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

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

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TME alone

RT + TME

Overall Survival eligible patients (n=1809)

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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

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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