GI dearth stalls CRC screening

UK program inspires Canada to look
to nurses for help

By Julia Cyboran

BRIT IDEA INVASION
These innovations from the UK are already inspiring changes in CRC screening here. The Brit model has served as the blueprint for the Ontario screening program. "The proposal we have submitted to the ministry is based on fecal occult blood test (FOBT) screening," explains Dr Linda Rabeneck, the vice-president of Cancer Care Ontario. "It reduces the manpower requirements compared to other more invasive tests."

England's Bowel Cancer Screening Program, which launches in about a month's time, is the first of its kind in Europe. It will screen all people between 60 and 69 every two years. But the key to the UK program is the use of nurses to do flexible sigmoidoscopy.

"We have very long waiting times in the service in England and the main constraint has been endoscopists' availability," explains Dr Roland Valori, the National Lead in Endoscopy Services in the UK. "There is room to do the procedure; we have the kits, we have the nursing staff to help but we don't have anyone to do the procedure." The UK now has more than 250 trained nurses to do endoscopy, some of whom are performing complicated procedures. Others are involved in training. "Nurse endoscopists have taken off big time here in England," adds Dr Valori.

TRICKY TRANSITION
But things didn't always run so smoothly. "In the early days physicians were very opposed to the idea as you can imagine," says Dr Valori. Many physician concerns are over the quality of endoscopy. But to fight those worries Dr Valori and his colleagues have developed the Global Rating Scale (GRS). "The GRS is the fundamental core of everything we are doing right now," he says. This assessment tool is a simple concept that lends serious credibility to the UK service. Dr Valori isn't worried about the skills of those performing endoscopies — at least the nurses. "It's a way of making [endoscopy] units ensure that everyone comes up to scratch," he adds. "I have no concerns about the competency of nurse endoscopists in the UK," says Dr Valori. "But we have audit data that shows our physician endoscopists could do better."

ONTARIO'S TURN
Dr Valori and some of the nurse endoscopists he works with were in Toronto on May 26 to talk about how effective nurse endoscopists could be and to push the concept of the GRS on Canadian policymakers. The province is set to launch a pilot project that will examine the viability of using nurses for flexible sigmoidoscopy. "The Canadian Task Force on Preventive Health Care recommended that all men and women 50-or-over be screened with either FOBT or flexible sigmoidoscopy and that is based on clear scientific evidence," says Dr Rabeneck. "We felt that it was important to evaluate flexible sigmoidoscopy in a pilot kind of way so that we'll learn the acceptability and feasibility of nurse performed flex sig for screening."

The use of nurses to do flexible sig will not be part of the provincial screening program, but if its success in the UK is any indication of how it can improve screening then it might be the way of things to come.

CONSERVATIVE APPROACH
Alberta, on the other hand, is looking to the more traditional model of CRC screening. "For a number of issues there isn't really a clear reason to decide on one particular screening test or interval for certain people," says Dr Heather Bryant, vice-president of the Alberta Cancer Board. "I think the model we will use will be FOBT screening through a family physician and a 1-800 call line would be available for patients to talk to a nurse or healthcare professional if their GP didn't have time to go over all the issues."

Alberta won't be looking to nurses for help with flexible sig either. "The two main thrusts in Alberta for CRC cancer screening are either the use of FOBT or colonoscopy," says Dr Robert Hilsden, a gastroenterologist and a member of the expert group of the Alberta Cancer Board. Alberta's main limitation to offer more endoscopy is a lack of resources. It's not a human resource problem, they have enough GIs, but rather a lack of endoscopy suites.

SCREENING USA
In the United States many FPs are now performing colonoscopies — causing a veritable turf war with gastros over patients. But that situation wouldn't likely occur in Canada with its severe GI shortages. Here, many gastros would welcome the help of family practitioners.

Ultimately, colonoscopy is probably too costly to become a ubiquitous screening tool in Canada. "For mass population cancer screening it isn't viable in any civilized country," says Dr Desmond Leddin, head of gastroenterology at the QEII in Halifax. "The Americans do it but only for the Visa-carrying public," he adds. Most countries that have CRC screening in place are using FOBT or flexible sig. The sheer cost and manpower required for an extensive colonoscopy program could bankrupt any publicly funded healthcare system. "If you look at the Nova Scotia figures there are 250,000 people over 50 who are eligible for screening. Last year at my hospital we did 2,500 colonoscopies so to ramp that up 100-fold would be completely ludicrous," says Dr Leddin. But on the flipside, some gastros argue that FOBT and flexible sig are too low sensitivity to be an adequate screening test (see "Leave colon cancer screening to the experts" on page 12).

GIs IN THE TRENCHES
Even if FOBT were the standard screening test, it will mean more folks will need colonoscopies, if only because many more people would be getting screened. In Ontario alone 2.8 million people are eligible for CRC screening — of those about 2% will require colonoscopy. That means 56,000 procedures to get through. "There is a need for allied health professionals to help with colorectal cancer screening. People like physician extenders and nurse endoscopists are a good way to handle the increased demand. But even with those there is a basic need to extend the number of GI specialists," says Dr Paterson.

In the end, for many Canadian GIs it comes down to not who does what but rather the quality of the procedure. "It should be no problem who does any procedure whether it be brain surgery, heart surgery, mole removal or colonoscopy so long as they have the training and experience and the support of others," says Dr James Gray, a Vancouver GP-turned gastro. "The key will be to obtain the training, competency assessment and ongoing quality review."