NICaN workshop: Colorectal Cancer Follow-up

NICaN workshop: Colorectal Cancer Follow-up The Changing Picture of Colorectal Cancer in Northern Ireland Dr Helen Coleman Lecturer in Cancer Epidemiology & CRUK Population Research Postdoctoral Fellow Centre for Public Health /NICR Queen s University Belfast h.coleman@qub.ac.uk

Colorectal cancer in Northern Ireland: overview - Trends in colorectal cancer incidence - Risk factors for colorectal cancer - Colorectal cancer survival - Impact of bowel cancer screening - On colorectal polyp diagnoses - On colorectal cancer staging

Colorectal cancer incidence, males

Colorectal cancer incidence, females

Northern Ireland Colorectal cancer incidence summary Age-standardised rates are relatively stable However, the actual number of colorectal cancer cases is rising due to ageing population 2011: 1,224 cases 2006:1,064 cases 2001: 967 cases 2 nd most common cancer in NI, 3 rd most common cancer in UK

Breast Colorectal Prostate Melanoma Lymphoma Lung Head and Neck Uterus Bladder Ovary Kidney Leukaemia Stomach Cervix Testis Multiple Oesophagus Brain Pancreas Liver Cancer Prevalence 4500 4000 3500 Prevalence of cancer in Northern Ireland: Diagnosed in 2000-2004, alive at the end of 2004 Female Male 3000 2500 2000 4186 1291 1500 1000 2544 500 0 26 1444 601 489 358 188 150 377 470 490 475 609 453 510 199 167 115 114 78 91 280 225 204 296 289 38 20 152 119 96 36 33 Cancer site

Colorectal cancer risk factors What we can t change: - Increasing age (median age of diagnosis 71 yrs in men; 73 years in women) - Being male - Genetic syndromes (<5%) What we can be change: - Lifestyle factors (up to 70%!!)

Colorectal cancer risk factors Less of this: More of this:

Limited improvements in survival rates over time in Northern Ireland Sex Time period Number of patients One-year survival Five-year survival % 95%CI % 95%CI Male 1993-1996 1,873 71.9 69.7 74.1 47.7 44.7 50.5 1997-2001 2,287 75.1 73.2 76.9 51.9 49.3 54.4 2002-2006 2,599 75.9 74.1 77.6 51.9 49.4 54.2 2007-2011* 80.6 79.1 82.0 56.5 54.2 58.7 Female 1993-1996 1,759 72.4 70.1 74.6 47.4 44.6 50.2 1997-2001 2,137 77.2 75.3 79.0 55.9 53.4 58.4 2002-2006 2,171 74.0 71.9 75.8 53.3 50.7 55.8 2007-2011* 78.0 76.2 79.6 58.3 55.8 60.7 Persons 1993-1996 3,632 72.0 70.4 73.5 47.2 45.2 49.2 1997-2001 4,424 76.2 74.9 77.5 53.9 52.1 55.7 2002-2006 4,769 75.0 73.6 76.2 52.4 50.7 54.1 2007-2011* 79.5 78.3 80.6 57.3 55.6 58.9

International Cancer Benchmarking Partnership www.icbp.org.uk

ICBP data and methods Colorectum, lung, breast (F), ovary 2.4 million cancer patients (aged 15-99) Diagnosed 1995-2007 Followed up to 31 December 2007 All primary, invasive cancers Relative survival Age-specific, age-standardised rates

ICBP Module 1 - summary Survival rose for all 4 cancers, all countries High in Australia, Canada, Sweden Intermediate in Norway Low in Denmark, UK Data quality and artefact unlikely Direct relevance to health policy after Richards, 2009

What could explain survival differences? Longer delays, more advanced disease Differences in co-morbidity Availability and uptake of screening Access to treatment Quality of treatment Organisation of treatment services Human and financial resources after Richards, 2009

Relative survival (%) Relative survival from colorectal cancer by stage: 1997-2000 N. Ireland 100% 90% Dukes A 80% Dukes B 70% 60% 50% Dukes C 40% Unstaged 30% 20% 10% Dukes D 0% 00 01 02 03 04 05 Time since diagnosis (years)

- Introduced in June 2010 - Rolled out to all 5 health & social care trusts by 2012 - FOBT - AIM: to detect bowel cancers at an early stage, when there are better chances of effective treatment.

% colorectal cancer Earlier stage of diagnosis shift seen in first three screening trusts (60-71yrs) 35 30 25 20 15 10 5 0 2007-2009 2010-2012 Stage

% colorectal cancer Stage of diagnosis shift not yet evident in other trusts (60-71 yrs) 35 30 25 20 15 10 5 0 2007-2009 2010-2012 Stage

% colorectal cancer Marginal knock-on effect in non-screen ages throughout NI? 30 25 20 15 10 5 2007-2009 2010-2012 0 Stage

Colorectal polyps and future cancer risk (outside of screening programmes) - Most colorectal cancers arise from precancerous lesion (polyps) Adenoma (+) Hyperplastic (-?) - NICR also has a colorectal polyp register - >11,000 individuals had colorectal polyps removed 2000-05 - Adenoma: 0.43% per year progress to colorectal cancer - Hyperplastic polyps: 0.17% per year progress to colorectal cancer

Colorectal cancer incidence after polypectomy Population group Standardised Incidence Ratio (95%CI) General 100 Adenoma all 285 (261-325) Adenoma men 276 (247-325) Adenoma women 269 (230-333) Hyperplastic all 179 (134-214) Hyperplastic men 167 (126-234) Hyperplastic women 189 (134-278) 50 66 100 150 200 300

Impact of screening on colorectal polyp diagnoses Compared with polyp register, BCS-detected polyp patients are more likely to: - Be male (64% vs. 57%) - Have polyp detected in colon (82% vs. 76%) - Have multiple polyps removed (55% vs. 20-32%)

Changing picture of colorectal cancer in Northern Ireland 1. More cases are being diagnosed 2. Bowel cancer screening IS WORKING, has led to: - Earlier stage of diagnosis - More males being diagnosed earlier Future picture: - Challenge for follow-up of more cases - Hope that screening will translate to better survival - Promotion of screening uptake - Promotion of healthier lifestyle factors to reduce recurrence

Thank you for your attention E-mail: h.coleman@qub.ac.uk