Transcript Bowel cancer - Back to Medical School

Bowel cancer:
- early symptoms
- screening
- treatment update
Ian Botterill
Dept 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
Equates to ~ 1 new case of bowel cancer / GP / annum
Latest CRUK figures
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
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FHx of CRC
HNPCC
FAP
UC & Crohns
15-20%
3-8%
1%
1%
Mortality of bowel cancer
Effect of subspecialist surgery / adjuvant therapy / liver surgery for mets
5 yr survival by stage at
presentation
• ~ 40% localised disease
• ~ 40% regional nodes
‘A’
‘B’
‘C’
90%
65%
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
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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
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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
DOH ‘pragmatic referral pathway’
Thompson et al, BMJ, DOH referral guidelines
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
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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
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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
• 1st degree relative <45 yrs
• 1st degree & 2nd degree relative
1:20
1:10
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’
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
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 op
eg 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
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N1
N2
<3 nodes
3+ nodes
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V1
vascular involvement
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R0
R1
R2
no margin involvement
microscopic margin involvement
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
to radiotherapy or surgery
• 5-20% post rectal resection
• Psycholgical / neurogenic / vasculogenic
• Rx: - nerve sparing surgery
- avoidance radiotherapy if feasible
- Viagra
- 2y
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
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Dutch trial - Local recurrence
Patients with R 0 (n=1789)
,20
TME alone
Local recurrence (%)
,15
5.8% vs 11.4%
p < 0.001
,10
,05
RT + TME
0,00
0
2
4
Years since surgery
6
8
Overall Survival
eligible patients (n=1809)
1,0
TME alone
,9
,8
64.2% vs 63.4%
p = 0.87
,7
,6
,5
RT + TME
,4
Cum Survival
,3
,2
,1
0,0
0
2
4
Years since surgery
6
8
Dutch trial - Local recurrence rate
Level from the anal verge
0 - 5 cm
6 - 10 cm *
,15
,15
,10
,05
,20
10.5% vs 11.9%
p = 0.53
,15
Local recurrence (%)
,20
Local recurrence (%)
,20
,10
,10
,05
0,00
0
2
4
Years since surgery
6
8
11 - 15 cm
,05
0,00
0,00
0
2
4
Years since surgery
6
8
0
2
4
Years since surgery
6
8
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