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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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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
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
demographics the problem
Demographics: the problem

Equates to ~ 1 new case of bowel cancer / GP / annum

Latest CRUK figures

demographics
Demographics
  • 3rd commonest cancer in EU
  • Lifetime risk 2-4%
  • Leeds Colorectal MDT - ~580 cases 2005 - ~630 cases 2007
incidence
Incidence
  • M>F
  • 90% of cases > 50yrs age
  • More common decade on decade post age 50yrs
  • Male incidence on increase
  • Median survival 40-50%
distribution of bowel cancer
Distribution of bowel cancer

‘proximal migration’

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

Effect of subspecialist surgery / adjuvant therapy / liver surgery for mets

5 yr survival by stage at presentation
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%
cancer surgery 30 day mortality
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%

doh initiatives to improve outcomes
DOH initiatives to improve outcomes
  • Raised awareness
  • Targeted urgent referral criteria - ‘2WW’ process
  • Bowel cancer screening
textbook symptoms
‘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
6 key 2ww referral criteria
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
effect of 2ww referral
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
doh pragmatic referral pathway
DOH ‘pragmatic referral pathway’

Thompson et al, BMJ, DOH referral guidelines

primary care assessment investigation
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
principles of screening
Principles of screening
  • Important / relevant disease
  • Definable sequence allowing intervention
  • Test - cheap / QUALY beneficial

- acceptable → uptake >70%

- sensitive & specific

- low risk

- reproducible

window for intervention polyp cancer sequence
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’
methods of screening
Methods of screening
  • Faecal occult blood
  • Flexible sigmoidoscopy
  • Ba enema
  • CT pneumocolon
  • Colonoscopy
fobt haemoccult sensa
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
slide25
FOBT
  • 38-60% uptake in previous trials
  • unpleasant / messy
  • severe dietary restrictions
  • avoidance of NSAIDs
flexible sigmoidoscopy screening
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
colonoscopy
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
uk bowel cancer screening pilot study
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
uk bowel cancer screening www cancerscreening nhs uk bowel
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’
colonoscopy quality control
Colonoscopy quality control
  • >90% caecal intubation rate
  • Consultant / approved non-consultant
  • Audited morbidity

- perforation 0.2% - death 0.01%

polypectomy
Polypectomy
  • Hot biopsy
  • Snare polypectomy
  • Endoscopic mucosal resection
cost of bowel cancer screening
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
bowel cancer surveillance
Bowel cancer surveillance
  • High risk FHx
  • Colitis
  • Previous high risk adenomas
  • Previous bowel cancers
  • Miscellaneous conditions
positive family history
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
colitis
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
previous sporadic colonic polyps
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
slide42
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

pre operative staging
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%)
enhanced recovery after surgery eras
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

slide45
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%
laparoscopic surgery
Laparoscopic surgery
  • Smaller incisions
  • Oncological equivalence
  • ↓ LOS
  • Technically more challenging
  • Pt requests
laparoscopic surgery47
Laparoscopic surgery
  • Suitable for majority of bowel cancer surgery
  • Relative contraindications - morbid obesity - previous abdominal surgery (adhesions) - bulky tumours - multi-visceral resections
more extensive surgery
More extensive surgery
  • Multi-visceral resections for anticipated cure - pelvic clearance - small bowel - stomach & duodenum - spleen
liver resection
Liver resection
  • Requirements - resectable 1y tumour - 3 healthy intact liver segments - no peritoneal mets - resectable extra-hepatic mets
synchronous liver resection
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
pathological staging
Pathological staging
  • Dukes A B C (D) - easily understood - still used - no account of vascular invasion - no account of resection margin involvement
  • Modified Dukes
  • TNM now routinely used
tnm classification
TNM classification

N1 <3 nodes

N2 3+ nodes

V1 vascular involvement

R0 no margin involvement

R1 microscopic margin involvement

R2 residual disease @ surgery

enhancing function after rectal resection
Enhancing function after rectal resection
  • Loss of rectum > ‘anterior resection syndrome’ - frequency, incomplete evacuation
  • Permanent stoma rate down to 15-20% for rectal cancer
  • Preserve distal rectum for upper 1/3rd cancers
  • Colon pouch anal anastomosis for TME
  • Avoid pre-op RT if staging favourable
sexual function after rectal resection
Sexual function after rectal resection
  • Erectile dysfunction - pre-existing - 2y to radiotherapy or surgery
  • 5-20% post rectal resection
  • Psycholgical / neurogenic / vasculogenic
  • Rx: - nerve sparing surgery - avoidance radiotherapy if feasible - Viagra
colonic rectal stenting
Colonic & rectal stenting
  • Palliation in malignant obstruction
  • Bridge to elective resection
  • Placement - screening & endoscopy - ~45 minutes - success ~ 80% - Cx: failure, perforation, displacement
neo adjuvant therapy for rectal cancer
neo-adjuvant therapy for rectal cancer
  • Historical local recurrence rates 5-40%
  • Goal of surgery ‘clear longitudinal & circumferential margins’
  • DRE & MRI assessment
  • Local recurrence reduced by - Total Mesorectal Excision - Short course radiotherapy - Long course chemoradiotherapy
  • Morbidity of post-op radiotherapy substantial
dutch trial local recurrence patients with r 0 n 1789
Dutch trial - Local recurrencePatients with R 0 (n=1789)

TME alone

5.8% vs 11.4%

p < 0.001

RT + TME

overall survival eligible patients n 1809
Overall Survival eligible patients (n=1809)

TME alone

64.2% vs 63.4%

p = 0.87

RT + TME

dutch trial local recurrence rate level from the anal verge
Dutch trial - Local recurrence rateLevel from the anal verge

0 - 5 cm 6 - 10 cm * 11 - 15 cm

10.5% vs 11.9%

p = 0.53

take home messages
Take home messages
  • Bowel cancer common
  • 1y care detection difficult – please refer if any doubt
  • Screening - likely to be beneficial - major hurdle patient acceptance: 1y care role
  • Bowel cancer care truly multi-disciplinary
  • Major advances in treatment of 1y cancer & metastases