1 / 47

Colorectal Cancer When to refer ?

Colorectal Cancer When to refer ? . Dr Devinder Singh Bansi BM FRCP DM Consultant Gastroenterologist Imperial College London 29.09.2011. 2003 Estimated US Cancer Cases*. Men 675,300. Men 675,300. Women 658,800. Women 658,800. Prostate 222,849 Lung/bronchus 94,542

torin
Download Presentation

Colorectal Cancer When to refer ?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Colorectal CancerWhen to refer ? Dr Devinder Singh Bansi BM FRCP DM Consultant Gastroenterologist Imperial College London 29.09.2011

  2. 2003 Estimated US Cancer Cases* Men675,300 Men675,300 Women658,800 Women658,800 Prostate 222,849 Lung/bronchus 94,542 Colon/rectum 74,283 Urinary bladder 40,518 Melanoma of 27,012skin Non-Hodgkin 27,012lymphoma Kidney 20,259 Oral cavity 20,259 Leukemia 20,259 Pancreas 13,506 All other sites 114,801 210,816 Breast 79,056 Lung/bronchus 72,468 Colon & rectum 39,528 Uterine corpus 26,352 Ovary 26,352 Non-Hodgkin lymphoma 19,764 Melanoma of skin 19,764 Thyroid 13,176 Pancreas 13,176 Urinary bladder 62,238 All other sites ONS=Other nervous system. *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2003.

  3. 2003 Estimated US Cancer Deaths* Men285,900 Women270,600 Lung/bronchus 88,629 Prostate 28,590 Colon & rectum 28,590 Pancreas 14,295 Non-Hodgkin 11,436lymphoma Leukemia 11,436 Esophagus 11,436 Liver/intrahepatic 8,577bile duct Urinary bladder 8,577 Kidney 8,577 All other sites 62,898 67,650 Lung/bronchus 40,590 Breast 29,766 Colon & rectum 16,236 Pancreas 13,530 Ovary 10,824 Non-Hodgkin lymphoma 10,824 Leukemia 8,118 Uterine corpus 5,412 Brain/ONS 5,412 Multiple myeloma 62,238 All other sites ONS=Other nervous system. *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2003.

  4. Colorectal cancerSome useful statistics • Approx 40,000 cases diagnosed in UK in 2008 (110 people/day) • >80% in people aged 60 or over • Incidence relatively stable in last 10 years • 5 yr survival rates doubled in last 40 yrs • STILL REMAINS 2nd most common cause of death from malignant disease in UK

  5. Bowel cancer -UK malesfemales New cases (2008) 22,097 17,894 Rate/100,00 pop. 58.5 37.8 5 yr survival (2001-6) 50% 51% (colon cancer) 5 yr survival 92001-6) 51% 55% (rectal cancer)

  6. Colon Polyp

  7. Colon Cancer

  8. How Does Colorectal Cancer Develop? Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.

  9. Colorectal cancer:At a local level • Individual GP would expect to diagnose only 1-2 cases per year • Bowel symptoms are common in the general population • Increased number of ‘worried well’ patients • ‘well publicised large bowel cancer awareness campaigns • How to select patients with large bowel symptoms who should be sent for urgent investigation ? • A selection policy will inevitably lead to missed cases and potential litigation

  10. Colorectal cancer:Symptoms may be site specific • Rectal cancer • Classically tenesmus/rectal bleeding • Sigmoid cancer • Altered bowel habit, with tendency to looser stool • Right sided cancers • No or few GI symptoms • Palpable mass or anaemia

  11. Colorectal cancer:Distribution of disease • Rectum 27% • Rectosigmoid junction 7% • Sigmoid colon 20% • Descending Colon 3% • Splenic flexure 2% • Transverse Colon 5% • Hepatic Flexure 3% • Ascending Colon 7% • Caecum 14% • Appendix 1% • Other and unspecified 9%

  12. Colorectal cancer:The significance of rectal bleeding • Arguably the most diagnostically difficult symptom for GPs • Common and, in isolation, only rarely caused by bowel cancer • Only 3% of 1000 pts with only rectal bleeding sent to hospital for investigation • Conversely, of all patients with left-sided CRC, approx. 60-70% report rectal bleeding as a principal symptom

  13. Colorectal cancer:The significance of age • Only 1% of all CRC occur in individuals <40 yrs • 4% CRC occur in age range 40-50 yrs • Risk rises more rapidly >50 yrs • BUT ‘No one is too young to have bowel cancer’

  14. Colorectal cancer:High Risk Individuals • Anaemia or palpable mass (any age) • >50 yrs with CIBH >6 weeks to looser stool and/or increased stool frequency • Rectal bleeding with CIBH (all ages) • >50 with rectal bleeding • The danger of not investigating this group, even if it appears to be from benign ano-rectal causes, is that the patient may be falsely reassured and not represent when symptoms persist or change • Patients of any age with symptoms and a strong FH of CRC • Iron deficiency anaemia without an obvious cause (all ages)

  15. Other symptomatic groups • <40 with symptoms of CIBH ? • May be acceptable to adopt wait and see approach for 6 weeks as in most cases symptoms will be self-limiting • However, important to have arrangements in place to review the patient and investigate if symptoms persist • Patients with ‘bloody diarrhoea’ may have IBD so should be referred urgently • <40 with symptoms of bright red bleeding but no CIBH ? • Do not require urgent referral but a definitive diagnosis should be made • Rectal examination/sigmoidoscopy as minimum. • Possibly watch and wait for 6 weeks but may be pressure to refer to specialist • If in doubt: REFER !

  16. Referral of suspected Colorectal Cancer:Have guidelines made a difference ? • British Journal of General Practice Aug 2004 • Exeter Primary Care Trust • All 361 cases of CRC (population 132000) from Jan 1998- Sept 2002 identified as part of a study examining GP records for pre-diagnostic clues to a malignant diagnosis • 200 cases randomly selected • 160 GP referral letters for suspected CRC available for study

  17. Features of importance in CRC identified by GPs • Rectal bleeding • CIBH (usually diarrhoea) • Weight loss • Iron deficiciency anaemia • Abdominal mass • History of IBD • History of colorectal polyps or signs of CRC on previous investigation • FH of CRC • GPs opinion that patient has CRC • Mucus per rectum • Abdominal pain

  18. Referrals made before and after the introduction of national cancer guidelines for CRC June 1997-June 2000 June 2000-Sept 2002 n= 92 n=65 Mean age 69.8 69.3 Men 51(55%) 32 (49) Patients referred urgently 38 (41) 32 (49) Satisfied criteria for urgent Referral 64/89 (72) 48/64 (75) Satisfied criteria and had Urgent referral 35/64 (55) 27/48 (56) Did not satisfy criteria And had urgent referral 2/25( 8) 5/16 (31) Duke’s A or B cancer 49/87 (56) 31/50 (62)

  19. Lessons ? • Positive predictive value of symptomatic guidelines for diagnosing CRC is only 10% • Significant number of patients diagnosed outside the ‘stream-lined’ referral route eg via A/E, other specialties • Little increase in numbers of urgent referrals may represent the fact that many colorectal cancers do not meet the criteria for urgent referral. • Urgent referrals outside the guidelines may be appropriate • WHAT TO DO ?!

  20. Referring Patients for Suspected Colorectal Cancer:Common reasons for litigation • Failure to refer a patient with high-risk large bowel symptoms and so provide inappropriate reassurance • Failure to do a rectal examination in a patient who subsequently proves to have a rectal cancer • In the event that a practitioner has decided upon urgent referral to a specialist , a rectal examination is not necessary • In the case of a ‘watch and see ‘ policy, better to do a rectal examination since the majority of expert witnesses tend to be of the ‘old school’ !! • Defence based on ‘lack of causative consequences’ • Demonstration of disseminated disease which would therefore not effect prognosis

  21. Survival by Dukes Stage

  22. Symptoms of Colorectal Cancer

  23. Staging of Colorectal Cancer

  24. Frequency of Colorectal Cancer by Dukes Stage

  25. Treatment of Colorectal Cancer by Stage

  26. Is Colorectal Cancer Preventable? YES! • Screening • Chemoprevention

  27. Screening Techniques for Colorectal Cancer • Fecal occult blood test (FOBT) every year, or • Flexible sigmoidoscopy every 5 years,or • A fecal occult blood test every year plus flexible sigmoidoscopy every 5 years (recommended by the American Cancer Society), or • Colonoscopy every 10 years (recommended by the American College of Gastroenterology).

  28. Screening For Colon Cancer SAVES LIVES!!! MortalityTest Reduction Fecal occult blood testing 33% Flexible sigmoidoscopy 66% (in portion of colon examined) FOBT + flexible sigmoidoscopy 43% (compared to sigmoidoscopy alone) Colonoscopy ~76-90% (after initial screening and polypectomy)

  29. Colorectal cancer screeningFirst assess RISK AVERAGE RISK INDIVIDUAL • All patients age 50 years and older, the asymptomatic general population HIGH RISK • Personal history – polyp or cancer • Family history – polyp or cancer in first degree relatives

  30. Why aren’t more people screened for colon cancer? Reasons for refusal of fecal occult blood testing • Fear of further testing and surgery • Feeling well • Unpleasantness of stool collection procedure But: • Strongest predictor of whether a patient will be screened = physician encouragement Hynam et al. J Epidemiol Comm Health 1995;49:84 Mandelson et al. Am J Prevent Med 2000;19:149

  31. Fecal Occult Blood Testing • Examination of stool for occult (“hidden”) blood • Can detect one teaspoon or less of blood in a bowel movement • Uses chemical reaction between blood and reagent

  32. FOBT improves survival Years after diagnosis

  33. Trends in FOBT, 1997-2001 Source: Behavioral Risk Factor Surveillance System, 1996-1997, 1999, 2001, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002.

  34. Site Distribution

  35. Flexible sigmoidoscopy • Pros • May be done in office • Inexpensive, cost-effective • Reduces deaths from rectal cancer • Easier bowel preparation, usually done without sedation • Cons • Detects only half of polyps • Misses 40-50% of cancers located beyond the view of the sigmoidoscope • Often limited by discomfort, poor bowel preparation Selby et al N Engl J Med 1992; 336:653 Stewart et al Aust NZ J Surg 1999; 69:2 Newcomb et al. JNCI 1992; 84:1572 Painter et al Endoscopy 1999; 3:269 Rex et al. Gastrointest Endosc 1999; 99:727

  36. Colonoscopy • Pros • Examines entire colon • Removal of polyps performed at time of exam • Well-tolerated with sedation • Easier bowel preparation, usually done without sedation • Cons • Expensive • Risk of perforation, bleeding low but not negligible • Requires high level of training to perform • Miss rate of polyps < 1 cm ~25%, > 1 cm ~5% Rex et al. Gastroenterology 1997; 112:24-8 Postic et al. Am J Gastroenterol 2002; 97:3182-5

  37. Chemopreventive agents

  38. Future techniques for colorectal cancer screening • Stool DNA testing • Capsule endoscopy (Givens capsule) • CT colography (virtual colonoscopy)

  39. Fecal Testing for Gene Mutations

  40. Fecal Testing for Gene Mutations • Pros • No sedation or preparation necessary • Home-based (sample mailed to physician) • No risk • Cons • Current tests not very good (~50% of cancers missed) • Cost • Frequency of exam unknown • Not therapeutic • Not covered by insurance

  41. Videocapsule

  42. Videocapsule Lymphoma

  43. CT Colography Colon Polyp

  44. CT Colography Colon Polyp

  45. CT Colography Colon Cancer

  46. CT Colography • Pros • No sedation necessary • 20 min procedure vs. 25 min for colonoscopy • Low risk • Extracolonic lesions may be detected • Cons • Preparation (residual fluid cannot be aspirated) • Air insufflation • Cost (? need for more frequent exams) • Radiation dose (similar to barium enema) • Not therapeutic • Not covered by insurance

  47. Summary • Colorectal cancer is the third most common cancer and cause of cancer death in the U.S. • Chemopreventive agents have modest benefit in average risk individuals • Screening for colorectal cancer saves lives! • Patient and physician compliance with screening is poor

More Related