Results of the 2019 National Bowel Cancer Audit

In January, findings from the annual National Bowel Cancer Audit (NBOCA) were published. The audit measures and compares outcomes across diagnosis, treatment, and care for over 30,000 bowel cancer patients across England and Wales and makes key improvement recommendations to health bodies. It is important that NBOCA findings are used by health bodies in England and Wales to understand where variations in care exist across the bowel cancer pathway and where key improvements can be made. This blog outlines the results of this audit and calls for health bodies to urgently implement its recommendations.

Routes to diagnosis and survival

Key findings of the audit

• One in ten patients (10%) are diagnosed with bowel cancer through national bowel cancer screening programmes in England and Wales. Over half of patients (55%) were diagnosed following a GP referral and a further 18% diagnosed in an emergency presentation (such as in A&E) where outcomes are less favourable. This is a slight improvement from last year (20%).
• Just over half of people (58% and 56% in England and Wales respectively) who receive the bowel cancer screening test complete it. Those who are diagnosed through the screening programme are more likely to be diagnosed at an early stage of the disease.
• Two thirds (67%) of all bowel cancer patients survive beyond two years. This has remained stable since 2012/13.

Recommendations

The 2019 NBOCA highlights that the percentage of people who receive the bowel cancer screening test and complete it, is less than the national target of 60% in both England Wales. Therefore NBOCA calls for Public Health England and Wales to reinvigorate national publicity campaigns for bowel cancer screening, emphasising that people who are diagnosed via screening often have less advanced disease and therefore have more favourable survival rates, as well as less major surgery.

Variations across the bowel cancer pathway

Key findings

• There is large geographical variation for the use of keyhole surgery, ranging from 38% to 76% of all bowel cancer resections across England. Patients having surgery to remove their tumour are recommended to have this less invasive approach where possible, which tends to have a shorter recovery time.
• There is considerable variation in the use of surgery that is performed with the intent to cure the patient of cancer, where a quarter of patients (25%) aged 75 and over are not receiving surgery with a view to being cured.
• Nearly two thirds of patients (63%) diagnosed with stage 3 bowel cancer received adjuvant chemotherapy. This is when chemotherapy is offered alongside other treatments, such as surgery. However this varies across hospitals from 55% to 75%.
• There is considerable variation in two-year survival rates at Trust and hospital level with Wales and several cancer alliances in England demonstrating large variation.

Recommendations

NBOCA recommends that NHS England do further work to explore the significant geographical variation in the use of laparoscopic surgery, curative resection rates, and two-year survival rates.

They also say that local policies for offering adjuvant chemotherapy to people following major resection for stage three bowel cancer should be reviewed. This should be done by multidisciplinary teams (the clinical team from different specialties who meet to discuss each cancer patient’s available treatment options), commissioners, and, for England, the Care Quality Commission to ensure that they are evidence-based.

What next?

Variations identified in the audit highlight a system defined by a postcode lottery for bowel cancer patients, with where they live affecting whether or not they receive the best available care. Although it is encouraging to see an increase in stage 3 patients receiving adjuvant chemotherapy, more needs to be done to ensure this is available to all patients who need it regardless of where they live.

The root cause of many of these variations is a system stretched to its limits. There are simply not enough staff in the NHS to diagnose and treat bowel cancer patients. The forthcoming NHS People Plan provides an opportunity to address these issues and must be adequately funded to deliver a system to provide the best care for all.

• Read more about how we plan to tackle the workforce crisis in our Ending the Capacity campaign.
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