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Clues to colorectal cancer presentation (silent killer) Direct access colonoscopy

Clues to colorectal cancer presentation (silent killer) Direct access colonoscopy. Mr Shafi Ahmed PhD, FRCS, FRCS(Gen.Surg) Consultant Laparoscopic Colorectal Surgeon Clinical and MDT Lead for Colorectal Cancer B arts Health NHS Trust Associate Dean and Honorary Senior Lecturer

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Clues to colorectal cancer presentation (silent killer) Direct access colonoscopy

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  1. Clues to colorectal cancer presentation (silent killer)Direct access colonoscopy Mr Shafi Ahmed PhD, FRCS, FRCS(Gen.Surg) Consultant Laparoscopic Colorectal Surgeon Clinical and MDT Lead for Colorectal Cancer Barts Health NHS Trust Associate Dean and Honorary Senior Lecturer RCS Tutor and TPD Core surgery Civilian Advisor to the Armed Forces Academic Surgery Unit Queen Mary University of London

  2. Who are we?

  3. NCBRSI

  4. Patients treated 2012-2013

  5. Oncology firm RLH

  6. Laboratory Research: Colorectal Cancer: Hypoxic biomarkers to predict response to therapy in rectal cancer. Influence of telomerase length and hTERT expression in prognostication in CRC. Tissue microarray in CRC. MicroRNA’s in CRC prognostication. Methylation markers in young age cancers in ethnic “Bangladeshi” population. Clinical and molecular profiling of “Signet ring cell” lower GI cancers Biomarkers of muscle damage in patients with parastomal hernia after bowel resection (cancer and non-cancer patients) Bowel Cancer Related Research Portfolio (Colorectal Cancer Team – Royal London Legacy Site)

  7. Anal Cancer HPV related methylation markers in patients with anal intra-epithelial neoplasia and anal squamous cell carcinoma Clinical Research including clinical trials:

  8. Cancer Related: Randomised controlled trial comparing laser ablative therapy versus active observation to prevent development of anal squamous cell carcinoma in HIV positive MSM patients with high-grade AIN (LOPAC trial) – NIHR-HTA funded. Development of a multi-modal therapy including exercise and cognitive interventions for improving quality of existence in cancer survivors (SURECAN) – NIHR programme development grant funded study. Epidemiology of “anterior resection syndrome” and validation of “LARS” scoring system in UK population. A clinical, molecular and functional study on discriminants of sphincter preserving restorative surgery in patients with low rectal cancer. An International, longitudinal cohort study of safety and feasibility of “APPEAR” technique in ultra-low rectal resections. RCT comparing SMART vs. conventional surgery for prevention of parastomal hernia Pilot, feasibility study of functional outcomes after laser ablative therapy of high grade AIN in HIV positive patients

  9. Technology/Innovation Research: Development of a novel locomotion technology for active colon capsule endoscopy – proof of concept study (QM Innovation funded). Evaluation of a novel combined laser and plethysmography probe to assess intra-operative bowel perfusion in patients undergoing restorative large bowel resection Development of a humanoid arm/hybrid robotic system for laparoscopic and open pelvic/rectal surgery.

  10. Presentation

  11. Right sided lesions Fe deficiency anaemia Palapable mass Left sided Change in bowel habit Looser more frequent stools Rectal bleeding Rectum Rectal bleeding Tenesmus Traditional teaching of presentation of colorectal cancer 2 week wait referrals

  12. 1078 per year 22 referrals per year Increasing every year Peaks with health campaign However only 10-15% of cancers diagnosed by 2ww Two week wait referrals

  13. A and E admissions with new onset cancer 25% of all patients presenting with colon cancer Bowel obstruction Perforations Elective mortality <10% Emergency mortality >30% Anaemia Incidental findings London Cancer emergency audit

  14. 10-15% 2ww 25% acute admission Screening 10-20% Therefore approx 50% are through other routes How to identify? The problem

  15. Direct Access Colonoscopy

  16. After consultation Colonoscopy >90% Flexible sigmoidoscopy CT Pneumocolon Plain CT Discharged

  17. Previous direct access flexible sigmoidoscopy Obsolete 2 week wait referrals to reduce the burden of 2 week wait Reduce the lead time for test and improve 31 and 62 day target Direct access colonoscopy

  18. Full management suppport To reduce the burden of OPD clinics Telephone triage Nurse led 2 pilot clinics QUIP - 2013

  19. Language Bowel preparation Assessment of suitability Time dependent on CNS Need support staff at RLH Problems faced

  20. 150 patients 2week and 18 week wait referral Current waiting times 8 weeks clinic appt 4- 6 weeks for colonoscopy 20min slots Nurse led DNA rate 1% Outcome 50% reduction in pathway for 2ww 67% for 18 week Shortlisted for BMJ prize for service innovation Whipps cross led by Ed Seward (Consultant Gastroenterologist)

  21. Flexible sigmoidoscopy

  22. Once only flexible sigmoidoscopy 55-64 113 000 Control and intervention group Colorectal cancer incidence in the intervention group was reduced by 23% mortality by 31%

  23. Pilot 2012 South of Tyne (Queen Elizabeth & South Tyneside) West Kent (West Kent & Medway) Norwich St Marks (London) Wolverhampton Surrey (Guildford) Roll out in 2014 Bowel Scope

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