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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

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colorectal cancer when to refer

Colorectal CancerWhen to refer ?

Dr Devinder Singh Bansi BM FRCP DM

Consultant Gastroenterologist

Imperial College



2003 estimated us cancer cases
2003 Estimated US Cancer Cases*





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.

2003 estimated us cancer deaths
2003 Estimated US Cancer Deaths*



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.

colorectal cancer some useful statistics
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
bowel cancer uk
Bowel cancer -UK


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)

how does colorectal cancer develop
How Does Colorectal Cancer Develop?

Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.

colorectal cancer at a local level
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
colorectal cancer symptoms may be site specific
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
colorectal cancer distribution of disease
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%
colorectal cancer the significance of rectal bleeding
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
colorectal cancer the significance of age
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’

colorectal cancer high risk individuals
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)
other symptomatic groups
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 !
referral of suspected colorectal cancer have guidelines made a difference
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
features of importance in crc identified by gps
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
referrals made before and after the introduction of national cancer guidelines for crc
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)

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 ?!
referring patients for suspected colorectal cancer common reasons for litigation
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
is colorectal cancer preventable
Is Colorectal Cancer Preventable?


  • Screening
  • Chemoprevention
screening techniques for colorectal cancer
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).
screening for colon cancer saves lives
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)

colorectal cancer screening first assess risk
Colorectal cancer screeningFirst assess RISK


  • All patients age 50 years and older, the asymptomatic general population


  • Personal history – polyp or cancer
  • Family history – polyp or cancer in first degree relatives
why aren t more people screened for colon cancer
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


  • 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

fecal occult blood testing
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
fobt improves survival
FOBT improves survival

Years after diagnosis

trends in fobt 1997 2001
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.

flexible sigmoidoscopy
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

  • 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

future techniques for colorectal cancer screening
Future techniques for colorectal cancer screening
  • Stool DNA testing
  • Capsule endoscopy (Givens capsule)
  • CT colography (virtual colonoscopy)
fecal testing for gene mutations40
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


ct colography
CT Colography

Colon Polyp

ct colography44
CT Colography

Colon Polyp

ct colography45
CT Colography

Colon Cancer

ct colography46
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
  • 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