Bowel CancerAlex Hill

Why screen for bowel cancer?Bowel cancer causes 16000 deaths per yrIt may be detected at asymptomatic stage by simple, safe and validated screening test generally acceptable to populationEarly treatment leads to better outcomes

Bowel Cancer Screening

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

From 1 minute http://www.cancerscreening.nhs.uk/bowel/

publications/video/bowel-screening-kit-cartoon.html

Bowel Cancer Screening

Possible Results:Clearly normal – no sample positive FOBCleary abnormal – 5-6 samples positiveUnclear – 1-4 samples positive

Up to 2 further tests required Screening considered abnormal if 2

subsequent tests unclear or abnormal

Bowel Cancer Screening

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

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

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

>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

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

Always do digital rectal examination Consider FBC in patients with equivocal

symptoms to assess urgency of further investigation or referral

Urgent referrals

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

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

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

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

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

www.cancerscreening.nhs.uk www.cks.nhs.uk Referral guidelines for suspected cancer:

lower gastrointestinal cancer [NICE, 2005]. http://www.nhs.uk/Conditions/Cancer-of-the-

colon-rectum-or-bowel/Pages/treatment.aspx

References