Post-operative mortality rates* and patient care for bowel cancer are steadily improving in England and Wales but there remains room for further improvement with apparent marked regional variations in how cases are managed. These are the findings of the 2009 annual report from the National Bowel Cancer Audit.

The report tracked and compared the care provided for 41,000 patients in almost all units in England and Wales over two periods between April 2006 and July 2008** – this equates to approximately two thirds of the total number of patients expected to be seen over each period – and found post-operative mortality for bowel cancer surgery has consistently improved from an estimated seven per cent in 2001 through five per cent in the 2007 audit report to 4.5 per cent in the current study.

The report highlighted some of the ways in which care has improved and where further improvement is necessary:

• Selection of treatment - Choosing the best treatment for each individual cancer patients needs the skills of radiologists, pathologists, anaesthetists and surgeons rather than a single clinician. 84 per cent of cases were discussed by a multidisciplinary team (MDTs) in 07/08 compared to 80 percent in 06/07. NICE recommends all patients should have their case discussed by MDT so there remains progress to be made.
• Specialist nursing - The proportion of patients who received advice and support of a specialist nurse improved from just 41 per cent in 06/07 to just over half in 07/08 and NICE recommends that all patients should have access. Data submission for this measure is poor, going someway to explaining the low level, but there remains improvement to be made on a service which would greatly benefit patient wellbeing and peace of mind.
• Diagnostic imaging – access to magnetic resonance (MR) and computerised tomography (CT) imaging improved over the period (MR from 41 to 51 percent; CT from 55 to 61 per cent). Most patients should be scanned so the stage*** of their disease can be fully known and the best possible choice of treatment be made. The audit suggests a quarter of patients are not getting the stage of their disease recorded.
• Regional variation – data submitted by Trusts shows very wide variation in how individual cancer networks treat bowel cancer. Some of this is undoubtedly due to incomplete reporting of data however major differences are seen and warrant further study in future years of the audit. For example, the percentage of patients undergoing major surgery for rectal cancer that needed a permanent stoma (ie. colostomy bag) ranged from 3 per cent to 51 per cent over the whole audit time period.

As a relatively young audit, the submission of some key statistics was poor with only half of units providing more than 80 per cent of the data items needed for each patient. One of the challenges between now and the next report will be to encourage Trusts to provide complete information about their patients. Colorectal units are spread out across the country providing care in most local hospitals so almost all NHS Trusts should be contributing data to the national audit.

Paul Finan, Consultant Coloproctologist and Clinical Lead of the National Bowel Cancer Audit said: “This report demonstrates that the outlook for bowel cancer patients has never been better and standards of care are moving in the right direction. But also provides hints to where we need to progress more quickly towards the very best standards and save more lives in the future. 

“Every patient should have their case and treatments discussed by a full team of experts and have the benefit of advice and support of a specialist nurse. There are now many different approaches to treating this disease and picking the best one for each patient needs universal access to diagnostic scanning so the stage of the disease can be assessed and the most well-informed decisions made.”

Tim Straughan, NHS Information Centre Chief Executive said: "Participation in the audit has improved significantly but there is an equally significant need to improve the completeness of the data that is submitted to the audit.   

"Trusts and cancer networks are falling below national guidance in some areas according to this audit, which could in reality be due to poor data completeness rather than inadequate care. It is vital submissions improve to provide a clear picture of the quality of care experienced by bowel cancer patients."

Bowel cancer is the third most common cancer and causes the deaths of around 16,000 people each year. The majority of patients receiving treatment are over 60 and more than half over 70. 

The 2009 National Bowel Cancer Audit Report is a collaboration between the Association of Coloproctology of Great Britain and Ireland and the NHS Information Centre with funding from the Healthcare Quality Improvement Partnership. Copies are available to download for free online at www.ic.nhs.uk/canceraudits; www.nbocap.org.uk; and www.acpgbi.org.uk.

Notes to Editors

1. *This is measured as deaths within 30 days of surgery – the established international standard for noting deaths linked to post-operative complication.
2. **Bowel cancer audit started as a clinician-led voluntary study by the Association of Coloproctology of Great Britain & Ireland (ACPGBI) in 2001 before being commissioned as a full National Audit from 2006 by the Healthcare Quality Improvement Partnership (HQIP) and run by the NHS Information Centre. The data analysis has been provided by the Northern & Yorkshire Cancer Registry and Information Service. It has now achieved near total national coverage with every Trust registered and 95 per cent of English units and all of Wales providing data. 
   
3.  ***Bowel cancer can be categorised by how advanced the illness is by a system called Dukes Stage (http://www.cancerhelp.org.uk/help/default.asp?page=5912) or TNM Classification (http://www.uicc.org/tnm). Scanning helps clinicians establish the disease stage and decide which treatment to undertake.
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