Transcript Colorectal Cancer

Colorectal Cancer: An Overview
S. Maitra
Colorectal Cancer
Colon
2/3rd
Equal in both sexes
Rectum
1/3rd
More common in men
Lung
Colorectal
Prostate
Men
Breast
Women
Incidence & Mortality, Colorectal Cancer, England*
Site
ICD
10
No regd
1999
M
W
Crude Inc
Rate/
Deaths
2000
Mortality/
100,000
100,000
M
W
M
W
M
W
Colon
C18
8822 9013 35.9 35.8 4814 4740 19.5 18
Rectal
C19
& 20
6009 3970 24.5 16.8 2605 1895 10.5 7.5
Anus
C21
255
382
*office of national statistics
1.0
1.5
78
104
0.3
0.4
And the problem is increasing….
•Ageing of the population
< 45- very low risk
45 –55- 25/100,000
•Lifestyle Factors
More meat ,
less vegetable
Obesity
Smoking
> 75-
300/100,000
Risk of Colon Cancer by Family H/O
60
Relative
Risk
50
45
55
65
75
40
30
20
65
10
45
0
4
3
2
1
Family History Category:1= No family H/O; 2= One first degree relative > 45 at diagnosis
3= One first degree relative < 45 at diagnosis
4= Two first degree relatives
Other risk factors………
•Familial Adenomatous Polyposis(FAP)
•Hereditary Non polyposis Colorectal Cancer
(HNPCC)
•Inflammatory Bowel Disease
Clinical Presentation
Early
•PR Bleeding
•Persistent change in
bowel habits
•Anaemia
Usually progresses slowly
from polyps over 10 yrs
Late
•Weight loss
20% arrive through A/E
•Abdo pain
•Abdo mass
Diagnostic Methods
Flexible sigmoidoscopy
(can pick up 60% of
tumours)
Colonoscopy
Double contrast
barium enema
Rigid sigmoidoscopy
Newer Diagnostic Method
Some evidence better than
Barium enema
Almost as accurate as
Colonoscopy for larger
Polyps(>10mm) only
Potential complications
(including perforation)
similar to other procedures
Alternative to Barium enema
Useful in frail & elderly as
initial screening
Diagnostic Issues: Who to be tested?
To pick up cancer /polyp at early stage.
What is the Benefit : Risk Ratio?
1. Symptomatic patients
2. High Risk group (Surveillance)
3. General Population Screening
1. Symptomatic Patients
(Urgent Referral Criteria)**
Sign,Symptom or Combination
Age threshold
Rectal bleeding with new diarrhoea for 6 weeks
Any age
Definite palpable right abdo mass
Any age
Definite palpable rectal( not pelvic) mass
Any age
Rectal bleeding WITHOUT anal symptoms
> 60 yrs*
New diarrhoea WITHOUT rectal bleed for 6
weeks
> 60 yr*
IDA# ( Hb < 11 in men and < 10 in
postmenopausal women) without obvious cause
No age criterion
*Maximum threshold. Local Network may elect lower values
#IDA= Iron Deficiency Anaemia
** Department of health
Which Test for Whom?
1.Rectal bleeding/
:Change in bowel habit
(ie left sided symptoms)
Flexi sigi
(chance of missing
cancer is 0.2%)
2.Right abdo pain
IDA
:-
Colonoscopy
if unsuccessful or
frail/elderly
Barium enema/
CT Colonography
3.Palpable abdo mass
:-
CT scan or
CT Colonography
2. Surveillance*
Disease Group
Procedure
First Screening Repeat
1-2 ; both< 1cm
Colonoscopy
None or at 5 yrs Stop after one
negative
3-4; or at least 1>
1cm
Colonoscopy
Three years
3 yearly till two
Negative
>4 or > 2 with 1 at
least >1 cm
Colonoscopy
One year
Annually till
out of this grp
IBD
Colonoscopy &
Bx every 10cm
8yrs-pancolitis 2nd dec- 3yrly
15yrs- left sided 3rd dec- 2yrly
>3rd - annually
FAP
Genetic test +
OGD + Flexi
Puberty
Annually
2 FDR or
1 FDR < 45 yrs
Colonoscopy
1st visit or
35- 40 yrs
If initial
Colonoscopy
clear then at 55
Colon Adenoma
* BSG Guidelines
3. Population Screening:
NHS Colorectal Cancer Screening Programme
Due to start from April 2006
35 million £
8 training centers
650 new endoscopists
FOBTsin men & women > 60 years
if positive Colonoscopy
Flexible Sigmoidoscopy as a pilot study in men > 50
FOBT (Faecal Occult Blood Test)
Reduces Mortality ( 3 American & 2 European RCTs)
Pre test dietary restriction for 3 days
(Avoid red meat, horseradish, Vitamin C)
High fibre diet advised
Six guiac strips to be smeared two each 3 consecutive stool
Any amount of blue in any one strip is positive
( Guainoic acid
Guanicum blue
Haemoglobin
Treatment
Dukes’
Stage
Definition
Frequency*
5year
Survival*
A
Cancer localized within
bowel wall
11%
83%
B
Cancer penetrating bowel
wall
35%
64%
C
Cancer in lymph nodes
26%
38%
D
Distant metastases
29%
3%
Duke A, BDuke CDuke D-
Curative surgery attempted
Surgery + Adjuvant Chemo
Surgery + liver resection (in 8%)
or
Palliative chemo/radiotherapy or stent
*St Vincent Hospital Dublin
Survival
Country
Relative survival (%) 1 year after diagnosis*
Colon
M
Rectum
W
M
W
England
64.9
64.2
70.5
71.8
Scotland
65.7
65.7
71.3
71.3
Wales
53.5
52.5
64.5
63.9
Europe
69.2
69.8
73.7
75.2
*1990- 1994 data from International agency for research
on Cancer
Welcome to the Colossal Colon Online Tour. In an
effort to educate the public on colorectal cancer
prevention, early detection and treatment, the
Colossal Colon Tour will visit 20 cities in the U.S. from
February 2003 to November 2003. The main
attraction of the Tour is the Colossal Colon, along with
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