Northern Ireland Bowel Cancer
Screening Programme
Guidance for Adenoma Surveillance
Version / 1Approved / Bowel Cancer Screening Programme QA Structure
Date / 25 July 2012
Review Date / July 2013
1. Introduction
This guidance has been developed to clarify the policy on which individuals should be offered surveillance within the Northern Ireland Bowel Cancer Screening Programme and to outline the operational arrangements for managing such patients.
It should be read in conjunction with:
· NI Bowel Cancer Screening Programme Pathways;
· NI Bowel Cancer Screening Programme SSP Protocols;
· NI Bowel Cancer Screening Programme Colonoscopy Protocols; and
· HSCB PAS Technical Guidance for patients who are added to an inpatient or daycase waiting list following referral from the Bowel Cancer Screening Programme (June 2010)
Adenoma surveillance is part of the screening programme, so surveillance colonoscopies must be undertaken in a nominated screening unit by an identified screening colonoscopist.
2. Indications for Surveillance
Adenoma surveillance within the screening programme is based on current British Society of Gastroenterology (BSG) guidelines. Surveillance colonoscopy should always be offered to:
· Individuals deemed to be at high risk following screening colonoscopy (at an interval of one year) if they remain within the screening age range.
· Individuals deemed to be at intermediate risk following screening colonoscopy (at an interval of three years) if they remain within the screening age range. There are no acceptable reasons for a shorter interval.
Surveillance is not required for individuals deemed to be at low risk following screening colonoscopy. They are returned to routine recall and sent another screening test kit (FOBt) in two years time if they remain within the screening age range.
Risk categorisation for screening purposes is based on the number, size and histology of the polyps.
Individuals requiring follow-up due to family history or for other pathology identified at a screening procedure are not included within the surveillance programme and should be managed within the Trust’s symptomatic service. Each screening unit must have an appropriate referral system in place to manage such patients.
Patients who require a follow-up colonoscopy to remove remaining polyps after an initial screening procedure are not deemed to be surveillance patients. These are follow-up diagnostic tests and are managed differently and as part of the original screening episode.
3. Age range for surveillance
The age range for eligibility for the screening programme is 60-71.
Individuals who are aged up to 74 when their surveillance appointment is due will be offered this within the screening programme.
Individuals who are aged 75 or over when their surveillance appointment is due are ceased from screening and will be referred to the symptomatic service if any follow up is required.
4. Management of surveillance patients
Individuals in surveillance are managed according to current BSG guidelines.
These are summarised as follows:
5. Managing surveillance on BSIMS
BSIMS automatically handles the surveillance process. The failsafe process within the system will not allow alternative surveillance intervals to be set. The actions required by SSPs and the associated outcome on BSIMS is summarised below.
BSIMS will automatically discharge a patient from surveillance after two consecutive negative results at three yearly intervals.
The clinical team can discharge a patient from surveillance for the following reasons:
· Informed patient choice
· No patient contact
· Clinical decision following discussion with the patient
Individuals who fail to attend their surveillance appointment (either SSP or colonoscopy) on two occasions should be returned to the routine screening programme.
Patients discharged from surveillance are automatically returned to routine screening recall if they remain within the eligible age range.
Risk category / Pathway / Action by SSP / Outcome on BSIMSLow Risk
1- 2 adenomas, both <1cm / Returned to routine recall and sent another FOBt kit in two years. / SSP records as back to routine recall / GP and participant informed***. BSIMS will invite patient in 2 years.
Intermediate Risk
3- 4 adenomas, OR at least 1 adenoma ≥ 1cm / Suspend from recall and offered a surveillance colonoscopy in 3 years / SSP records as Intermediate Risk against Adenoma on page 5, Participant Management
Not to be recorded as a repeat / GP and participant informed***. BSIMS will generate invite to patient for assessment by SSP in 3 years.
High Risk
≥ 5 adenomas, OR ≥3 with at least 1 ≥ 1cm / Suspend from recall and offered a surveillance colonoscopy in 12 months / SSP records as High Risk against Adenoma on page 5, Participant Management. Not to be recorded as a repeat. / GP and participant informed***. BSIMS will generate invite to patient for assessment by SSP in 12 months
*** It is the Trust’s responsibility to inform the GP and participant of the result of colonoscopy.
NB- Tattooing of polypectomy sites for polyps greater than 2cm is mandatory and at the discretion of the colonoscopist if less than 2cm.
6. Follow-up diagnostic procedures
A repeat colonoscopy or flexible sigmoidoscopy may be carried out as part of the original screening or surveillance episode. These are not appointments for adenoma surveillance.
A patient can be referred for a follow-up diagnostic test for the following reasons:
· polyp not fully resected
· check polyp site
· multiple polyps, not all removed
· biopsies required
· unexplained symptoms
· therapies required
· incomplete procedure
The need for a follow-up procedure must be manually recorded on BSIMS by the SSP. This can only be set at a maximum of 6 months from the initial colonoscopy.
As a failsafe process, BSIMS will inform the relevant SSP when the follow-up diagnostic test is due.
BSIMS does not generate invitation letters directly to patients for follow-up diagnostic procedures. The appointment must be set by the SSP who makes contact with the patient.
Trusts should have their own protocols in place as to the level of assessment required for patients in advance of a repeat procedure. If a face to face appointment is needed, the SSP should inform the call recall centre.
A new management form must be completed on BSIMS for each procedure that is carried out (including follow up diagnostic tests).
The patient is temporarily suspended from screening recall until the repeat procedure has taken place. The patient is then either returned to routine screening or entered into surveillance if at high or intermediate risk after an adenoma is identified. If the patient is moved into the surveillance programme, future invites are managed by BSIMS as outlined above.
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