Screening

I have been an independent high quality colonoscopist for two decades and became a “ bowel cancer screener” in 2015. There is a national process of accrediting endoscopists with specialist skills in screening and removing complex polyps.

In the UK there is a national bowel cancer screening programme. This is unique and an exceptional service. Currently people from age of 60-74 are offered bowel cancer screening every two years. In August 2018, ministers agreed that in the future bowel cancer screening in England will start at the age of 50. The NHS is starting to reduce the age range for bowel cancer screening from April 2021. However there are lots of logistics and currently our local screening age starts at 60 years.

I have been an independent high quality colonoscopist for two decades and became a “ bowel cancer accredited screener” in 2015.

In the UK there is a national bowel cancer screening programme. This is unique and an exceptional service. Currently people from age of 60-74 are offered bowel cancer screening every two years.

So would one do this? This testing stool for hidden or “Occult” blood is used as a screening tool. You will hear the term FOB i.e. Faecal Occult Blood. These days you hear the word FIT. It stands for Faecal Immunochemical Test. People from the age of 60 onwards are screened in the UK. An important issue is that ther I s evidence that screening can help from the age of 50. In 2018 ministers agreed that in the future bowel cancer screening in England will start at the age of 50. This is not yet in place and the NHS is working towards it. There are many logistics and operational issues that are considered in order to deliver this.

Bowel cancer screening is done by testing stool for “occult” blood. “Occult” means blood that you don’t see at all. It feels paradoxical in some ways. You don’t see any blood and yet you may have a tumour which is shedding small amounts of blood. If the test for stool occult blood is positive the person is offered colonoscopy. It is worth remembering that even n that advanced age group the positivity of the test is only 2%. And for those who fall into that 2% category and then go on to have a colonoscopy 50% of them have some form of pathology. By which I mean having polyps or cancer. Actually the cancer is only 10%, the polyps occur in 40%. Which means that 1 in 2 people are normal and have no findings at colonoscopy and so you could argue that with the benefit of retrospective wisdom that he did not need the colonoscopy at all! But of course he/ she did not know this in advance. You see colonoscopy is not without risks. Then there is the issue of oral bowel preparation which is essentially drugs that are given to cause an intense diarrhoea. By that I mean you will empty your bowels 10 or 15 times. Then you go to the endoscopy unit and an experienced colonoscopists passes a colonoscope and inspects your entire large bowel. In order to inspect it properly you need it to be clean and hence the oral bowel preparation. If there are polyps in the colon these are removed. If there is cancer it is biopsied and then other tests are planned so you gather information of the feasibility of curing it. This procedure of colonoscopy is not without risks. The 2 most important risks are bleeding and making a hole in the bowel. Fortunately they are both rare. Bleeding happens about 1:250 people and perforation about 1:1000. But as polyp intervention is performed the perforation rate increases. This varies form 1:500 to gradually increasing odds. If a perforation happens it is a big deal and it is likely you will need emergency surgery to correct the issue. But consider this – if you had no problems at all and then someone tells you that you have some blood in the stool even if you do not see it and then a colonoscopy is done and a cancer is found you would feel very grateful that it was picked up at an early stage and treated and your life saved. But what if you were found to have a polyp and that was removed and you suffered a complication and then needed emergency surgery!

You feel so hard done by. There you are happily going through life and now suddenly a whole lot of hardship has been put on you – unnecessarily you would say! And you

would be right. That is why it is important that the complications are kept to a minimum. Life being as it is one cannot make the risk of complications zero. That is not feasible just like it is not possible to say that there can be zero risk of any accident on the road as you leave your home. The question comes then how do you minimise the risk. One way is to make the quality of the entire process very high quality in the way the stool test is performed, in the way the results are conveyed, the way the information is given and the quality of the units where the colonoscopy happens and of course the quality control of the colonoscopists.

In the UK these specialist endoscopists are called “Screeners”. This means Bowel Cancer Screener and the person has to go through special accreditation examinations. Not every endoscopists is a screener. I had to a Multiple Choice Questions examination and pass them. Then after the theoretical knowledge was judged as having reached a good standard I had to go to a different hospital and there I was watched while I performed colonoscopy on two people who were national experts themselves. They watched how I reassured the patient but explained the procedural details, answered questions, and my technical ability to perform it. And they assess if I am competent to be a screener. And then I start doing screening lists with my figures regularly audited and compared to other screeners and such audits are done regularly and reviewed. I don’t want those who read this to imagine that if an endoscopist is not a “Bowel Cancer Screener” they are not a good colonoscopists. There are lots of good colonoscopists who As was I before I was certified as a screener. I was a good colonoscopists doing advanced colonoscopy and then one day I passed the exams and from that day onwards I became certified a screener. That is all it is – a means of certification which reviews quality openly and tightly controls quality of the whole process – so that if a complication happens there is no collapse of confidence in the system. There is a wonderful link of Bowel Cancer screening in the UK with some facts and figures that is worth reading and how it is. https://www.gov.uk/guidance/bowel-cancer-screening-programme-overview