bowel cancer: - early symptoms - screening - treatment update ian botterill dept colorectal surgery,...
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Bowel cancer:- early symptoms
- screening - treatment update
Ian BotterillDept Colorectal Surgery, The General Infirmary
Leeds
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
Latest CRUK figures
Equates to ~ 1 new case of bowel cancer / GP / annum
Demographics
• 3rd commonest cancer in EU
• Lifetime risk 2-4%
• Leeds Colorectal MDT - ~580 cases 2005- ~630 cases 2007
Incidence
• M>F
• 90% of cases > 50yrs age
• More common decade on decade post age 50yrs
• Male incidence on increase
• Median survival 40-50%
Effect of age
Distribution of bowel cancer
‘proximal migration’
Colorectal cancer
• 75% sporadic ie average risk
• 15-20% FHx of CRC
• 3-8% HNPCC
• 1% FAP
• 1% UC & Crohns
Mortality of bowel cancer
Effect of subspecialist surgery / adjuvant therapy / liver surgery for mets
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
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
• Raised awareness
• Targeted urgent referral criteria- ‘2WW’ process
• Bowel cancer screening
Symptom assessment
‘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• 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
‘Identikit’ of typical patient with bowel cancer
Age > 60yrs with rectal bleeding & looser stool
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
Thompson et al, BMJ, DOH referral guidelines
DOH ‘pragmatic referral pathway’
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
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
• 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
• Faecal occult blood• Flexible sigmoidoscopy• Ba enema• CT pneumocolon
• Colonoscopy
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
FOBT
• 38-60% uptake in previous trials
• unpleasant / messy
• severe dietary restrictions
• avoidance of NSAIDs
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
• 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
• 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
• 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
• >90% caecal intubation rate
• Consultant / approved non-consultant
• Audited morbidity
- perforation 0.2%- death 0.01%
Polypectomy
• Hot biopsy
• Snare polypectomy
• Endoscopic mucosal resection
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
Surveillance for bowel cancer
Bowel cancer surveillance
• High risk FHx
• Colitis
• Previous high risk adenomas
• Previous bowel cancers
• Miscellaneous conditions
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
• 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
• >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
What’s new in bowel cancer treatment ?
• 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
• 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’
• 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
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
• Smaller incisions
• Oncological equivalence
• ↓ LOS
• Technically more challenging
• Pt requests
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
• Multi-visceral resections for anticipated cure - pelvic clearance - small bowel - stomach & duodenum - spleen
Liver resection
• Requirements - resectable 1y tumour - 3 healthy intact liver segments - no peritoneal mets - resectable extra-hepatic mets
•
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 opeg R hemicolectomy & R hemihepatectomy
• Else staged resection
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
• 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
• 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
• 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
• 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
• 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)
5.8% vs 11.4% p < 0.001
Years since surgery
86420
Lo
cal r
ecu
rre
nce
(%
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TME alone
RT + TME
Overall Survival eligible patients (n=1809)
Years since surgery
86420
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m S
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iva
l
1,0
,9
,8
,7
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,5
,4
,3
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64.2% vs 63.4% p = 0.87
TME alone
RT + TME
Dutch trial - Local recurrence rate
Level from the anal verge
10.5% vs 11.9% p = 0.53
Years since surgery
86420
Loca
l rec
urre
nce
(%)
,20
,15
,10
,05
0,00
Years since surgery
86420
Loca
l rec
urre
nce
(%)
,20
,15
,10
,05
0,00
Years since surgery
86420
Loca
l rec
urre
nce
(%)
,20
,15
,10
,05
0,00
0 - 5 cm 6 - 10 cm * 11 - 15 cm
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
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