Excellent Practices

Early Cancer Detection in High Risk Individuals

Practice Category: Prevention and Early Detection

Centre: The Christie NHS Foundation Trust

Andrew Renehan

Professor of Cancer Studies and Surgery; Anal Cancer MDT lead

andrew.renehan@nhs.net

Challenge addressed by the practice

Populations at high risk of Breast Cancer (BC) and Anal Cancer (AC) need to be identified to initiate effective screening and early treatment strategies, when mortality is reduced. At The Christie we have established two exemplar services to address these challenges:

  • In women treated with radiotherapy to cure lymphomas and other cancers, in adolescence there is a very high risk of BC and BC mortality in later life. We identified that the existing screening service was ineffective (Howell et al., BJC 2009) and implemented a new national programme: Breast Cancer After Radiotherapy Dataset (BARD).
  • There are around 1,600 new AC cases in the UK every year with incidence rising by 78% since 1990 and predicted to reach 2,400 by 2038. High stage disease requires chemoradiotherapy, associated with much morbidity and 20% risk of long-term stoma. Anal cancer can be detected early because it is preceded by a detectable precursor lesion, known as anal intra-epithelial neoplasm (AIN).

Solution

  • The Breast Cancer After Radiotherapy Dataset (BARD) was established by Christie oncologists and is a national database and referral system for women treated with radiotherapy (as above). BARD prospectively identifies all women in England, eligible for early screening and refers directly into the NHS very high-risk breast screening programme (VHRBSP). Adoption into the VHRBSP was in 2020 and is the only point of entry for such women to the screening service nationally. The BARD project manager, based at The Christie, is now co-funded by NHSE and The Christie.
  • We have implemented a new technique called high-resolution anoscopy (HRA) for the surgical ablation of AIN, the earliest precursor of AC. This technique requires specialist training with a limited number of centres across the UK using therapeutic HRA. International efforts, including our own, have better defined the categories at high-risk of AC and this knowledge can now feed into our clinical pathways.

Impact

  • We have identified 4,552 women nationally at increased risk of breast cancer. All eligible women have been referred for MRI-based annual breast screening which has previously been shown to reduce mortality in high-risk populations. National audit of uptake and outcomes is ongoing. The BARD research group was established to personalise risk prediction in this cohort: 2 BARD PhD students to date, one completed 2024 and one ongoing.
  • In September 2023, the Christie extended the existing early anal cancer service and introduced HRA. The service expanded to a second colorectal surgeon from October 2025. We now run two theatre lists per month with 8 patients undergoing HRA. In 2023, there were 23 new referrals from outside the Christie; in 2025, there were 47 new external referrals. The new HRA service has underpinned two PhD projects, and the HRA service practice guidelines underpin new national guidelines.

Critical success factors

BARD

  • Recognition of increased risk in the BARD population and ineffective coverage of current screening service (Swerdlow AJ…Radford JA JCO 2012; Howell SJ BCJ 2009)
  • Grant funding for a dedicated project manager who developed relationships with all radiotherapy centers to achieve complete national coverage
  • Integration with NHS England and the NHS VHRBSP through persistent lobbying
  • BARD newsletter, website, and responsive email address to provide information to patients and oncology teams

HRA Service

  • Between 09/2023 and 12/2025, 140 HRA procedures were performed in 88 patients, with laser ablations in two-thirds
  • Among 54 women, 43% had additional intra-epithelial neoplasia of the vulva or vagina, known as MZIN cases, are at high risk of cancer development and are challenging for complete clearance of precursor lesions
  • 7 new anal cancers, all T1 and cured by simple local surgery
  • We have developed patient information documents and refined our clinical pathways

Next steps

BARD

  • Extend eligibility to BARD through the national screening committee to include irradiated age <10 years, non-lymphoma diagnoses, and TBI
  • Further research to personalise breast cancer risk, including modern radiotherapy techniques, the amount of radio-dense breast tissue involved in RT fields, and integration with other hormonal and genetic risk factors
  • Development of a national virtual service for BARD cancer prevention.

HRA Service

  • Develop HRA in the outpatient setting
  • Improve integration with gynaecologists for women with MZIN disease
  • Develop certified training courses to disseminate the use of this surgical technology to other national centres
  • Widen the research portfolio to HRA-based early trials