Bowel cancer: - early symptoms - screening - treatment update

1
Bowel cancer- early symptoms - screening -
treatment update

• Ian Botterill
• Dept Colorectal Surgery, The General Infirmary
• Leeds

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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

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Demographics the problem
Equates to 1 new case of bowel cancer / GP /
annum
Latest CRUK figures
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Demographics

• 3rd commonest cancer in EU
• Lifetime risk 2-4
• Leeds Colorectal MDT - 580 cases
  2005 - 630 cases 2007

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Incidence

• MgtF
• 90 of cases gt 50yrs age
• More common decade on decade post age 50yrs
• Male incidence on increase
• Median survival 40-50

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Effect of age
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Distribution of bowel cancer
proximal migration
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Colorectal cancer

• 75 sporadic ie average risk
• 15-20 FHx of CRC
• 3-8 HNPCC
• 1 FAP
• 1 UC Crohns

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Mortality of bowel cancer
Effect of subspecialist surgery / adjuvant
therapy / liver surgery for mets
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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

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Cancer surgery- 30 day mortality
Age lt80yrs gt80yrs Elective R
colon 1-2 5 Elective ant resection 1-5 10-
20 Obstructed L colon 5 20 Perforated
colon 10 40
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DOH initiatives to improve outcomes

• Raised awareness
• Targeted urgent referral criteria - 2WW
  process
• Bowel cancer screening

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Symptom assessment
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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

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6 key 2WW referral criteria

• R sided abdo mass
• Rectal mass
• gt6/52 of ABH
• Rectal bleeding in absence of anal symptoms
• Anaemia lt10 F / lt 11.5 M
• Colicky abdo pain
• Low risk symptoms - hard infreq stool -
  BRRB perianal symptoms - abdo pain but no
  colic

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Identikit of typical patient with bowel cancer

• Age gt 60yrs with rectal bleeding looser stool

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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

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DOH pragmatic referral pathway
Thompson et al, BMJ, DOH referral guidelines
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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

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Screening
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Principles of screening

• Important / relevant disease
• Definable sequence allowing intervention
• Test - cheap / QUALY beneficial
• - acceptable ? uptake gt70
• - sensitive specific
• - low risk
• - reproducible

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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

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Methods of screening

• Faecal occult blood
• Flexible sigmoidoscopy
• Ba enema
• CT pneumocolon
• Colonoscopy

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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

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FOBT

• 38-60 uptake in previous trials
• unpleasant / messy
• severe dietary restrictions
• avoidance of NSAIDs

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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

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Colonoscopy

• detects 90 of colonic pathology
• cost 150-400
• perforation rate 11500
• bleeding rate 11500
• highly skilled workforce required
• compliance poor if used as stand alone test

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UK bowel cancer screening pilot study

• Coventry
• 480,000 invited gt 57 completed FOBT
• 2 of FOBT positive ? colonoscopy
• 550 cancers detected
• 367 early cancers (Dukes A)
• 4X ? in early cancers

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UK bowel cancer screening- www.cancerscreening.nh
s.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

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Colonoscopy quality control

• gt90 caecal intubation rate
• Consultant / approved non-consultant
• Audited morbidity
• - perforation 0.2 - death 0.01

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Polypectomy

• Hot biopsy
• Snare polypectomy
• Endoscopic mucosal resection

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Endoscopic mucosal resection
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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

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Surveillance for bowel cancer
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Bowel cancer surveillance

• High risk FHx
• Colitis
• Previous high risk adenomas
• Previous bowel cancers
• Miscellaneous conditions

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Positive family history

• Lifetime risk of bowel cancer 150
• Key relevant factors - age lt45 yrs -
  1st degree relative
• 1st degree relative risk 120
• 1st degree relative lt45 yrs 110
• 1st degree 2nd degree relative 115

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colitis

• Risk of bowel cancer ? in UC Crohns colitis
• Similar increased risk for UC CD
• Overall ? risk 6 fold cf normal population
• Risk _at_ 20yrs 10
• Risk _at_ 30yrs 20
• Presence of PSC doubles risk

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Previous sporadic colonic polyps

• gt3 adenomas of lt1cm size
• 1 or more adenomas of gt1cm - repeat
  colonoscopy _at_ 12/12 - once colon clean ? 5yr
  repeat scope
• No routine F/U beyond age 75 yrs if low risk /
  average risk

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Whats new in bowel cancer treatment ?
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• 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

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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 (lt5)

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Enhanced recovery after surgeryERAS
Goal better analgesia / earlier diet / earlier
mobility / less ileus

• 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

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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 lt 10

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Laparoscopic surgery

• Smaller incisions
• Oncological equivalence
• ? LOS
• Technically more challenging
• Pt requests

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Laparoscopic surgery

• Suitable for majority of bowel cancer surgery
• Relative contraindications - morbid
  obesity - previous abdominal surgery
  (adhesions) - bulky tumours - multi-visceral
  resections

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More extensive surgery

• Multi-visceral resections for anticipated
  cure - pelvic clearance - small
  bowel - stomach duodenum - spleen

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Liver resection

• Requirements - resectable 1y tumour - 3
  healthy intact liver segments - no peritoneal
  mets - resectable extra-hepatic mets

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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 op eg R
  hemicolectomy R hemihepatectomy
• Else staged resection

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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

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TNM classification

• N1 lt3 nodes
• N2 3 nodes
• V1 vascular involvement
• R0 no margin involvement
• R1 microscopic margin involvement
• R2 residual disease _at_ surgery

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Enhancing function after rectal resection

• Loss of rectum gt 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

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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

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Colonic rectal stenting

• Palliation in malignant obstruction
• Bridge to elective resection
• Placement - screening endoscopy -
  45 minutes - success 80 - Cx
  failure, perforation, displacement

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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

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Dutch trial - Local recurrence Patients with
R 0 (n1789)
TME alone
5.8 vs 11.4 p lt 0.001
RT TME
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Overall Survival eligible patients (n1809)
TME alone
64.2 vs 63.4 p 0.87
RT TME
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Dutch trial - Local recurrence rate Level
from the anal verge
0 - 5 cm 6 - 10 cm 11 - 15 cm
10.5 vs 11.9 p 0.53
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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