How an iPhone attachment is helping streamline cancer referrals

9th January 2025

Dr Chris Coulson, ENT consultant at Queen Elizabeth Hospital Birmingham, UK, and CEO of Endoscope-i, talks to Beth Gault about how a new iPhone-compatible device being piloted in the West Midlands aims to streamline throat cancer referrals.

Beth Gault (BG): What is Endoscope-I and how did you first come up with the idea?

Chris Coulson (CC): Me and another ENT surgeon selfishly tried to solve our problems. We spend a lot of time looking in people’s ears, noses and throats and we generally use an endoscope for that, which you put to your eye to look through and see the area of concern.

About 12 years ago, we recognised we had a decent camera in our pocket, on our phone, and thought why don’t we connect it with the endoscope. So, we did. We created an adapter to align the endoscope with the phone to allow you to take an image or video of the ear, nose or throat, which is what the device is.

We progressed to thinking we could train someone to take a video, which then comes through to me and if the clinician has filled out a history and done a hearing test, then I could just sit down and look at them remotely. So, we put that system together.

ENT is an interesting field in that only 10% of people who see me in clinic need an operation, 90% of people – with appropriate information – can be managed remotely. That’s classically done through a face-to-face consultation, but we wondered how much of that information can I get through other means?

BG: How does the tool work?

CC: You just attach the aligner, which is a bit like a phone case, with the endoscope and the iPhone and then take a video or image and upload it to our cloud system via our referral app. It’s currently only on iPhone, not Android, but the iPhones are included with the service.

BG: The tool is now being used to try and detect and rule out throat cancer – what role can it play in cancer referrals?

CC: The symptoms that are concerning with head and neck cancer are also symptoms that sound like a cold, like a hoarse voice or a sore throat. They are general, non-specific symptoms. Most people with a two-week wait referral for cancer do not have cancer.

The number of people picked up from an urgent cancer referral clinic is tiny – about 3%.  So, the trouble that us head and neck surgeons have is how do we sift through these huge numbers of referrals to get to people who actually have cancer?

Capacity is a huge problem, so the number of referrals go up and up and up and actually the numbers of cancers are not. But you still have to deal with these referrals because you never know who is going to have the cancer.

We set up this referral pathway in Stoke where anyone with low risk for cancer went to a nurse-led clinic. The nurse used the endoscope with our camera system, took a video of their throat and then sent it to the head and neck surgeons. They were able to have a look and say who did not have cancer, and then who needed a further appointment in the clinic.

It’s really quick for us to look and know whether they do not have cancer, because it’s what we do every day. Within seconds you can look at a video and tell, but in a consultation, it takes 20 minutes.

We found through this that we can safely run a service where the nurse sees the vast majority of patients, but the consultant reports on it so it’s a consultant-level answer. 

BG: What funding have you received for this?

CC: We designed and delivered it ourselves without funding. But we then got funding from the Small Business Research Initiative to run an assessment of its delivery. We did this in Dorset County Hospital and Stoke University Hospital for head and neck cancer.

BG: What were the results of the test?

CC: We don’t have impressive numbers that say we’ve caught all these cancers, because our aim is not to find cancer, it’s to deal with the people who don’t have cancer. If you deal with them, you can have more capacity to deal with the cancer patients.

We put 1,800 people through the service and found around six cancers. All of these were low risk, so they’d likely go on to have a late diagnosis if they hadn’t used the service.

BG: If a system was interested, would integrated care boards (ICBs) or Trusts be the one to fund this?

CC: Up to now it’s been Trust funded, because it’s a way of increasing their capacity and saving money. But we do have a couple of ICBs around the country who are looking at it for delivery in their patch. My guess is in a few years we will have a combination of ICBs and hospitals. However, the one thing we won’t have is GPs funding this. The location of delivery could be in primary care, which I think is advantageous to the population, but I don’t think it will be primary care-led funding.

BG: What does it cost?

CC: Around £100,000 upfront for the kit, training and integration and then there’s a monthly license fee for security updates and ongoing support.

BG: How do you see the tool being used in the future in the NHS?

CC: I don’t see GPs using it, it’s one of the core things we’re trying to do is to make things easier for GPs, not delivering something else for them to do. It would work best with someone doing it in high volumes, rather than intermittent users, so it might be that trained staff will go out to practices or any healthcare facility to do it. It would work well in a diagnostic treatment centre as well.

We are also looking at artificial intelligence and if at some stage we can automate some diagnoses or letters, this would further increase efficiency.

BG: How do you think digital tools like this can make a difference to the NHS?

CC: There’s clearly a huge opportunity for digital tech to improve healthcare. But one of the challenges is how can you make sure that your digital tech doesn’t make things worse. We’ve got to be cautious that we don’t make things more complex.

But it’s also got to be clinically led. As soon as there’s tech designed by tech people with tech people in mind, most of us struggle to get on with it. It needs to solve a clinical problem.

This article was originally published by our sister publication Healthcare Leader.

Screening endoscopy before 50 associated with reduced risk of CRC diagnosis in women

9th June 2022

Screening endoscopy in women under 50 significantly reduces the risk of a colorectal cancer diagnosis at age 55 according to a US study

The use of screening endoscopy in women before the age of 50 is associated with a 55% lower risk of being diagnosed with colorectal cancer (CRC) at age 55. This was the conclusion of a prospective cohort study of US women.

According to the International Agency for Research on Cancer, in 2020 there were almost 2 million colorectal cancer diagnoses and nearly one million deaths, making it the third most commonly diagnosed cancer type in the world.

Although incidence rates among those of screening age have decreased, data from the US shows that among individuals under 50 years of age, the incidence rate has increased by approximately 2% between 2011 and 2016.

According to the American Cancer Society, screening for CRC is associated with a significant reduction in CRC incidence and CRC-related mortality and have recommended that adults aged 45 years and older with an average risk of CRC should undergo regular screening.

Furthermore, long-term follow studies suggest that screening endoscopy is associated with a reduced colorectal-cancer mortality. Nevertheless, there are limited data on the value of screening endoscopy in younger patients.

For the present study, the US researchers used data in the Nurses’ Health Study II, primarily because participants in this prospective registry were aged 26 to 45 at enrolment and this therefore provided an opportunity to examine any potential associations between the age of screening endoscopy and the development of CRC.

Using 1991 as the baseline because this was the first year when questions about screening endoscopy were included, participants were asked in subsequent questionnaires if they had undergone sigmoidoscopy or colonoscopy in the past two years and the reason for this screening.

The primary endpoint was overall CRC incidence although the researchers included the incidence of younger-onset CRC (diagnosed before age 55) and CRC mortality as secondary outcomes.

Screening endoscopy and development of colorectal cancer

A total of 111,801 women with a median of 36 years at enrolment were included in the analysis and followed for 26 years, during which time 519 incident cases of CRC were documented. Compared to women who underwent screening endoscopy age 50 or later, those who underwent a screen before 45 years of age were more likely to have a family history of CRC.

When compared to women who did not undergo screening endoscopy, the adjusted hazard ratios (HRs) for any CRC were 0.37 (95% CI 0.26 – 0.53) for women aged under 45 years, 0.43 (95% CI 0.29 – 0.62) for those 45 to 49 years of age and 0.46 (95% CI 0.30 – 0.69) for those 55 years and older. Hence there was a significantly lower risk of incident CRC when screening was started before the age of 45.

The authors calculated that the absolute reduction in the estimated cumulative incidence of CRC up to age 60 was 72 per 100,00 people if screening endoscopy was started between the ages of 45 to 49 compared to being performed between the ages of 50 to 54.

The risk of being diagnosed with CRC at age 55 was 55% lower if screening was started before the age of 45 (HR = 0.45, 95% CI 0.29 – 0.70) and equally lower (HR = 0.43) when started between the ages of 45 and 49.

The authors concluded that earlier screening endoscopy (before 50 years of age) was associated with a significantly lower risk of both CRC and a diagnosis before age 55.

Citation
Ma W et al. Age at Initiation of Lower Gastrointestinal Endoscopy and Colorectal Cancer Risk Among US Women JAMA Oncol 2022