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Colorectal Cancer: An Overview

S. Maitra

Colorectal Cancer

Colon Rectum2/3rd 1/3rd Equal in both sexes More common in men

Lung Colorectal

Prostate Breast

Men Women

Crude Inc Crude Inc Rate/Rate/100,000100,000

DeathsDeaths20002000

Mortality/Mortality/100,000100,000

MM WW MM WW MM WW MM WW

ColonColon C18C18 88228822 90139013 35.935.9 35.835.8 48144814 47404740 19.519.5 1818

RectalRectal C19 C19 & 20& 20

60096009 39703970 24.524.5 16.816.8 26052605 18951895 10.510.5 7.57.5

AnusAnus C21C21 255255 382382 1.01.0 1.51.5 7878 104104 0.30.3 0.40.4

Site ICD No regd 10 1999

Incidence & Mortality, Colorectal Cancer, England*

*office of national statistics

And the problem is increasing….

•Ageing of the population

•Lifestyle Factors

< 45- very low risk

45 –55- 25/100,000

> 75- 300/100,000More meat ,less vegetable

Obesity

Smoking

Risk of Colon Cancer by Family H/O

0

10

20

30

40

50

60

4 3 2 145

65

45556575

Family History Category:-1= No family H/O; 2= One first degree relative > 45 at diagnosis3= One first degree relative < 45 at diagnosis4= Two first degree relatives

Rel

ativ

e

Ris

k

Other risk factors………

•Familial Adenomatous Polyposis(FAP)

•Hereditary Non polyposis Colorectal Cancer (HNPCC)

•Inflammatory Bowel Disease

Clinical PresentationEarly

Late

Usually progresses slowlyfrom polyps over 10 yrs

20% arrive through A/E

•PR Bleeding

•Persistent change in bowel habits

•Anaemia

•Weight loss

•Abdo pain

•Abdo mass

Diagnostic Methods

Rigid sigmoidoscopy

Flexible sigmoidoscopy(can pick up 60% of tumours)

ColonoscopyDouble contrast barium enema

Newer Diagnostic Method

Some evidence better thanBarium enema

Almost as accurate as Colonoscopy for largerPolyps(>10mm) only

Potential complications (including perforation)similar to other procedures

Alternative to Barium enemaUseful 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 CombinationSign,Symptom or Combination Age thresholdAge threshold

Rectal bleeding with new diarrhoea for 6 weeksRectal bleeding with new diarrhoea for 6 weeks Any ageAny age

Definite palpable right abdo massDefinite palpable right abdo mass Any ageAny age

Definite palpable rectal( not pelvic) massDefinite palpable rectal( not pelvic) mass Any ageAny age

Rectal bleeding WITHOUT anal symptomsRectal bleeding WITHOUT anal symptoms > 60 yrs*> 60 yrs*

New diarrhoea WITHOUT rectal bleed for 6 New diarrhoea WITHOUT rectal bleed for 6 weeksweeks

> 60 yr*> 60 yr*

IDA# ( Hb < 11 in men and < 10 in IDA# ( Hb < 11 in men and < 10 in postmenopausal women) without obvious causepostmenopausal women) without obvious cause

No age criterionNo age criterion

*Maximum threshold. Local Network may elect lower values#IDA= Iron Deficiency Anaemia ** Department of health

1.Rectal bleeding/ :- Flexi sigi Change in bowel habit (chance of missing (ie left sided symptoms) cancer is 0.2%)

2.Right abdo pain :- Colonoscopy IDA if unsuccessful or frail/elderly Barium enema/ CT Colonography

3.Palpable abdo mass :- CT scan or CT Colonography

Which Test for Whom?

2. Surveillance*Disease GroupDisease Group ProcedureProcedure First ScreeningFirst Screening RepeatRepeatColon AdenomaColon Adenoma

1-2 ; both< 1cm1-2 ; both< 1cm ColonoscopyColonoscopy None or at 5 yrsNone or at 5 yrs Stop after one Stop after one negativenegative

3-4; or at least 1> 3-4; or at least 1> 1cm1cm

ColonoscopyColonoscopy Three yearsThree years 3 yearly till two3 yearly till twoNegativeNegative

>4 or > 2 with 1 at >4 or > 2 with 1 at least >1 cmleast >1 cm

ColonoscopyColonoscopy One yearOne year Annually till Annually till out of this grpout of this grp

IBDIBD Colonoscopy &Colonoscopy &Bx every 10cmBx every 10cm

8yrs-pancolitis8yrs-pancolitis15yrs- left sided15yrs- left sided

22ndnd dec- 3yrly dec- 3yrly33rdrd dec- 2yrly dec- 2yrly>3>3rdrd - annually - annually

FAPFAP Genetic test + Genetic test + OGD + FlexiOGD + Flexi

PubertyPuberty AnnuallyAnnually

2 FDR or2 FDR or1 FDR < 45 yrs1 FDR < 45 yrs

ColonoscopyColonoscopy 11stst visit or visit or 35- 40 yrs 35- 40 yrs

If initial If initial Colonoscopy Colonoscopy clear then at 55 clear then at 55

* BSG Guidelines

3. Population Screening:

NHS Colorectal Cancer Screening Programme

Due to start from April 2006

FOBTs- in men & women > 60 years if positive Colonoscopy

Flexible Sigmoidoscopy as a pilot study in men > 50

35 million £8 training centers650 new endoscopists

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

TreatmentDukes’Dukes’StageStage

DefinitionDefinition Frequency*Frequency* 5year5year Survival*Survival*

A A Cancer localized withinCancer localized withinbowel wallbowel wall

11%11% 83%83%

BB Cancer penetrating bowelCancer penetrating bowelwallwall

35%35% 64%64%

CC Cancer in lymph nodesCancer in lymph nodes 26%26% 38%38%

DD Distant metastasesDistant metastases 29%29% 3%3%

Duke A, B- Curative surgery attemptedDuke C- Surgery + Adjuvant ChemoDuke D- Surgery + liver resection (in 8%) or Palliative chemo/radiotherapy or stent*St Vincent Hospital Dublin

Survival

EnglandEngland 64.964.9 64.264.2 70.570.5 71.871.8

ScotlandScotland 65.765.7 65.765.7 71.371.3 71.371.3

WalesWales 53.553.5 52.552.5 64.564.5 63.963.9

EuropeEurope 69.269.2 69.869.8 73.773.7 75.275.2

Country Relative survival (%) 1 year after diagnosis*

Colon Rectum

M W M W

*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 nine interactive educational stations. Missed the Tour when it came through your city? Did the Tour not visit your hometown? Had so much fun at the Tour that you want to see it again? Click on the entrance below to visit our ten stations -- from prevention to treatment!

                                                                                                

                                                                                                  

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