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Colorectal Cancer When to refer ? Dr Devinder Singh Bansi BM FRCP DM Consultant Gastroenterologist Imperial College London 29.09.2011.

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Presentation on theme: "Colorectal Cancer When to refer ? Dr Devinder Singh Bansi BM FRCP DM Consultant Gastroenterologist Imperial College London 29.09.2011."— Presentation transcript:

1 Colorectal Cancer When to refer ? Dr Devinder Singh Bansi BM FRCP DM Consultant Gastroenterologist Imperial College London

2 2003 Estimated US Cancer Cases* ONS=Other nervous system. *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, Men 675,300 Women 658, ,816Breast 79,056Lung/bronchus 72,468Colon & rectum 39,528Uterine corpus 26,352Ovary 26,352Non-Hodgkin lymphoma 19,764Melanoma of skin 19,764Thyroid 13,176Pancreas 13,176Urinary bladder 62,238All other sites Prostate 222,849 Lung/bronchus 94,542 Colon/rectum 74,283 Urinary bladder 40,518 Melanoma of 27,012 skin Non-Hodgkin 27,012 lymphoma Kidney20,259 Oral cavity 20,259 Leukemia 20,259 Pancreas13,506 All other sites114,801 Men 675,300 Women 658,800

3 2003 Estimated US Cancer Deaths* ONS=Other nervous system. *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, Men 285,900 Women 270,600 67,650Lung/bronchus 40,590Breast 29,766Colon & rectum 16,236Pancreas 13,530Ovary 10,824Non-Hodgkin lymphoma 10,824Leukemia 8,118Uterine corpus 5,412Brain/ONS 5,412Multiple myeloma 62,238All other sites Lung/bronchus 88,629 Prostate 28,590 Colon & rectum 28,590 Pancreas 14,295 Non-Hodgkin 11,436 lymphoma Leukemia11,436 Esophagus11,436 Liver/intrahepatic8,577 bile duct Urinary bladder8,577 Kidney8,577 All other sites62,898

4 Colorectal cancer Some 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 2 nd most common cause of death from malignant disease in UK

5 Bowel cancer -UK malesfemales New cases (2008)22,09717,894 Rate/100,00 pop yr survival (2001-6)50%51% (colon cancer) 5 yr survival )51%55% (rectal cancer)

6 Colon Polyp

7 Colon 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 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

10 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

11 Colorectal cancer: Distribution of disease Rectum 27% Rectosigmoid junction7% Sigmoid colon20% Descending Colon 3% Splenic flexure2% Transverse Colon5% Hepatic Flexure3% Ascending Colon7% Caecum 14% Appendix1% Other and unspecified9%

12 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 % report rectal bleeding as a principal symptom

13 Colorectal cancer: The significance of age Only 1% of all CRC occur in individuals <40 yrs 4% CRC occur in age range yrs Risk rises more rapidly >50 yrs BUT ‘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 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)

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-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 !

16 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 ) from Jan 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

17 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

18 Referrals made before and after the introduction of national cancer guidelines for CRC June 1997-June 2000June 2000-Sept 2002 n= 92n=65 Mean age Men51(55%)32 (49) Patients referred urgently38 (41)32 (49) Satisfied criteria for urgent Referral64/89 (72)48/64 (75) Satisfied criteria and had Urgent referral35/64 (55)27/48 (56) Did not satisfy criteria And had urgent referral2/25( 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 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 ?!

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 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

21 Survival by Dukes Stage

22 Symptoms of Colorectal Cancer Time CourseSymptomsFindings EarlyNone Occult blood in stool MidRectal bleeding Change in bowel habits Rectal mass Blood in stool LateFatigue Anemia Abdominal pain Weight loss Abdominal mass Bowel obstruction

23 Staging of Colorectal Cancer

24 Frequency of Colorectal Cancer by Dukes Stage

25 Treatment of Colorectal Cancer by Stage

26 Is Colorectal Cancer Preventable? YES! Screening Chemoprevention

27 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).

28 Screening For Colon Cancer SAVES LIVES!!! Mortality TestReduction 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)

29 Colorectal cancer screening First assess RISK AVERAGE RISK INDIVIDUAL All patients age 50 years and older, the asymptomatic general population HIGH RISK Personal history – polyp or cancer Family history – polyp or cancer in first degree relatives

30 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 But: 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

31 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

32 FOBT improves survival Years after diagnosis

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

35 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; 336:653Stewart et al Aust NZ J Surg 1999; 69:2 Newcomb et al. JNCI 1992; 84:1572Painter et al Endoscopy 1999; 3:269 Rex et al. Gastrointest Endosc 1999; 99:727

36 Colonoscopy 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 ~5% Rex et al. Gastroenterology 1997; 112:24-8 Postic et al. Am J Gastroenterol 2002; 97:3182-5

37 Chemopreventive agents FiberNot effective AspirinMay be effective NSAIDs (ibuprofen, etc)Probably effective Vitamin E, vitamin C, beta carotene Not effective FolateEffective if obtained in diet CalciumEffective EstrogenEffective, but has other problems

38 Future techniques for colorectal cancer screening Stool DNA testing Capsule endoscopy (Givens capsule) CT colography (virtual colonoscopy)

39 Fecal Testing for Gene Mutations

40 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

41 Videocapsule

42 Lymphoma

43 CT Colography Colon Polyp

44 CT Colography Colon Polyp

45 CT Colography Colon Cancer

46 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

47 Summary 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

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