Colon capsule endoscopy for bowel cancer investigation

Following appropriate bowel preparation, CCE can take place in a clinic or home setting. The pill-sized camera is swallowed and the capsule travels through the gastrointestinal tract. Using a light and camera, images are taken of the bowel which are transmitted to a receiver. It can take between 2 and 15 hours to pass the capsule. The capsule is single use, so it is disposed after the procedure. Images are uploaded to a computer for a trained clinician to read, and a second opinion may be required before results can be shared. 

CCE could be used for a variety of applications: 

• Triage prior to endoscopy 
• Targeted screening or surveillance 
• Alternative to colonoscopy 

In the UK, only Pillcam Colon 2 (CCE-2) is licenced for use. Uptake has increased in recent years as more evidence has become available and while endoscopy services continue to face significant demand. 

Scotland

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The ScotCAP trial assessed CCE to triage surveillance patients and symptomatic patients with a positive FIT before endoscopy in Scotland.

Key results:

• Across both cohorts, over 70% had a complete CCE test (defined as full colonic visualisation or if the capsule was excreted during its battery life).
• 37% of symptomatic patients and 28% of surveillance patients required no further tests following CCE.
• Out of 509 patients undergoing CCE, 2 serious adverse events were reported.

The trial suggested that CCE was safe and that it could play a role in ruling out further investigation for some patients. After the trial ended in 2020, CCE has been implemented in Scotland to support post-pandemic endoscopy recovery.

England 

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NHS England is trialling CCE for symptomatic patients with an average risk of colorectal cancer (those with a positive FIT result between 10 – 100 ug Hb/g). At some sites, it was assessed for surveillance patients too.

Interim results:  

• The pilot shows that CCE can provide additional diagnostic capacity.
• 70% of patients are spared colonoscopy after CCE. For those who undergo colonoscopy, 54% are downgraded to non-urgent colonoscopy.

Patient experience will be evaluated as part of the pilot to inform any future roll out.

Wales 

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In 2023, a small CCE pilot was run in Wales across 4 health boards.

Key results:

• 69% of patients had a complete CCE procedure and 57% had significant bowel disease detected.
• The pilot found that at least a third of patients could be discharged without further investigation following CCE.

Following the pilot, there is interest in embedding CCE as part of a national service in Wales.

Advantages

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1. Patient experience: CCE is less invasive and reduces embarrassment and discomfort for many patients compared to a colonoscopy. 
2. Being able to do CCE at home or locally at a clinic can widen access to investigations and address some health inequalities. 
3. The CCE procedure can cause side effects; however, research suggests there are fewer and less severe adverse side effects associated with CCE compared to colonoscopy [1].
4. Studies suggest CCE has greater sensitivity for small polyps (<6mm) than CT colonography [2].
5. Use of CCE for triage could increase capacity and reduce the endoscopy backlog, with pilots suggesting that up to 70% of patients are spared colonoscopy following CCE. 
6. Minimal training is required for staff to administer CCE. 
7. CCE can be offered to patients who can’t do a colonoscopy (including those at risk of bleeding or have a sedation risk). 

Disadvantages

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1. CCE is not a suitable test for some people, such as those with swallowing difficulties or who are pregnant.
2. If CCE results indicate cancer, a colonoscopy would still be required for biopsy and diagnosis. This can cause delays and impact patient experience.
3. Extensive bowel preparation is required before the procedure which can be uncomfortable for patients.
4. There is a higher risk of an incomplete test for CCE compared to other tests such as CT colonography. This can be attributed to inadequate bowel prep or low battery life of the capsule.
   • The addition of prucalopride to the bowel prep process has been suggested to improve completion rates, but more research is required [3].
5. Extra training is required to review CCE images, and it can take up to an hour of clinician time.
   • Additionally, some research shows poor agreement between independent image reviews [4].
6. CCE can have a greater cost as it requires capsules, software and hardware to read images (currently only available from 1 supplier). Additionally, some patients still need to have a colonoscopy following CCE which has an associated cost.