7/21/2016

Colorectal Cancer Referrals

Mr Henry Tilney MD FRCS

Consultant Colorectal Surgeon/Lead Clinician For Colorectal Cancer
BSCP Colonoscopist
Frimley Park Hospital NHS Foundation Trust

Bowel Cancer

Bowel cancer is the second most common

cancer in women (after breast)
Third most common in men (after prostate
and lung).

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In 2009, 41,142 people in the UK were

diagnosed with bowel cancer.

In 2010 there were 16,013 deaths from bowel

cancer in the UK.
In 2005-2009, 54% of men and 56% of women
in England survived their bowel cancer for five
years or more.

Risk Factors?

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High Risk Families

Lifetime risk
death (no
surveillance)

Age of 1st
Colonoscopy

Interval

1/6-10

50

5 yearly

CRC in 2 FDR
degree
kinship) mean age <60

1/6-10

50

5 yearly

CRC in 2 FDR >60

1/12

55

One off

CRC in 1 FDR <50

1/12

55

One off

History

CRC in 3 FDR (1st degree

kinship) none <50
(1st

Gut 2010;59:666-690

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UK CRC 5 yr Survival by Stage

Dukes A

(Stage I)

93.2%

Dukes B

(Stage II)

77.0%

Dukes C

(Stage III)

47.7%

Dukes D

(Stage IV)

6.6%

So.
Early diagnosis makes a difference..
BUT

Adenoma-Carcinoma Sequence

Peak onset adenomas 7 years before cancer

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FOBT-Based BCSP

Process:
60-74 yrs
Biennial FOBT
Positive FOBT invited for colonoscopy
High Quality Colonoscopy

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UK Colorectal Cancers

Screening Detected Cancers

Number Needed to Prevent 1 CRC

Death
1,282 FOBT invitations
769 return test
15 colonoscopies
Assuming 20% of High Risk Polyps WOULD
have become cancers then numbers needed
to PREVENT a cancer are the same

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Effect of Screening.
Regardless of compliance, every 4 screening
colonoscopy lists will prevent:
1 Colorectal cancer death
1 person developing colorectal cancer

Important Points
Fewer patients present with advanced disease
15-16% Mortality reduction
Up to 20% reduction in CRC incidence
Costs?
1.50/head population/year for screening
0.20/head population/year for surgery

Sensitivity FOBT 55-92.2%

False Negative rate colonoscopy 1%

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Flexi-Sig Screening

UK Flexi-Sig Trial
11 years follow-up
Cumulative incidence (including prevalent)
cancer reduced by:
50% for distal cancers (rectum/sigmoid)
33% for colorectal cancer overall

Colorectal cancer mortality reduced by 43%

Flexi Sig Screening Nationally

55 yrs one-off flexi
10 scope lists per week at FPH

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Tailored Cancer Care

2 Week Rule

NICE 2015

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CEA?
Follow-up Tool
Not useful in diagnosis
Dont waste the money..

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Referrals
Straight to test?
Which test?
Fit for investigation? Fit for treatment?

Cancer exclusion service?

Clinical problem vs ?cancer

Rationalisation of TWR?
Strict adherence to criteria
Direct contact for concerning patients not fitting
box

?CRC

CEA
Family History
Dont be falsely reassured by FOBT
U&E Please! (Frimley Lab or copy results)
Anaemia: MCV/Ferritin

Patients informed that they are on an cancer

pathway

Questions?
Contacts:
Secretary: Jane
01276 604236

henry.tilney@fhft.nhs.uk
Mobile
07958697273

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CEA levels may also be raised in..

gastric carcinoma,
pancreatic carcinoma,
lung carcinoma
breast carcinoma
medullary thyroid
carcinoma

ulcerative colitis
pancreatitis,
cirrhosis,
COPD
Crohn's disease
Hypothyroidism
smokers

Foods which may falsely elevate

FOBT
Red Meat
Cantaloupe and other
melon
Grapefruit
Figs
Broccoli
Turnips
Radishes
Horseradish

Cauliflower
Cucumber
Carrot
Cabbage
Potato
Pumpkin
Zucchini
Parsley

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FIT vs gFOBT

Does Screening Prevent Cancer?

NEJM 2000; 343:1603-07
18 year CRC Incidence:
Control group: 507
Biennial screening group: 435
Odds ratio: 0.83 (CI 0.73-0.94)

Population Outcomes
Per million population with 60% Uptake
600 Colonoscopies/year
65 Cancers
200 high risk polyps
39 lives per year saved

1 million population generates 500

cancers/year. Assume 50% mortality and 16%
reduction in cancer mortality associated with
screening

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