it develops . These can be broadly categorised into two groups:1. Those that detect cancer early (e.g. the guaiac faecal occult blood test [FOBt] and thefaecal immunochemical test [FIT]);2. Those that prevent cancer through the timely detection and removal of adenomas(e.g. flexible sigmoidoscopy and colonoscopy).Guidelines on the delivery of CRC screening vary between parts of the UK and areoutlined as follows.Bowel scope screening for men and women aged 55–59 years (England only)Introduced in 2013, bowel scope screening is gradually being rolled out to all men andwomen aged 55–59 years who are registered with a GP in England. It involves anendoscopic test called a ‘flexible sigmoidoscopy’ that examines the rectum and sigmoidcolon (the most distal third of the large bowel where cancer is most likely to develop) foradenomas and cancer. Patients are invited to a one-off test at the age of 55 years,however, patients are able to self refer up to their 60th birthday. This test has been shownto reduce CRC incidence among users by up to 33% and CRC mortality by up to 50% . Faecal occult blood test screening for men and women aged 60–74 years (England,Wales and Northern Ireland)This home-based screening test is offered once every two years to men and women aged60–74 years who are registered with a GP in England, Wales and Northern Ireland .People aged 75 years or older can ask for a kit every two years by calling the free bowelcancer screening helpline on 0800 7076060.Individuals complete the FOBt by applying a small stool sample onto a test cardimpregnated with guaiac (a resin that acts as phenolic redox indicator), using a cardboardapplicator (see Figure 1). Two samples are usually taken from each bowel motion, so as toreduce the chances of obtaining a false negative result (i.e. a negative result for a samplethat contains faecal occult blood). As tumours and adenomas can bleed intermittently,and the test may not be sensitive enough to detect particularly low concentrations offaecal haemoglobin , the stool sampling process is repeated so that a sample is takenfrom up to three separate bowel motions.The test kit is returned by post to a screening centre for analysis . If there is a positive[34][35][36][37][38][37] 5/11The test kit is returned by post to a screening centre for analysis . If there is a positiveresult in five or six panels, the patient is referred to their local screening centre forsuitability assessment for a colonoscopy . If there is a positive result in one tofour panels, another kit is sent to the patient’s home address for repeat testing.Figure 1: Guaiac faecal occult blood test kit used by the NHS Bowel CancerScreening ProgrammeSource: Victor de Schwanberg / Science Photo LibraryFaecal immunochemical test screening for men and women aged 50–74 years(Scotland)This home-based screening test is offered once every two years to men and women aged50–74 years registered with a GP in Scotland. Similar to the FOBt, individuals completingthe FIT are required to collect a sample of their stool. However, rather than applying asample to a test card, it is stored in a bottle containing buffer solution using a plasticapplicator (see Figure 2) . As with the FOBt, the FIT is completed in the individual’s homeand then returned to a screening centre where it is examined by a medical laboratoryassistant using an analyser.A recent pilot study examining the use of FIT in England showed a 7% increase in uptakecompared with the FOBt . As a result, Public Health England (PHE) has recentlyconfirmed that FIT will replace the FOBt in the English Bowel Cancer ScreeningProgramme and is scheduled to be phased in spring 2019. There are alsorecommendations that the screening age of the English programme is to be lowered from60 to 50 years, as is currently the case in Scotland .[37][37],[39],[40][41][42][43]6/11Figure 2: Instructions for the faecal immunochemical test kit piloted by theNHS Bowel Cancer Screening ProgrammeSource: Reproduced with permission from Gut 2017;66(9):1631–1644Step 1:Write date on sample bottle; use layers of toilet paper to catch the sample;twist cap to open sample bottle.Step 2:Collect sample by scraping the green, stick along the sample until allgrooves are covered.Step 3:Put stick back in and ‘click’ the green cap to close it; do not repeat thecollection; wash hands after use.Step 4Put the sample bottle back into the box; write your name on the box in thespace provided; peel off tape, close and seal the box.Uptake of CRC screeningCRC screening uptake across the UK is lower than the other cancer screening 7/11CRC screening uptake across the UK is lower than the other cancer screeningprogrammes, and there are considerable inequalities between areas and demographics.PHE has an uptake target of 75% but the most recent uptake figure stands at 56% . Insome parts of the country, uptake is as low as 33% according to figures from BowelCancer UK. Seven out of ten of the worst areas in the country are in London and 44% ofclinical commissioning groups in England are below the national average .In 2016, PHE established the quality criteria for community pharmacies to gain HealthLiving Pharmacy Status and the role of health promotion in meeting public health needs.This was further defined in the National Institute for Health and Care Excellence guideline‘Community pharmacies: promoting health and wellbeing’, published in August 2018 .Building a relationship with a local bowel cancer screening centre and collaborating on thepromotion of CRC screening in the local population will assist community pharmacies indemonstrating how they are meeting the criteria laid out in these documents. Forexample, Healthy Living Pharmacies could ensure information, including the upcomingchanges to the NHS Bowel Cancer Screening programme, is part of their Health PromotionZones with relevant information on their local screening centre. Team leaders withincommunity pharmacies could ensure all staff receive training on bowel cancer to include:Providing up-to-date information – the facts about CRC;Benefits of early detection (including ‘red flag’ symptoms to look out for);The change to the FIT home testing kit;Ensuring staff feel confident on how to use the CRC testing kit and are able toexplain it to patients in a simple and concise manner.The table explains how pharmacy staff can support their local population with advice andinformation on CRC screening.[44][44][45]8/11Table: Advice pharmacists can provide people concerned aboutcolorectal cancer screeningSource: St Mark’s Hospital, MiddlesexReferences: Cancer Research UK. Bowel cancer incidence statistics. 2018. Available at:http://www.cancerresearchuk.org/cancer-info/cancerstats/types/bowel/incidence/uk-bowel-cancer-incidence-statistics (accessed January 2019) Cancer Research UK. Bowel cancer mortality statistics. 2018. Available at:http://www.cancerresearchuk.org/cancer-info/cancerstats/types/bowel/mortality/(accessed January 2019) Cancer Research UK. Cancer incidence for common cancers. 2018. Available at:http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/common-cancers-compared#heading-Zero (accessed January 2019) Cancer Research UK. Cancer mortality for common cancers. 2018. Available at:http://www.cancerresearchuk.org/health-professional/cancer-statistics/mortality/common-cancers-compared#heading-Zero (accessed January 2019) Office for National Statistics. Bowel cancer rates have risen in England since 1971. 2013.Available at:https://webarchive.nationalarchives.gov.uk/20140112045301/http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations–england–series-mb1-/no–41–2010/sty-bowel-cancer-rates-in-england.html?translation-component=&calling-id=77-6741-4&currLang=English&format=normal (accessed January 2019) van Duijnhoven FJ, Bueno-De-Mesquita HB, Ferrari P et al. Fruit, vegetables, andcolorectal cancer risk: the European Prospective Investigation into Cancer and Nutrition.Am J Clin Nutr 2009;89(5):1441–1452. doi: 10.3945/ajcn.2008.27120 Cho E, Smith-Warner SA, Ritz J et al. Alcohol intake and colorectal cancer: a pooledanalysis of 8 cohort studies. Ann Int Med 2004;140(8):603–613. PMID: 15096331 Botteri E, Iodice S, Bagnardi V et al. Smoking and colorectal cancer: a meta-analysis.JAMA 2008;300(23):2765–2778. doi: 10.1001/jama.2008.839 Liang PS, Chen TY & Giovannucci E. Cigarette smoking and colorectal cancer incidenceand mortality: Systematic review and meta‐analysis. Int J Cancer 2009;124(10):2406–2415.doi: 10.1002/ijc.24191 Chan D, Lau R, Aune D et al. Red and processed meat and colorectal cancer incidence:[1][2][3][4][5][6][7][8][9][10] 9/11 Chan D, Lau R, Aune D et al. Red and processed meat and colorectal cancer incidence:meta-analysis of prospective studies. PLOS One 2011;6(6):e20456 doi:10.1371/journal.pone.0020456 Moghaddam AA, Woodward M & Huxley R. Obesity and risk of colorectal cancer: ameta-analysis of 31 studies with 70,000 events. Cancer Epidem Biomar 2007;16(12):2533–2547. doi: 10.1158/1055-9965.EPI-07-0708 Ning Y, Wang L & Giovannucci E. A quantitative analysis of body mass index andcolorectal cancer: findings from 56 observational studies. Obes Rev 2010;11(1):19–30. doi:10.1111/j.1467-789X.2009.00613.x Slattery ML. Physical activity and colorectal cancer. Sports Med 2004;34(4):239–252.PMID: 15049716 Wei EK, Giovannucci E, Wu K et al. Comparison of risk factors for colon and rectalcancer. Int J Cancer 2004;108(3):433–442. doi: 10.1002/ijc.11540 Wolin K, Yan Y, Colditz G & Lee I. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer 2009;100(4):611–616. doi: 10.1038/sj.bjc.6604917 Boyle T, Fritschi L, Heyworth J & Bull F. Long-term sedentary work and the risk ofsubsite-specific colorectal cancer. Am J Epidemiol 2011;173(10):1183–1191. doi:10.1093/aje/kwq513 Cancer Research UK. Bowel cancer incidence statistics by age. 2018. Available at:http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/incidence#heading-One (accessed January 2019) Winawer SJ. Colorectal cancer screening. Best Pract Res Clin Gastroenterol2007;21(6):1031–1048. doi: 10.1016/j.bpg.2007.09.004 Canavan C, Abrams K & Mayberry J. Meta‐analysis: Colorectal and small bowel cancerrisk in patients with Crohn’s disease. Alimen Pharm Ther 2006;23(8):1097–1104. doi:10.1111/j.1365-2036.2006.02854.x Jess T, Rungoe C & Peyrin-Biroulet L. Risk of colorectal cancer in patients withulcerative colitis: a meta-analysis of population-based cohort studies. Clin GastroenterolHepatol 2012;10(6):639–645. doi: 10.1016/j.cgh.2012.01.010 Cancer Research UK. Bowel cancer symptoms. 2018. Available at:http://www.cancerresearchuk.org/about-cancer/type/bowel-cancer/about/bowel-cancer-symptoms (accessed January 2019) Cancer Research UK. Bowel cancer survival statistics. 2017. Available at:http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/survival#ref-0 (accessed January 2019) Cancer Research UK. Treatment decisions for early bowel cancer. 2015. Available at:http://www.cancerresearchuk.org/about-cancer/bowel-cancer/treatment/treatment-decisions (accessed January 2019) Cancer Research UK. Treatment for advanced cancer. 2018. Available at:[10][11][12][13][14][15][16][17][18][19][20][21][29][32][33] 10/11 Cancer Research UK. Treatment for advanced cancer. 2018. Available at:http://www.cancerresearchuk.org/about-cancer/bowel-cancer/advanced/treatment(accessed January 2019) Incisive Health & Cancer Research UK. Saving lives, averting costs: An analysis of thefinancial implications of achieving earlier diagnosis of colorectal, lung and ovarian cancer.Available at: https://www.incisivehealth.com/wp-content/uploads/2018/08/Saving-lives-averting-costs.pdf (accessed January 2019) Elmunzer BJ, Hayward RA, Schoenfeld PS et al. Effect of flexible sigmoidoscopy-basedscreening on incidence and mortality of colorectal cancer: A systematic review and meta-analysis of randomized controlled trials. PLoS Med 2012;9(12):e1001352. doi:10.1371/journal.pmed.1001352 Royal Exeter and Devon NHS Trust. Bowel screening service. 2012. Available at:http://www.rdehospital.nhs.uk/patients/services/bowel_cancer_screening.html (accessedJanuary 2019) Moss S, Mathews C, Day TJ et al. Increased uptake and improved outcomes of bowelcancer screening with a faecal immunochemical test: results from a pilot study within thenational screening programme in England. Gut 2017;66(9):1631–1644. doi: 10.1136/gutjnl-2015-310691 Public Health England. Bowel screening to start at 50. 2018. Available at:https://www.gov.uk/government/news/bowel-screening-to-start-at-50 (accessed January2019) Public Health England. Health matters: improving the prevention and diagnosis ofbowel cancer. 2016. Available at: https://www.gov.uk/government/publications/health-matters-preventing-bowel-cancer/health-matters-improving-the-prevention-and-detection-of-bowel-cancer (accessed January 2019) National Institute for Health and Care Excellence. Community pharmacies: promotinghealth and wellbeing. NICE guideline [NG102]. 2018. Available at:https://www.nice.org.uk/guidance/ng102 (accessed January 2019)Citation: The Pharmaceutical Journal, January 2019, Vol 302, No 7921, online | DOI:10.1211/PJ.2019.20205674[33][34][36][40][42][43][44][45]11/11

Colorectal cancer screening and the role of community pharmacy

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Colorectal cancer screening and the role of community pharmacy

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