Result card

  • ORG3: What kind of staff, training and other human resources are required?
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What kind of staff, training and other human resources are required?

Authors: Principal investigators: Valentina Prevolnik Rupel, Nika Berlic Investigators: Dominika Novak Mlakar, Taja Čokl, Plamen Dimitrov, Marta López de Argumedo

Internal reviewers: Americo Cicchetti, Daniela D'Angela, Marco Marchetti

Acknowledgments: /

Analysis of selected studies extracted from the basic literature search. One report and one document with guidelines were relevant to this question.

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Depending on each country’s health system and culture, different health professionals can be involved in kit delivery and stool sampling collection or in delivering bowel preparation for endoscopy screening (i.e. GPs, nurses, paramedics, pharmacists, volunteers from no-profit organisations, etc.). Each country should follow quality assurance standards for the facilities and establish minimum training requirements for each type of professional, fulfilling the present guidelines {4}.

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. 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 {4}.

The success of a colorectal cancer screening programme is dependent 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 {4}:

  • 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. 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.);
  • Epidemiologists (As many disciplines contribute to providing data required for monitoring and evaluating of a colorectal screening programme it is essential that a designated individual with relevant epidemiological expertise oversees the collection and analyses 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. 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.);

  • Laboratory staff (In the case of FOBT cancer screening programme, where screening is based on a laboratory test, 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 require supervision by an appropriately qualified individual with expertise in clinical biochemistry, 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); and this requires centralisation, either on a national or regional basis, of the testing process. 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:

  • Managerial skills;

  • An appreciation of internal quality control and external quality assurance; and

  • A thorough understanding of the interactions between the laboratory process and the whole screening programme.

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.;

  • Primary care physicians (There is ample evidence for the importance of involving primary care physicians in the implementation of colorectal cancer screening programmes. 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.

  • Endoscopists (Endoscopists carrying out 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. 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);

  • 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.);

  • 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.

They also need 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.

  • 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 dependent 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. 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. 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.

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.;

  • 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. 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.

  • Public health specialists (Considering the different healthcare environments, public health specialists with adequate epidemiological knowledge or equivalent expertise are recommended. These professionals are needed from the onset, to ensure that the programme includes a population-based information system that monitors each step of the screening process. They will then be responsible for gathering data and for ongoing monitoring in order to identify problems that need intervention. These public health specialists can be based at a national or regional level, whereas the other health professionals who are providing screening services are needed in each area.. 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. 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.

Public health specialists should therefore have training in and an understanding of basic epidemiology, statistics and communication. Courses or the ability to visit screening centres can provide this specific training.

 

Criteria for personnel and training

All staff involved in the delivery of a colorectal cancer screening programme requires knowledge of the basic principles of colorectal cancer screening. 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. Professional requirements of oncologists are not discussed in this chapter because; stage for stage, their role in the treatment of screen-detected disease is no different from that in symptomatic disease {4}.

According to the Report on the implementation of the Council Recommendation on cancer screening, very high level of adequate training is reported in the European level. Twenty (i.e. Austria, Belgium, Cyprus, Czech Republic, Estonia, France, Germany, Greece, Hungary, Italy, Latvia, Lithuania, Luxembourg, Netherland, Poland, Slovakia, Slovenia, Spain, Sweden, UK) out of 22 responding Member States (91%) reported that screening programme personnel is adequately trained at all levels to ensure that they are able to deliver high quality screening{5}.

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Rupel P et al. Result Card ORG3 In: Rupel P et al. Organisational aspects In: Jefferson T, Cerbo M, Vicari N [eds.]. Fecal Immunochemical Test (FIT ) versus guaiac-based fecal occult blood test (FOBT) for colorectal cancer screening [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali; 2014. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=206

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