Recommendations[1]
General requirements
6.1 Colorectal cancer screening programmes should be operated by an adequately trained
multidisciplinary team (see Ch. 8 [25], Rec. 8.1) (VI – A).Sect 6.2; 8.2
6.2 Key performance indicators should be developed for the monitoring of a national
or regional screening programme (VI – B).Sect 6.2
Administrative and Clerical Staff
6.3 National or regional colorectal cancer programmes should be run in conjunction
with other screening programmes by an experienced administrative team (VI – B).Sect 6.3
6.4 All administrative and clerical staff in a colorectal screening programme should
acquire a basic understanding of colorectal screening and specific courses should
be developed for this purpose (VI – A).Sect 6.3
6.5 Management, communication and project management skills for the administrative
staff of a colorectal screening programme should be acquired by means of formal courses
(VI – A). Sect 6.3
Epidemiologist
6.6 A specifically trained epidemiologist should be seconded to a national or regional
colorectal cancer screening programme (VI – B).Sect 6.4
6.7 Training of epidemiologists inexperienced in evaluation and monitoring in colorectal
cancer screening should be organised as secondments to established screening centres
running population-based screening programmes. Additional didactic courses on relevant
aspects of the work should be attended depending on individual knowledge and experience
(VI – B).Sect 6.4
Laboratory staff
6.8 A fully trained laboratory staff with appropriate management should be in place
for a national or regional colorectal cancer screening programme and internal quality
control and external quality assurance mechanisms should be put in place for the laboratory
(see Ch. 4 [9], Rec. 4.10 and 4.12) (VI – A).Sect 6.5; 4.3.3.4; 4.3.4
6.9 Training in the form of courses or secondments to existing laboratories should
be available for all laboratory personnel (VI – B).Sect 6.5
6.10 A European laboratory network should be established in order to provide appropriate
external quality assurance (VI – C).Sect 6.5
Primary care physicians
6.11 All general practitioners should be informed about national or regional colorectal
cancer screening programmes and provided with appropriate infrastructure and training,
including adequate training to be able to help people make informed decisions about
CRC screening (see Ch. 2 [12], Rec. 2.12; and Ch. 10 [4] Rec. 10.21) (II – C).Sect 6.6; 2.4.3.4.2; 10.4.2.3.2
Endoscopists
6.12 Endoscopists who participate in a colorectal cancer screening programme should
be fully trained in colonoscopy or flexible sigmoidoscopy, depending on the procedure
they perform in the programme (V – A).Sect 6.7
6.13 Endoscopists who participate in a colorectal cancer screening programme should
be fully trained in biopsy and polypectomy (V – A).Sect 6.7
6.14 Endoscopists who intend to participate in a colorectal cancer screening programme
should undergo assessment to ensure an adequate level of expertise before commencing
practice within the programme (VI – B).Sect 6.7
6.15 Endoscopists who participate in a colorectal cancer screening programme should
be able to demonstrate high completion rates, low morbidity and appropriate adenoma
detection rates (VI – B).Sect 6.7
Radiologists
6.16 Radiologists participating in a colorectal cancer screening programme should
have specialist training in colorectal imaging (VI – A).Sect 6.8
6.17 Radiologists working within a screening programme should participate in quality
assurance where at least a proportion of radiological examinations are double-read
(VI – B).Sect 6.8
Pathologists
6.18 Pathologists participating in a colorectal cancer screening programme should
have specific training in colorectal pathology (VI – B).Sect 6.9
6.19 Pathologists participating in a colorectal cancer screening programme should
develop a network with other pathologists in order to share experience (see also Ch.
7 [19], Rec. 7.16) (VI – B).Sect 6.9; 7.6; 7.7
Surgeons
6.20 Surgeons treating patients with screen-detected disease should specialise (although
not necessarily exclusively) in colorectal cancer surgery and should be able to demonstrate
a high-volume practice (III – B).Sect 6.10
Nurses
6.21 Nurses participating in colorectal cancer screening programmes should have a
specific training to equip them with the necessary skills, including adequate training
to be able to help people make informed decisions about CRC screening (see Ch.10 [4], Rec. 10.21) (VI – C).Sect 6.11; 10.4.2.3.2
Public Health
6.22 Public health physicians should be involved in national or regional colorectal
cancer screening programmes and should be provided with appropriate training (VI – C).Sect 6.12
6.23 Where necessary, public health specialists should have access to courses or the
ability to visit screening centres to obtain this specific training (VI – C).Sect 6.12
6.1 Introduction
The success of a colorectal cancer screening programme is dependant on specially trained
individuals committed to implementation, provision and evaluation of a high quality,
efficient service. The multidisciplinary team that is responsible for a colorectal
screening programme includes:
All staff involved in the delivery of a colorectal cancer screening programme must
have knowledge of the basic principles of colorectal cancer screening. To achieve
this it would be appropriate for them to attend a course of instruction at an approved
training centre prior to the commencement of the programme. The need for specialist
training in screening differs between the different disciplines and is most important
for those involved in the delivery of the service and diagnosis, e. g. laboratory
staff, endoscopists, radiologists, pathologists and nurses. The surgical treatment
of screen-detected cancer and post-operative treatment is not performed differently
according to whether a cancer is screen- detected or symptomatic, but there are certain
considerations for the surgeon to take into account when treating a screen-detected
cancer. Oncologists are not mentioned in this document, as, stage for stage, their
role in the treatment of screen-detected disease is no different from that in symptomatic
disease. High-quality screening performance is based on a multidisciplinary approach,
and it is important that appropriate training packages are offered. Updating knowledge
as part of continuing medical education should be encouraged.
Participation in training courses should be documented and certificates of attendance
issued based on the levels of skill attained and evaluated. Specific training requirements
in terms of quality and volume should determine eligibility for any certification
or accreditation process which must be applied only to centres with sufficiently skilled
personnel.
6.2 General requirements
The evidence that Multidisciplinary Teams (MDTs) improve outcomes for cancer patients
is still scanty, but beginning to accumulate [8]. However, there is general agreement that multidisciplinary services provide better
patient care for a variety of conditions and in colorectal cancer, multidisciplinary
management is strongly recommended [17]. Effective communication between the various professionals of a colorectal multidisciplinary
team is essential and training courses should therefore focus on good inter-professional
communication. Joint courses given for the multidisciplinary team may facilitate this
goal.
Continuing education including refresher courses at various intervals is essential
to gaining information on new developments and to improve the quality of the screening
and diagnostic therapeutic processes. It is important to keep records of training
activities as they are useful indices of the quality of a service. These would be
part of a certification or accreditation review process.
Staff – all staff involved in the screening programme require basic knowledge of the
foundation of the programme. Relevant topics are:
-
Colorectal cancer epidemiology (incidence, prognosis, mortality);
-
Introduction to screening theory;
-
Screening terminology (sensitivity, specificity, predictive value, etc);
-
Current screening practices (screening modalities used, methods of identifying target
population, methods of invitation)
-
Evaluation of screening effectiveness (key performance indicators)
Key performance indicators are essential for the effective monitoring of a national
or regional colorectal cancer screening programme [24]. As a bare minimum, the key performance indicators of a colorectal screening programme
include:
-
Uptake of screening test;
-
Time between screening test and definitive diagnosis (where screening test is not
colonoscopy);
-
Proportion of those with a positive test undergoing colonoscopy (where colonoscopy
is not the screening test);
-
Colonoscopy completion rate;
-
Colonoscopy complication rate;
-
Positivity rate (for a non-endoscopic screening test);
-
Cancer detection rate;
-
Stage of cancer at diagnosis;
-
Adenoma detection rate;
-
Positive predictive value for cancer and adenomas; and
-
Interval cancer rate.
Summary of evidence
Recommendations
Colorectal cancer screening programmes should be operated by an adequately trained
multidisciplinary team (see Ch. 8 [25], Rec. 8.1) (VI – A).Rec 6.1
Key performance indicators should be developed for the monitoring of a national or
regional screening programme (VI – B).Rec 6.2
6.3 Administrative and clerical staff
A colorectal screening programme can be run under the umbrella of a screening programmes
division associated with the national or regional health department where this exists.
This allows the colorectal screening programme staff to benefit from the experience
gained from other screening programmes. In the UK, the organisation of the colorectal
screening programmes is overseen by a programme manager who reports to a national
or regional screening coordinator responsible for all screening programmes. In addition
to a programme manager each centre that is responsible for sending out invitations
and/or organising screening tests for those who accept the invitations is overseen
by a screening manager who is responsible for the efficient operation of the screening
programme and managing the staff of the screening centre [18]
[21]. The staffing of the screening centre depends on the structure of the programme
itself; e. g. if it is a centralised programme, staff are required for identifying
individuals to be invited, sending out invitations, replying to those who have undergone
testing and, where appropriate, organising further investigations for those with positive
tests. The basic training requirements for all screening administrative and clerical
staff should include the following:
-
Basic understanding of colorectal cancer, the potential benefits and harms of screening,
and the prime importance of quality assurance
-
Basic understanding of the colorectal cancer screening programme; and
-
Basic information technology skills.
In addition, the centre manager requires:
-
Advanced managerial skills; and
-
Advanced communication skills (for dealing with queries, complaints etc).
In addition, the programme manager requires
Management communication and project management skills can be acquired by means of
formal courses. However the administrative structure required for a colorectal cancer
screening programme will depend very much on local and national conditions and must
be modified accordingly.
Summary of evidence
Recommendations
National or regional colorectal cancer programmes should be run in conjunction with
other screening programmes by an experienced administrative team (VI – B).Rec 6.3
All administrative and clerical staff in a colorectal screening programme should acquire
a basic understanding of colorectal screening and specific courses should be developed
for this purpose (VI – A). Rec 6.4
Management, communication and project management skills for the administrative staff
of a colorectal screening programme should be acquired by means of formal courses
(VI – A).Rec 6.5
6.4 Epidemiologist
As many disciplines contribute to providing data required for monitoring and evaluating
a colorectal screening programme it is essential that a designated individual with
relevant epidemiological expertise be assigned the task of overseeing the collection
and analysis of the data required for evaluation. Assessing a programme’s impact on
colorectal cancer mortality is only possible if adequate provision has been made in
the planning process for adequate collection and analysis of data (see Chapter 3 [16]).
Basic Training: The individual overseeing data collection and analysis requires training
in clinical epidemiology and statistics.
Specific training: Training for epidemiologists involved in a colorectal cancer screening
programme focuses on:
-
Colorectal cancer epidemiology (incidence, prevalence, mortality, trends);
-
Screening theory (pre-clinical disease, lead time, selection, length bias);
-
Colorectal cancer screening terminology (sensitivity, specificity, positive predictive
value etc);
-
The colorectal screening programme (organisation, current screening modalities);
-
Ethical and confidentiality issues;
-
Setting up a colorectal cancer screening programme (identification and an invitation
of target population, call-recall system, follow-up system);
-
Strategies for data collection and management (use of appropriate databases, individual
files, computerised archives, linkage to appropriate registries, classification of
screening outcomes, quality control procedures and data collection);
-
Statistical analysis and interpretation of results (performance indicators for evaluation,
predictors of the impact of screening, assessing screening impact and effectiveness,
cost-effectiveness calculations); and
-
Presentation of data and report writing.
Acquisition of these skills may require specific courses for the individuals involved.
Summary of evidence
Recommendations
A specifically trained epidemiologist should be seconded to a national or regional
colorectal cancer screening programme (VI – B).Rec 6.6
Training of epidemiologists inexperienced in evaluation and monitoring in colorectal
cancer screening should be organised as secondments to established screening centres
running population-based screening programmes. Additional didactic courses on relevant
aspects of the work should be attended depending on individual knowledge and experience
(VI – B).Rec 6.7
6.5 Laboratory staff
Where a screening programme is based on a laboratory test (in the case of colorectal
cancer screening the only currently available laboratory test is faecal occult blood
testing), it is self-evident that an adequately staffed laboratory is necessary. It
is similarly self-evident that the training and skills required by the laboratory
staff are dependent on the type of test (guaiac or immunochemical, qualitative or
quantitative). The laboratory staff requires supervision by an appropriately qualified
individual with expertise in clinical biochemistry (see Ch. 4 [9], Rec. 4.11), and the day-to-day running of the laboratory must be managed by an
appropriately skilled scientific officer. When faecal occult blood testing is being
used as the primary test for a colorectal screening programme it is essential that
this be done with appropriate internal quality control (IQC) and external quality
assurance (EQAS) (see Ch. 4 [9], Rec. 4.10 and 4.12, Sect. 4.3.3.4 and 4.3.4); and this requires centralisation,
either on a national or regional basis, of the testing process [18]
[21]. Delegation to individual practitioners is not appropriate.
The training required for the laboratory staff should include the following:
-
A basic understanding of colorectal cancer and the benefits of early diagnosis (a
basic understanding of the colorectal cancer screening process);
-
Training in good laboratory practice;
-
Training in the performance of the faecal occult blood test (the specific training
will depend on whether a guaiac or immunochemical test is used and whether it is a
qualitative or quantitative test); and
-
Training in the use of the IT system used to record results.
In addition, the training required by the Laboratory Manager includes:
An individual with expertise in clinical biochemistry is ultimately responsible for
the operation of the laboratory and requires training in the following:
-
An in-depth understanding of colorectal cancer (diagnosis, treatment, prognosis, staging
and the importance of stage at diagnosis);
-
An in-depth understanding of the colorectal cancer screening process (including screening
theory and especially the potential benefits and harms of screening and the prime
importance or quality assurance);
-
Extensive knowledge of performance characteristics of different types of faecal occult
blood test; and
-
An in-depth understanding of the technology required to perform the faecal occult
blood test.
In some parts of Europe the screening programme may not be based on faecal occult
blood testing. Where it is, however, it is essential to ensure a uniformly high standard
of testing, and a European laboratory network would facilitate this.
Summary of evidence
-
No literature evidence was retrieved for this topic. Appropriately trained laboratory
staff are essential for a FOBT-based colorectal cancer screening programme (VI).
-
No literature evidence was retrieved for this topic. Internal quality control and
external quality assurance are essential to ensure consistency of FOBT reporting (VI).
Recommendations
A fully trained laboratory staff with appropriate management should be in place for
a national or regional colorectal cancer screening programme and internal quality
control and external quality assurance mechanisms should be put in place for the laboratory
(see Ch. 4 [9], Rec. 4.10 and 4.12, Sect. 4.3.3.4 and 4.3.4) (VI – A).Rec 6.8
Training in the form of courses or secondments to existing laboratories should be
available for all laboratory personnel (VI – B).Rec 6.9
A European laboratory network should be established in order to provide appropriate
external quality assurance (VI – C).Rec 6.10
6.6 Primary care physicians
There is ample evidence for the importance of involving primary care physicians in
the implementation of colorectal cancer screening programmes (see Ch. 2 [12], Rec. 2.8, 2.12 and 2.13; and Sect. 2.3.1 and 2.4.3). The role of primary care physicians
in colorectal cancer screening will vary widely from one European country to another.
In some instances the general practitioner (GP) is required to invite the target population,
in some instances they are required to encourage their patients to participate in
a centrally organised screening programme and in some instances they may not play
a direct role in the screening programme but will clearly be required to answer questions
on screening posed by their patients. It must be emphasised however, that general
practitioners should not be encouraged to perform faecal occult blood tests on an
individual basis as it is impossible to ensure adequate quality assurance for the
performance of the test.
The training required of general practitioners working in an area where there is an
active screening programme should include the following:
-
A thorough knowledge of colorectal cancer (diagnosis, treatment, prognosis, staging
and importance of stage at diagnosis;
-
An in-depth understanding of the colorectal screening process (including screening
theory and particularly the potential benefits and harms of screening, and the prime
importance of quality assurance); and
-
A thorough knowledge of the organisation of the local screening programme and the
role of GPs within the programme.
Whenever a colorectal screening programme is introduced into a region it is essential
that all GPs serving the region are informed, and that specific training events for
GPs are made available, including adequate training to be able to help people make
informed decisions about CRC screening (see Ch. 10 [4], Rec. 10.21, and Sect. 10.4.2.3.2).
Summary of evidence
The involvement of primary care physicians (general practitioners) in a screening
programme can enhance uptake (I) (see Chapter 2 [12]).
From evidence derived from two good-quality RCTs, it appears that educational programmes
on CRC screening rationale, recommendation, CRC risk etc., towards primary care physicians
are effective in improving CRC screening rates [7]
[11]. However, a third RCT did not confirm such results [30] (II).
Recommendations
All general practitioners should be informed about national or regional colorectal
cancer screening programmes and provided with appropriate infrastructure and training,
including adequate training to be able to help people make informed decisions about
CRC screening (see Ch. 2 [12], Rec. 2.12, Sect. 2.4.3.4.2; Ch. 10 [4], Rec. 10.21 and Sect. 10.4.2.3.2) (II – C).Rec 6.11
6.7 Endoscopists
Endoscopists carrying out either flexible sigmoidoscopy or colonoscopy as the primary
screening test, or colonoscopy as the investigation following a positive primary screening
test, are central to the delivery of a successful screening programme. It is essential
that they be skilled in complete examination of the colonic mucosa and in recognising
both cancers and pre-cancerous lesions (i. e. adenomas). It is also essential that
they be skilled in biopsy and polypectomy technique such that they can carry out lower
gastrointestinal endoscopy safely and effectively. If the endoscopy associated with
a colorectal cancer screening programme has an appreciable morbidity or mortality,
this has the potential to negate any benefit derived from the programme. Likewise
if a high proportion of neoplastic lesions are missed on endoscopy, this will undermine
the confidence of the population in the screening programme and has the potential
to create a damaging “certificate of health” effect.
In order to ensure that only the highest quality of colonoscopy is delivered by the
national screening programme in the United Kingdom, a specific assessment process
has been introduced, and all colonoscopists wishing to participate in the programme
must complete this successfully. The assessment consists of a test of knowledge and
direct observation of procedural skills [23] (for level of competency for endoscopists see Ch. 5 [27], Sect. 5.1.2).
Different countries will employ different types of health professionals to undertake
endoscopy, including medically qualified gastroenterologists, medically qualified
surgeons, nurse endoscopists and, in some instances, endoscopists who have neither
a formal medical nor a nursing qualification.
In all cases, however, endoscopists working within a colorectal screening programme
should meet national professional requirements for performing endoscopy (FS and/or
colonoscopy depending on the type of programme and the role of the respective endoscopist)
and should fulfil the following training requirements:
-
Good knowledge of the normal large bowel, its anatomy and its physiology;
-
Good knowledge of the disease processes that can affect the large bowel and its endoscopic
appearance;
-
An understanding of digital endoscopy technology including maintenance and cleaning;
-
Full training in the performance of either flexible sigmoidoscopy or colonoscopy as
required including appropriate accreditation where this is available;
-
Full training in safe biopsy and polypectomy technique (note: in some instances where
endoscopic mucosal resection or endoscopic sub-mucosal resection of extensive lesions
is required, tertiary referral may be necessary); and
-
Full training in managing complications of endoscopic procedures performed in screening
and diagnosis, including local protocols for management of severe complications.
To ensure the requisite high quality of endoscopy within a screening programme, all
participating endoscopists must engage in quality assurance, and they must provide
the data and reports required to routinely generate returns on numbers of endoscopies
performed, completion rates, morbidity rates (including perforation, bleeding and
death) and both adenoma and cancer detection rates.
It is difficult to conclude which professional and training requirements for endoscopists
can affect the efficacy, safety, tolerability, and accuracy of endoscopic procedures,
but evidence suggests that the following patient variables should be identified and
taken into account prior to FS or colonoscopy because they can be associated with
more adverse events, more time duration, and incomplete examination:
Furthermore, the conditions under which endoscopy is conducted also have an impact
on performance (see Ch. 5 [27], Rec. 5.21, 5.30, 5.37 – 39, Sect. 5.1.3. 5.3.3 and 5.4.5.1):
-
Poor bowel preparation is associated with lower rate of complete colonoscopy;
-
Deep sedation is associated with a greater rate of complete colonoscopy but also with
a higher risk of cardiovascular events;
-
The volume of colonoscopy is associated with completeness of examination and lower
complication rates.
Recommendations
Endoscopists who participate in a colorectal cancer screening programme should be
fully trained in colonoscopy and/or flexible sigmoidoscopy, depending on the procedure
they perform in the programme [2]
[26] (V – A).Rec 6.12
Endoscopists who participate in a colorectal cancer screening programme should be
fully trained in biopsy and polypectomy [2]
[26] (V – A).Rec 6.13
Endoscopists who intend to participate in a colorectal cancer screening programme
should undergo assessment to ensure an adequate level of expertise before commencing
practice within the programme [2]. However another study did not confirm these results [1] (VI – B).Rec 6.14
Endoscopists who participate in a colorectal cancer screening programme should be
able to demonstrate high completion rates, low morbidity and appropriate adenoma detection
rates (VI – B).Rec 6.15
6.8 Radiologists
While the majority of European countries will employ colonoscopy as either the main
investigative technique for a positive test or as the primary screening test, radiology
expertise is required to investigate the colon in those individuals in whom a complete
follow-up or surveillance colonoscopy is not achievable. It is essential that the
radiological examination be carried out by an experienced gastrointestinal radiologist.
There is evidence that the “miss rate” is highest in situations where a colonoscopy
has been incomplete and a subsequent radiological examination has not detected pathology.
Radiologists working within the colorectal cancer screening programme have the following
training requirements:
-
Good knowledge of the normal colon, its anatomy and physiology;
-
Good knowledge of the disease processes that can affect the colon and their radiological
appearances;
-
An understanding of the technology underlying barium enema and computer tomographic
(CT) colography[2]; and
-
Full training in the performance of either barium enema or CT colography or both,
depending on local availability.
For quality assurance, a proportion of radiological examinations should be double-read.
The use of virtual colonoscopy2 following an incomplete colonoscopy assessment is increasing for patients with poor
health. The same requirements, specific for training to barium enema, should apply
to virtual colonoscopy.
Summary of evidence
Recommendations
-
Radiologists participating in a colorectal cancer screening programme should have
specialist training in colorectal imaging (VI – A).Rec 6.16
-
Radiologists working within a screening programme should participate in quality assurance
where at least a proportion of radiological examinations are double-read (VI – B).Rec 6.17
6.9 Pathologists
Pathologists working within a colorectal cancer screening programme require full training
in the histopathology of gastrointestinal disease with specific emphasis on colorectal
cancer. These pathologists should be skilled in the following areas:
-
The interpretation of biopsies taken from benign and malignant tumours of the colon
and rectum;
-
The preparation and histological interpretation of endoscopic polypectomy specimens;
and
-
The preparation and histological interpretation of surgical resection specimens.
The histological examination of a polypectomy specimen is a particularly demanding
area within a screening programme, as large, complex endoscopically removed lesions
are common and often exhibit equivocal features of possible invasive malignancy. It
is also particularly important for a pathologist to be able to comment on the degree
of differentiation, the presence or absence of lymphovascular invasion, and distance
of invasive cancer from the resection margin in endoscopically excised pT1 i. e. “polyp”
cancers.
In addition, quality control of surgery is particularly important within a screening
programme, as it is essential that individuals with lesions detected at screening
are afforded the highest possible standards of care (see Ch. 8 [25]). The pathologist has an essential role in the quality assurance of surgery by assessing
the completeness of tumour excision in surgical resection specimens.
Pathologists working within a colorectal screening programme have the following training
requirements:
-
Good knowledge of the disease processes that can affect the colon and their histological
appearances;
-
An ability to distinguish between benign and malignant biopsy specimens;
-
An ability to distinguish between benign and malignant polypectomy specimens;
-
An ability to access the risk factors associated with recurrence after endoscopic
excision of malignant polyps;
-
An appreciation of immunohistochemistry where it relates to histological interpretation
of colorectal tumours; and
-
The ability to prepare a colorectal resection specimen, with particular emphasis on
harvesting lymph nodes and assessing the circumferential resection margin.
Quality assurance in pathology is important and essential within a colorectal screening
programme and image exchange is an important component of ensuring consistency of
reporting, particularly with the interpretation of difficult endoscopically removed
lesions (see Ch. 7 [19], Sect. 7.7).
Summary of evidence
-
Colorectal cancer screening results in increased workload for pathology departments,
and creates significant demands in terms of the interpretation of complex histology
of endoscopically removed lesions (see Ch. 7 [19], Rec. 7.17 and 7.22, Sect. 7.6.5.2) (V).
Recommendations
Pathologists participating in a colorectal cancer screening programme should have
specific training in colorectal pathology (VI – B).Rec 6.18
Pathologists participating in a colorectal cancer screening programme should develop
a network with other pathologists in order to share experience (see also Ch. 7 [19], Rec. 7.16, Sect. 7.6 and 7.7) (VI – B).Rec 6.19
6.10 Surgeons
Most cancers and a small proportion of large adenomas detected within a colorectal
screening programme will require surgical excision, and it is important that this
be carried out as effectively and safely as possible. The beneficial effect of early
detection of colorectal cancer is dependant on low mortality and morbidity rates associated
with the subsequent surgery.
It is now recognised that both short- and long-term results of surgery for both rectal
and colon cancer are highly surgeon-dependant and there is now good evidence that
specialisation associated with high volume is associated with improved results [15]
[20]. It is therefore mandatory that all screen-detected cancers requiring surgery are
treated by surgeons who specialise in colorectal surgery, preferably with a particular
interest in cancer. It is also essential that these surgeons work in multidisciplinary
teams with access to oncologists experienced in both adjuvant and palliative treatment
of colorectal cancer (see Ch. 8 [25], Rec. 8.1).
It follows that surgeons treating patients with screen-detected colorectal cancer
should be fully trained and possess the appropriate qualifications for a colorectal
surgeon. In addition to the specialist training that this entails, surgeons working
within a colorectal screening programme have the following training requirements:
-
An understanding of the basic principles of screening, with particular reference to
colorectal cancer; and
-
An understanding of the significance of pT1 cancers with reference to the need for
completion surgery (see Ch. 8 [25], Rec. 8.17).
Screen-detected cancers may be particularly suitable for laparoscopic resection, and
it is essential that any surgeon utilising this technique is fully trained and, where
appropriate, accredited. While some surgeons may be in a position to obtain appropriate
training for laparoscopic surgery within their own institutions, this may not always
be the case; and it is essential that surgeons wishing to carry out laparoscopic colorectal
surgery should attend the appropriate courses and obtain the appropriate training
wherever this is available.
Summary of evidence
Surgeons
All surgeons treating patients with screen-detected disease should specialise (although
not necessarily exclusively) in colorectal cancer surgery and should be able to demonstrate
a high-volume practice (III – B).Rec 6.20
6.11 Nurses
Nurses have important roles throughout the colorectal screening pathway, from the
initial contact with the screening invitees through diagnostic endoscopy both as an
endoscopy nurse or as a nurse endoscopist, to the care of the patient requiring surgery
[18]
[21]. The importance of these roles will vary from country to country and indeed from
region to region within countries. The nursing skills required to care for screening
patients are essentially the same as those required to care for symptomatic colorectal
patients in many situations. However, the specialist colorectal nurse may have a specific
role to play, particularly in counselling individuals with positive screening tests.
Such nurses are fully qualified and have experience in specialist colorectal nursing.
The training requirements for nurses in a colorectal cancer screening programme include
the following:
-
An in-depth understanding of colorectal cancer (diagnosis, treatment, prognosis, staging
and importance of stage at diagnosis);
-
An in-depth understanding of the colorectal screening process (including screening
theory and particularly the potential benefits and harms of screening, and the prime
importance of quality assurance); and
-
Advanced communication skills.
Appropriate courses should be available for nurses involved specifically in colorectal
cancer screening programmes to address these issues, including adequate training to
be able to help people make informed decisions about CRC screening.
Recommendations
Nurses participating in colorectal cancer screening programmes should have a specific
training to equip them with the necessary skills, including adequate training to be
able to help people make informed decisions about CRC screening (see Ch. 10 [4], Rec. 10.21) (VI – C). Rec 6.21
6.12 Public health
The role of the public health specialist in a colorectal cancer screening programme
is to ensure coordination of the component parts of the screening programme in such
a way as to optimise delivery of the programme to the target population [18]
[21]. This will include endeavouring to maximise uptake by means of health promotion
initiatives and addressing inequality issues.
The role of the public health physician may vary from country to country and from
region to region within countries, but public health specialists are well placed to
act in a coordinating role.
Public health specialists engaging in colorectal cancer have the following training
requirements:
-
An in-depth understanding of colorectal cancer (diagnosis, treatment, prognosis, staging
and the importance of stage at diagnosis);
-
An in-depth understanding of the colorectal cancer screening process (including screening
theory and particularly the potential benefits and harms of screening, and the prime
importance of quality assurance);
-
A full understanding of the mechanisms whereby colorectal cancer screening is delivered
in their population; and
-
Training in effective health promotion.
Courses or the ability to visit screening centres can provide this specific training.
Summary of evidence
Recommendations
Public health physicians should be involved in national or regional colorectal cancer
screening programmes and should be provided with appropriate training (VI – C).Rec 6.22
Where necessary, public health specialists should have access to courses or the ability
to visit screening centres to obtain this specific training (VI – C).Rec 6.11