Bowel cancer: - early symptoms - screening - treatment update - PowerPoint PPT Presentation

Bowel cancer:- early symptoms - screening - treatment update

Ian Botterill

Dept Colorectal Surgery, The General Infirmary

Leeds

• 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

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

Latest CRUK figures

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

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

‘proximal migration’

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

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

• ~ 40% localised disease ‘A’ 90% ‘B’ 65%
• ~ 40% regional nodes ‘C’ 40%
• ~ 20% distant mets ‘D’ 5%
• Overall median survival 40-50%

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%

• Raised awareness
• Targeted urgent referral criteria - ‘2WW’ process
• Bowel cancer screening

Symptom assessment

• 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

• 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

• ~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

Thompson et al, BMJ, DOH referral guidelines

• 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

Screening

• Important / relevant disease
• Definable sequence allowing intervention
• Test - cheap / QUALY beneficial

- acceptable → uptake >70%

- sensitive & specific

- low risk

- reproducible

• 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’

• Faecal occult blood
• Flexible sigmoidoscopy
• Ba enema
• CT pneumocolon
• Colonoscopy

• 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

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

• ‘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

• 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

• Coventry
• ~480,000 invited > 57% completed FOBT
• 2% of FOBT positive → colonoscopy
• 550 cancers detected
• 367 early cancers (Dukes A)
• 4X ↑ in early cancers

• 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’

• >90% caecal intubation rate
• Consultant / approved non-consultant
• Audited morbidity

- perforation 0.2% - death 0.01%

• Hot biopsy
• Snare polypectomy
• Endoscopic mucosal resection

• 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

Surveillance for bowel cancer

• High risk FHx
• Colitis
• Previous high risk adenomas
• Previous bowel cancers
• Miscellaneous conditions

• 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

• 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

• >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

↓ 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

• 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%)

• 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

• ↓ 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%

• Smaller incisions
• Oncological equivalence
• ↓ LOS
• Technically more challenging
• Pt requests

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

• Multi-visceral resections for anticipated cure - pelvic clearance - small bowel - stomach & duodenum - spleen

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

• ~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

• 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

N1 <3 nodes

N2 3+ nodes

V1 vascular involvement

R0 no margin involvement

R1 microscopic margin involvement

R2 residual disease @ surgery

• 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

• 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

• Palliation in malignant obstruction
• Bridge to elective resection
• Placement - screening & endoscopy - ~45 minutes - success ~ 80% - Cx: failure, perforation, displacement

• 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

TME alone

5.8% vs 11.4%

p < 0.001

RT + TME

TME alone

64.2% vs 63.4%

p = 0.87

RT + TME

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

10.5% vs 11.9%

p = 0.53

• 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