Challenges for specialty outlined during meeting

The planned extension of BowelScreen must come with increased resources and staffing, a number of gastroenterologists warned at the ISG Winter Meeting.

During his presentation, Dr Eoin Slattery, Consultant Gastroenterologist, University Hospital Galway, raised concern about the dramatic increase in workload the age extension of BowelScreen will bring.

Currently, the national bowel cancer screening programme screens eligible people from the ages of 60-to-69 years, but this is being extended to cover the ages of 55-to-74 years within the next two-to-three years, “and whilst that is only 10 years, it increases the workload three-fold”.

“Most units are struggling to cope with their current workload as it is, so to triple the workload without real investment in terms of infrastructure and capital is going to be an extraordinary challenge,” Dr Slattery told the Medical Independent. “We want to do the work but we need the funding to do it and need more people and facilities to do that.”

During his presentation, Dr Slattery explained how BowelScreen has “been a rip-roaring success — it will save lives unequivocally”.

“In many ways, it has been a victim of its own success because we’ve managed to recruit so many patients and stop cancer in its tracks. But for it to continue to be a success and to expand it, the facilities that we work in, the infrastructure that we work in has to go with that too.”

He noted that as BowelScreen is quite a new programme compared to many existing programmes internationally, one key benefit was that it started when faecal immunochemical testing (FIT) was standard, replacing less-accurate faecal occult blood tests used in other bowel cancer screening programmes.

The first round of screening under BowelScreen picked up a significant amount of cancers and adenomas, creating a corresponding workload, Dr Slattery commented.

According to published data, in its first screening round, BowelScreen invited 488,628 eligible people for screening, completed screening in 196,238, performed 8,062 colonoscopies and detected 521 cancers. This represents a screening uptake rate of 40.2 per cent and a cancer detection rate of 2.65 per 1,000 people screened.

“Most of the cancers were at an early stage with an adenoma detection rate of 54 per cent….About 10 per cent of those were classified as advanced adenomas, which are just simple ‘snip-off’ polypectomies, but a lot of these were advanced procedures that need an advanced skill set.”

Dr Slattery said the evolution of endoscopy techniques and the advent of endoscopic mucosal resection (EMR) has been a great benefit for BowelScreen patients.

“I think mucosal resection has changed the pathway for patients with advanced colorectal lesions so surgery is no longer a necessity for those patients and they can be managed endoscopically, by and large very successfully. All that based on the work of BowelScreen, which identifies these patients earlier,” he told MI.

Dr Slattery also praised the quality of the “cutting-edge” equipment (high-definition scopes and ScopeGuide) in use in the BowelScreen centres, saying all units should have the latest technology.

However, he said there was a need for more rooms to carry out endoscopy and noted he is the only public gastroenterologist providing EMR services in the west of Ireland, covering Galway, Roscommon, Mayo and Sligo, with increasing demand.

EMR takes longer, about an hour compared to about 20 minutes with colonoscopies, and is more complex, so that has to be factored into future planning, he explained.

Dr Slattery also stressed the importance of appropriate stratification of patients (ie, whether they are fit for EMR), and referral pathways for those outside the remit of the programme, ie, polyps over 2cm and those of difficult pathology who need surgical management.

Speaking to MI following the endoscopy session, ISG President Prof Laurence Egan said that while gastroenterologists in Ireland are currently facing many challenges, foremost among these is the challenge of meeting increasing “practically insatiable” demand for endoscopic services. “As well as that, there are increased advanced endoscopic techniques, and risk of complications and increased scrutiny in key performance indicators at individual endoscopist level, so all those factors contribute to making endoscopy an extremely exciting field, where we can really help patients a lot, but, as many things go, we don’t quite have the resources to match demand and that has to be addressed.”