Colorectal Cancer. Mark Chapman. MA MS FRCS EBSQ(coloproct) 21 st March 2018 Consultant Coloproctologist

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1 Colorectal Cancer Mark Chapman MA MS FRCS EBSQ(coloproct) 21 st March 2018 Consultant Coloproctologist

2 Overview Epidemiology of colorectal cancer Adenoma carcinoma sequence Tumour diagnosis & staging Treatment of early colorectal cancer Treatment of late colorectal cancer Role of chemo & radiotherapy Risk reduction strategies Screening / Public awareness

3 Epidemiology of bowel cancer Second commonest cause of cancer death 19,000 per year Life time risk 1 in 30 50% 5 year survival

4 Epidemiology of bowel cancer Risk Factors Colitis 1% FAP 1% HNPCC 2% Family history 15-20% Western disease Rapidly transmitted to immigrant population

5 Polyp Cancer

6 Dukes staging A C B

7 Dukes stage 5 year survival

8 Clinical features Rectal bleeding Change in bowel habit Abdominal pain Abdominal mass Rectal mass Anaemia

9 Diagnosis and staging Colonoscopy CT Virtual Contrast studies CEA Biopsy PET

10 Treatment of early colo-rectal cancer

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12 Endoscopic snaring of lesions

13 Trans anal endoscopic microsurgery TEMS

14 Trans anal endoscopic microsurgery

15 Treatment of late colo-rectal cancer

16 Colon resections Right hemicolectomy Left hemicolectomy/sigmoid colectomy

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19 Rectal cancer

20 Use of staple guns to facilitate low anastomoses

21 Total Mesorectal Excision

22 Chemotherapy Potentially cured patients ADJUVANT Stage C 5-10% survival advantage Stage B 3% Advanced disease PALLIATIVE 3 months 18 months added life

23 How can we do better? Prevent polyps developing Lifestyle Dietary Pharmacologically Remove polyps before malignant transformation Pharmacologically Surgery Detect cancers at Stage A or B 2 week waits Patient awareness of symptoms Screening

24 Dietary prevention of colorectal cancer Evidence Decreases No relationship Increases risk risk Convincing Physical activity Vegetables Probable Aspirin Red meat Alcohol Possible Fibre Starch Carotenoids Calcium Selenium Fish Obesity Tall Sugar Processed meat Insufficient Resistant starch Vitamins C D E Cereals Coffee Folate Heavily cooked meat Iron

25 Diagnosis of polyps & early malignancy Awareness of symptoms Risk reduction programmes Target high risk groups Population based

26 High risk groups FAP, Colitis Family history Population risk 1 in 35 one 1st degree relative 1 in 12 one 1st + one 2nd degree relative 1 in 11 one 1st degree relative < 45 yrs 1 in 10 two 1st degree relatives 1 in 6 three 3 1st degree relatives 1 in 2

27 FOBT Risk reduction screening Flexi sigmoidoscopy+/- FOBT Colonoscopy CTVC programmes

28 FOBT screening Nottingham screening study people FOBT 15% reduction in CRC mortality in those offered screening 39% reduction in CRC mortality in those accepting screening

29 NBCSP yrs 2 yearly screening Up to 74 FOBT 98% normal Colonoscopy 40% polyp 10% cancer

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31 Flexible sigmoidoscopy screening Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial Incidence of distal colorectal cancer (rectum and sigmoid colon) was reduced by 50% (0 50, ; secondary outcome). The numbers needed to be screened to prevent one colorectal cancer diagnosis or death, by the end of the study period, were 191 (95% CI ) and 489 ( ), respectively

32 How to avoid bowel cancer! Pick your parents Don t get colitis Exercise Eat a high vegetable/fibre diet Screen your bowel for polyps