Clues to colorectal cancer presentation silent killer direct access colonoscopy
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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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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

Who are we?


Patients treated 2012-2013

Oncology firm RLH

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)

Anal Cancer

HPV related methylation markers in patients with anal intra-epithelial neoplasia and anal squamous cell carcinoma

Clinical Research including clinical trials:

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

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.


Right sided lesions

Fe deficiency anaemia

Palapable mass

Left sided

Change in bowel habit

Looser more frequent stools

Rectal bleeding


Rectal bleeding


Traditional teaching of presentation of colorectal cancer 2 week wait referrals

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

A and E admissions with new onset cancer

25% of all patients presenting with colon cancer

Bowel obstruction


Elective mortality <10%

Emergency mortality >30%


Incidental findings

London Cancer emergency audit

10-15% 2ww

25% acute admission

Screening 10-20%

Therefore approx 50% are through other routes

How to identify?

The problem

Direct Access Colonoscopy

After consultation

Colonoscopy >90%

Flexible sigmoidoscopy

CT Pneumocolon

Plain CT


Previous direct access flexible sigmoidoscopy


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

Full management suppport

To reduce the burden of OPD clinics

Telephone triage

Nurse led

2 pilot clinics

QUIP - 2013


Bowel preparation

Assessment of suitability

Time dependent on CNS

Need support staff at RLH

Problems faced

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%


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)

Flexible sigmoidoscopy

Once only flexible sigmoidoscopy


113 000

Control and intervention group

Colorectal cancer

incidence in the intervention group was reduced by 23%

mortality by 31%

Pilot 2012

South of Tyne (Queen Elizabeth & South Tyneside)

West Kent (West Kent & Medway)


St Marks (London)


Surrey (Guildford)

Roll out in 2014

Bowel Scope

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