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Bowel cancer: - early symptoms - screening - treatment update

Bowel cancer: - early symptoms - screening - treatment update. Ian Botterill Dept Colorectal Surgery, The General Infirmary Leeds. Areas to be addressed. Demographics Key symptoms of bowel cancer - DOH referral guidelines

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Bowel cancer: - early symptoms - screening - treatment update

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  1. Bowel cancer:- early symptoms - screening - treatment update Ian Botterill Dept Colorectal Surgery, The General Infirmary Leeds

  2. Areas to be addressed • Demographics • Key symptoms of bowel cancer - DOH referral guidelines • UK population bowel cancer screening programme – ie asymptomatic individuals • Bowel cancer surveillance – ie predisposing factor • Recent developments in treatment

  3. Demographics: the problem Equates to ~ 1 new case of bowel cancer / GP / annum Latest CRUK figures

  4. Demographics • 3rd commonest cancer in EU • Lifetime risk 2-4% • Leeds Colorectal MDT - ~580 cases 2005 - ~630 cases 2007

  5. Incidence • M>F • 90% of cases > 50yrs age • More common decade on decade post age 50yrs • Male incidence on increase • Median survival 40-50%

  6. Effect of age

  7. Distribution of bowel cancer ‘proximal migration’

  8. Colorectal cancer • 75% sporadic ie average risk • 15-20% FHx of CRC • 3-8% HNPCC • 1% FAP • 1% UC & Crohns

  9. Mortality of bowel cancer Effect of subspecialist surgery / adjuvant therapy / liver surgery for mets

  10. 5 yr survival by stage at presentation • ~ 40% localised disease ‘A’ 90% ‘B’ 65% • ~ 40% regional nodes ‘C’ 40% • ~ 20% distant mets ‘D’ 5% • Overall median survival 40-50%

  11. Cancer surgery- 30 day mortality Age <80yrs >80yrs Elective R colon 1-2% 5% Elective ant resection 1-5% 10-20% Obstructed L colon 5% 20%+ Perforated colon 10% 40%

  12. DOH initiatives to improve outcomes • Raised awareness • Targeted urgent referral criteria - ‘2WW’ process • Bowel cancer screening

  13. Symptom assessment

  14. ‘Textbook’ symptoms • Rectal bleeding +/- mucous • Altered bowel habit • Abdominal mass / rectal mass • Tenesmus • Wt loss • Distension • Colicky abdominal pain • PPV rectal bleeding being cancer - 0.1% in 1y acre - 5% in colorectal practice

  15. 6 ‘key’ 2WW referral criteria • R sided abdo mass • Rectal mass • >6/52 of ABH • Rectal bleeding in absence of anal symptoms • Anaemia: <10 F / < 11.5 M • Colicky abdo pain • Low risk symptoms: - hard infreq stool - BRRB & perianal symptoms - abdo pain but no colic

  16. Age > 60yrs with rectal bleeding & looser stool ‘Identikit’ of typical patient with bowel cancer

  17. Effect of ‘2WW’ referral • ~30% of cancers via 2WW forms - ‘+ ve’ for cancer in ~ 9% of cases • ~30% of cancers still referred conventionally - waiting time ↑ • ~40% still present as emergencies • UK audit: ~20-30% of 2WW referrals ‘inappropriate’ - age / recent normal test / normocytic anaemia / dementia

  18. DOH ‘pragmatic referral pathway’ Thompson et al, BMJ, DOH referral guidelines

  19. Primary care assessment & investigation • Check core symtoms & FHx of CRC • Abdomino-rectal examination • FBC • stool culture • CRP • No role for tumour markers • Any doubt please refer – symptoms are notoriously unreliable

  20. Screening

  21. Principles of screening • Important / relevant disease • Definable sequence allowing intervention • Test - cheap / QUALY beneficial - acceptable → uptake >70% - sensitive & specific - low risk - reproducible

  22. Window for intervention?-polyp cancer sequence • distribution of adenomas mirrors bowel cancer • adenomas predate bowel cancer by 5-10 yrs • adenomas & cancers often found in close proximity • malignant change in adenomas ‘polyp cancers’

  23. Methods of screening • Faecal occult blood • Flexible sigmoidoscopy • Ba enema • CT pneumocolon • Colonoscopy

  24. FOBT: ‘haemoccult sensa’ • detects microscopic blood in stool • 3 successive daily stool samples • dietary restriction • guaic acid based test (unrehydrated) • peroxidase based reaction in response to haem • reactor strip turns blue

  25. FOBT • 38-60% uptake in previous trials • unpleasant / messy • severe dietary restrictions • avoidance of NSAIDs

  26. Flexible sigmoidoscopy screening • ‘UK flexiscope trial’ • polyps in L colon used as trigger for colonoscopy • ↑ detection of early cancers • ↑ survival • ongoing pilot studies - 25% of neoplasia is proximal - labour intensive 1st test

  27. Colonoscopy • detects ~90% of colonic pathology • cost ~ £150-400 • perforation rate ~ 1:1500 • bleeding rate ~ 1:1500 • highly skilled workforce required • compliance poor if used as stand alone test

  28. UK bowel cancer screening pilot study • Coventry • ~480,000 invited > 57% completed FOBT • 2% of FOBT positive → colonoscopy • 550 cancers detected • 367 early cancers (Dukes A) • 4X ↑ in early cancers

  29. UK bowel cancer screening- www.cancerscreening.nhs.uk/bowel • 5 hubs , 90 centres • 2 yearly FOBTx3 for age 60-69 • Positive test triggers colonoscopy • Negative test – pt reassured • Equivocal test – FOBT repeated • Cancers referred to local MDT by screening ‘hub’

  30. Colonoscopy quality control • >90% caecal intubation rate • Consultant / approved non-consultant • Audited morbidity - perforation 0.2% - death 0.01%

  31. Polypectomy • Hot biopsy • Snare polypectomy • Endoscopic mucosal resection

  32. Endoscopic mucosal resection

  33. Cost of bowel cancer screening • Target: 10% of UK population (60-69 yr olds) • Cost £22,000,000 / annum • National pilot cost £2600 / QALY • Benchmark for cost effectiveness ~ £20,000

  34. Surveillance for bowel cancer

  35. Bowel cancer surveillance • High risk FHx • Colitis • Previous high risk adenomas • Previous bowel cancers • Miscellaneous conditions

  36. Positive family history • Lifetime risk of bowel cancer 1:50 • Key relevant factors - age <45 yrs - 1st degree relative • 1st degree relative risk 1:20 • 1st degree relative <45 yrs 1:10 • 1st degree & 2nd degree relative 1:15

  37. colitis • Risk of bowel cancer ↑ in UC & Crohns colitis • Similar increased risk for UC & CD • Overall ↑ risk = 6 fold cf normal population • Risk @ 20yrs – 10% • Risk @ 30yrs – 20% • Presence of PSC doubles risk

  38. Previous sporadic colonic polyps • >3 adenomas of <1cm size • 1 or more adenomas of >1cm - repeat colonoscopy @ 12/12 - once colon ‘clean’ → 5yr repeat scope • No routine F/U beyond age 75 yrs if low risk / average risk

  39. What’s new in bowel cancer treatment ?

  40. Pre-op staging ↓ L.O.S - ‘ERAS’ & laparoscopic surgery More extensive open surgery - primary resections - liver & thoracic resections - surgery for recurrence Pathological staging F/U programmes Enhancing functional outcome Stenting Neoadjuvant chemo / radiotherapy

  41. Pre-operative staging • Colon cancer - CT (C/A/P) & full colonic assessment (CTC) • Rectal cancer - full colonic assessment - pelvic MRI (TNM & CRM assessment) - ERUSS for local resections (<5%)

  42. Enhanced recovery after surgery‘ERAS’ • Pre-op information ↑ (& pre-op stoma education) • Same day admission • Much reduced use of bowel prep - ↓ dehyration & lethargy - ↓ electrolyte imbalance • Laparoscopic / dermatomal incisions - less pain - routine epidural Goal: better analgesia / earlier diet / earlier mobility / less ileus

  43. ERAS • ↓ use of tubes / drains • goal setting & care pathways - immediate resumption oral fluids - dietary supplements - post-op mobility • ave LOS ~ 4/7 for colonic resection (cf 8-10/7 historically) • readmission rates < 10%

  44. Laparoscopic surgery • Smaller incisions • Oncological equivalence • ↓ LOS • Technically more challenging • Pt requests

  45. Laparoscopic surgery • Suitable for majority of bowel cancer surgery • Relative contraindications - morbid obesity - previous abdominal surgery (adhesions) - bulky tumours - multi-visceral resections

  46. More extensive surgery • Multi-visceral resections for anticipated cure - pelvic clearance - small bowel - stomach & duodenum - spleen

  47. Liver resection • Requirements - resectable 1y tumour - 3 healthy intact liver segments - no peritoneal mets - resectable extra-hepatic mets

  48. Synchronous liver resection • ~20% present with metastatic disease • Appropriate for - complex bowel surgery with simple liver op eg anterior resection & liver metastectomy - ‘simple’ colectomy and more complex liver op eg R hemicolectomy & R hemihepatectomy • Else staged resection

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