1. Bowel Cancer Alex Hill

2. Why screen for bowel cancer?  Bowel cancer causes 16000 deaths per yr  It may be detected at asymptomatic stage by simple, safe and validated screening test generally acceptable to population  Early treatment leads to better outcomes Bowel Cancer Screening

3.  Who is screened?  Men and women in their 60s are sent a FOB testing kit every 2 yrs  People over 70 can request a kit  Two samples are collected from three separate bowels motions and returned within 14 days of first sample Bowel Cancer Screening

4.  From 1 minute  http://www.cancerscreening.nhs.uk/bowel/publicatio ns/video/bowel-screening-kit-cartoon.html Bowel Cancer Screening

6. Possible Results:  Clearly normal – no sample positive FOB  Cleary abnormal – 5-6 samples positive  Unclear – 1-4 samples positive  Up to 2 further tests required  Screening considered abnormal if 2 subsequent tests unclear or abnormal Bowel Cancer Screening

7.  Abnormal FOB result  10% bowel cancer  40% benign polyp  60% people with colorectal cancer will have abnormal FOB results  Proportion of people with negative FOB and bowel cancer (false negative) unknown Bowel Cancer Screening

8.  Offered colonoscopy or other imaging if not appropriate  Suspicious lesions biopsied  Benign polyps usually removed  Low risk polyps; return to screening  Medium risk polyps; colonoscopy every 3yrs until 2 examinations negative  High risk polyps; colonoscopy after 1yr then every 3 yrs until 2 examinations negative Bowel Cancer Screening

9.  Complications colonoscopy  Heavy bleeding 1/600  Bowel perforation 1/1200  Death 1/14,000  Inappropriate reassurance from negative result  Anxiety over false positive result Bowel Cancer Screening

10.  >40y/o rectal bleeding with change in bowel habit towards looser stools and/or increased stool frequency for >6wks  >60 y/o with either change in bowel habit as above >6wks OR rectal bleeding without anal symptoms Urgent Referrals

11.  RLQ mass consistent with involvement large bowel  Palpable rectal mass  Men; unexplained iron deficiency anaemia with Hb ≤ 11g/100ml  Non menstruating women; unexplained iron deficiency anaemia with Hb ≤10g/100ml Urgent Referrals

12.  Always do digital rectal examination  Consider FBC in patients with equivocal symptoms to assess urgency of further investigation or referral Urgent referrals

13.  High risk of developing colorectal cancer after 10 yrs with extensive colitis  Surveillance colonoscopy recommended for people who have had extensive colitis for 10 yrs  Frequency usually 1-5 yrs depending on severity of colitis, patient preference and additional risk factors eg family history Ulcerative Colitis

14.  Care of patients by MDT  Surgery  Stenting  Chemotherapy  Adjuvant, palliative or combined with radiotherapy in rectal cancers  Radiotherapy  Biological agents - Cetuximab only available on the NHS when:  bowel cancer has spread to the liver and cannot be surgically removed  surgery to remove the cancer in the colon or rectum has been carried out or is possible  a person is fit enough to undergo surgery to remove the cancer from the liver if this becomes possible after treatment with cetuximab Treatment options

15.  74 y/o man  Positive faecal occult blood test as part of bowel screening program Oct 2008  Colonoscopy showed ulcerated polpoid growth – confirmed adenocarcinoma sigmoid colon  Nov 2008 Anterior resection and ileostomy and adjuvant chemotherapy Case Presentation

16.  Nov 2009 – CT showed lung metastasis  Commenced on palliative chemotherapy completed March 2010 – significant side effects  Jan 2012 admitted with bowel obstruction secondary to strangulated incisional hernia  Problems with wound infection post op – required debridement and VAC therapy  Further exploration of wound April 2012 Case Presentation

17.  Progression of lung metastases and feeling tired  Further 3 cycles of chemotherapy – stopped early due to side effects  Currently feeling tired, weak  Very reluctant to discuss situation with GP or family – happier when having some treatment  Wife struggling emotionally Case Presentation

18.  www.cancerscreening.nhs.uk www.cancerscreening.nhs.uk  www.cks.nhs.uk www.cks.nhs.uk  Referral guidelines for suspected cancer: lower gastrointestinal cancer [NICE, 2005].NICE, 2005  http://www.nhs.uk/Conditions/Cancer-of-the-colon- rectum-or-bowel/Pages/treatment.aspx References