Presentation on theme: "Colorectal Cancer When to refer ?"— Presentation transcript:
1 Colorectal Cancer When to refer ? Dr Devinder Singh Bansi BM FRCP DMConsultant GastroenterologistImperial CollegeLondon
2 2003 Estimated US Cancer Cases* Men 675,300Men 675,300Women 658,800Women 658,800Prostate 222,849Lung/bronchus 94,542Colon/rectum 74,283Urinary bladder 40,518Melanoma of 27,012 skinNon-Hodgkin 27,012 lymphomaKidney 20,259Oral cavity 20,259Leukemia 20,259Pancreas 13,506All other sites 114,801210,816 Breast79,056 Lung/bronchus72,468 Colon & rectum39,528 Uterine corpus26,352 Ovary26,352 Non-Hodgkin lymphoma19,764 Melanoma of skin19,764 Thyroid13,176 Pancreas13,176 Urinary bladder62,238 All other sitesONS=Other nervous system.*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2003.
3 2003 Estimated US Cancer Deaths* Men 285,900Women 270,600Lung/bronchus 88,629Prostate 28,590Colon & rectum 28,590Pancreas 14,295Non-Hodgkin 11,436 lymphomaLeukemia 11,436Esophagus 11,436Liver/intrahepatic 8,577 bile ductUrinary bladder 8,577Kidney 8,577All other sites 62,89867,650 Lung/bronchus40,590 Breast29,766 Colon & rectum16,236 Pancreas13,530 Ovary10,824 Non-Hodgkin lymphoma10,824 Leukemia8,118 Uterine corpus5,412 Brain/ONS5,412 Multiple myeloma62,238 All other sitesONS=Other nervous system.*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2003.
4 Colorectal cancer Some useful statistics Approx 40,000 cases diagnosed in UK in 2008 (110 people/day)>80% in people aged 60 or overIncidence relatively stable in last 10 years5 yr survival rates doubled in last 40 yrsSTILL REMAINS 2nd most common cause of death from malignant disease in UK
5 Bowel cancer -UKmales females New cases (2008) 22,097 17,894 Rate/100,00 pop yr survival (2001-6) 50% 51% (colon cancer) 5 yr survival ) 51% 55% (rectal cancer)
8 How Does Colorectal Cancer Develop? Janne PA, Mayer RJ. N Engl J Med 2000;342:1960.
9 Colorectal cancer: At a local level Individual GP would expect to diagnose only 1-2 cases per yearBowel symptoms are common in the general populationIncreased number of ‘worried well’ patients‘well publicised large bowel cancer awareness campaignsHow 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
10 Colorectal cancer: Symptoms may be site specific Classically tenesmus/rectal bleedingSigmoid cancerAltered bowel habit, with tendency to looser stoolRight sided cancersNo or few GI symptomsPalpable mass or anaemia
11 Colorectal cancer: Distribution of disease Rectum %Rectosigmoid junction 7%Sigmoid colon 20%Descending Colon 3%Splenic flexure 2%Transverse Colon 5%Hepatic Flexure 3%Ascending Colon 7%Caecum %Appendix 1%Other and unspecified 9%
12 Colorectal cancer: The significance of rectal bleeding Arguably the most diagnostically difficult symptom for GPsCommon and, in isolation, only rarely caused by bowel cancerOnly 3% of 1000 pts with only rectal bleeding sent to hospital for investigationConversely, of all patients with left-sided CRC, approx % report rectal bleeding as a principal symptom
13 Colorectal cancer: The significance of age Only 1% of all CRC occur in individuals <40 yrs4% CRC occur in age range yrsRisk rises more rapidly >50 yrsBUT‘No one is too young to have bowel cancer’
14 Colorectal cancer: High Risk Individuals Anaemia or palpable mass (any age)>50 yrs with CIBH >6 weeks to looser stool and/or increased stool frequencyRectal bleeding with CIBH (all ages)>50 with rectal bleedingThe 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 changePatients of any age with symptoms and a strong FH of CRCIron deficiency anaemia without an obvious cause (all ages)
15 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-limitingHowever, important to have arrangements in place to review the patient and investigate if symptoms persistPatients 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 madeRectal examination/sigmoidoscopy as minimum.Possibly watch and wait for 6 weeks but may be pressure to refer to specialistIf in doubt: REFER !
16 British Journal of General Practice Aug 2004 Referral of suspected Colorectal Cancer: Have guidelines made a difference ?British Journal of General Practice Aug 2004Exeter Primary Care TrustAll 361 cases of CRC (population ) from Jan Sept 2002 identified as part of a study examining GP records for pre-diagnostic clues to a malignant diagnosis200 cases randomly selected160 GP referral letters for suspected CRC available for study
17 Features of importance in CRC identified by GPs Rectal bleedingCIBH (usually diarrhoea)Weight lossIron deficiciency anaemiaAbdominal massHistory of IBDHistory of colorectal polyps or signs of CRC on previous investigationFH of CRCGPs opinion that patient has CRCMucus per rectumAbdominal pain
18 Referrals made before and after the introduction of national cancer guidelines for CRC June 1997-June 2000 June 2000-Sept 2002n= 92 n=65Mean ageMen 51(55%) 32 (49)Patients referred urgently 38 (41) 32 (49)Satisfied criteria for urgentReferral 64/89 (72) 48/64 (75)Satisfied criteria and hadUrgent referral 35/64 (55) 27/48 (56)Did not satisfy criteriaAnd had urgent referral 2/25( 8) 5/16 (31)Duke’s A or B cancer 49/87 (56) 31/50 (62)
19 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 specialtiesLittle 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 appropriateWHAT TO DO ?!
20 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 reassuranceFailure to do a rectal examination in a patient who subsequently proves to have a rectal cancerIn the event that a practitioner has decided upon urgent referral to a specialist , a rectal examination is not necessaryIn 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
22 Symptoms of Colorectal Cancer Time CourseSymptomsFindingsEarlyNoneOccult blood in stoolMidRectal bleedingChange in bowel habitsRectal massBlood in stoolLateFatigueAnemiaAbdominal painWeight lossAbdominal massBowel obstruction
26 Is Colorectal Cancer Preventable? YES!ScreeningChemoprevention
27 Screening Techniques for Colorectal Cancer Fecal occult blood test (FOBT) every year, orFlexible sigmoidoscopy every 5 years,orA fecal occult blood test every year plus flexible sigmoidoscopy every 5 years (recommended by the American Cancer Society), orColonoscopy every 10 years (recommended by the American College of Gastroenterology).
28 Screening For Colon Cancer SAVES LIVES!!! Mortality Test ReductionFecal occult blood testing %Flexible sigmoidoscopy %(in portion of colon examined)FOBT + flexible sigmoidoscopy %(compared to sigmoidoscopy alone)Colonoscopy ~76-90%(after initial screening and polypectomy)
29 Colorectal cancer screening First assess RISK AVERAGE RISK INDIVIDUALAll patients age 50 years and older, the asymptomatic general populationHIGH RISKPersonal history – polyp or cancerFamily history – polyp or cancer in first degree relatives4
30 Why aren’t more people screened for colon cancer? Reasons for refusal of fecal occult blood testingFear of further testing and surgeryFeeling wellUnpleasantness of stool collection procedureBut:Strongest predictor of whether a patient will be screened = physician encouragementHynam et al. J Epidemiol Comm Health 1995;49:84Mandelson et al. Am J Prevent Med 2000;19:149
31 Fecal Occult Blood Testing Examination of stool for occult (“hidden”) bloodCan detect one teaspoon or less of blood in a bowel movementUses chemical reaction between blood and reagent
33 Trends in FOBT,Source: Behavioral Risk Factor Surveillance System, , 1999, 2001, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002.
34 Site Distribution 17. Site Distribution At one time, conventional wisdom held that half of all colorectal tumors could be reached with the examining finger, or at least the rigid sigmoidoscope. This reflects the distal predominance of colorectal cancer, whose distribution roughly corresponds to that of adenomas. A gradual shift toward a more proximal distribution may be occurring. Whether this is due to improved detection of right-sided tumors, to a change in dietary carcinogen-related exposure of the mucosa, or to other factors, is unknown.• Vukasin AP, Ballantyne GH, Flannery JT, et al: Increasing incidence of cecal and sigmoid carcinoma. Data from the Connecticut Tumor Registry. Cancer, 66:2442-9, 1990.• Shinya Y, Wolff WI: Morphhology, anatomic discribution, and cancer potential of colonic polyps. Ann Surg, 190:679-83, 1979.
35 Flexible sigmoidoscopy ProsMay be done in officeInexpensive, cost-effectiveReduces deaths from rectal cancerEasier bowel preparation, usually done without sedationConsDetects only half of polypsMisses 40-50% of cancers located beyond the view of the sigmoidoscopeOften limited by discomfort, poor bowel preparationSelby et al N Engl J Med 1992; 336:653 Stewart et al Aust NZ J Surg 1999; 69:2Newcomb et al. JNCI 1992; 84:1572 Painter et al Endoscopy 1999; 3:269Rex et al. Gastrointest Endosc 1999; 99:727
36 Colonoscopy Pros Examines entire colon Removal of polyps performed at time of examWell-tolerated with sedationEasier bowel preparation, usually done without sedationConsExpensiveRisk of perforation, bleeding low but not negligibleRequires high level of training to performMiss rate of polyps < 1 cm ~25%, > 1 cm ~5%Rex et al. Gastroenterology 1997; 112:24-8Postic et al. Am J Gastroenterol 2002; 97:3182-5
37 Chemopreventive agents FiberNot effectiveAspirinMay be effectiveNSAIDs (ibuprofen, etc)Probably effectiveVitamin E, vitamin C, beta caroteneFolateEffective if obtained in dietCalciumEffectiveEstrogenEffective, but has other problems
38 Future techniques for colorectal cancer screening Stool DNA testingCapsule endoscopy (Givens capsule)CT colography (virtual colonoscopy)
40 Fecal Testing for Gene Mutations ProsNo sedation or preparation necessaryHome-based (sample mailed to physician)No riskConsCurrent tests not very good (~50% of cancers missed)CostFrequency of exam unknownNot therapeuticNot covered by insurance
46 CT Colography Pros No sedation necessary 20 min procedure vs. 25 min for colonoscopyLow riskExtracolonic lesions may be detectedConsPreparation (residual fluid cannot be aspirated)Air insufflationCost (? need for more frequent exams)Radiation dose (similar to barium enema)Not therapeuticNot covered by insurance
47 SummaryColorectal cancer is the third most common cancer and cause of cancer death in the U.S.Chemopreventive agents have modest benefit in average risk individualsScreening for colorectal cancer saves lives!Patient and physician compliance with screening is poor