Cancer treatments, clinical developments and future plans of the - - PowerPoint PPT Presentation

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Cancer treatments, clinical developments and future plans of the - - PowerPoint PPT Presentation

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Cancer treatments, clinical developments and future plans of the bowel cancer screening programme Mr Austin Obichere MD, FRCS, FRCS (Gen) Consultant Colorectal / Laparoscopic Surgeon JAG Accredited Colonoscopist Director Bowel Cancer Screening

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SLIDE 1

Cancer treatments, clinical developments and future plans of the bowel cancer screening programme

Mr Austin Obichere MD, FRCS, FRCS (Gen) Consultant Colorectal / Laparoscopic Surgeon JAG Accredited Colonoscopist Director Bowel Cancer Screening Programme UCLH

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SLIDE 2

U.K survival (45%), U.K survival (45%), but note ! but note ! France France -

  • 50%

50% Germany Germany -

  • 60%

60%

Bowel Cancer Bowel Cancer

Nearly 60% of symptomatic patients present with advanced disease

National U.K Figures

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SLIDE 3

Stage UCLH PILOT Data

Polyp Cancer (20) 17% 15% Dukes A (30) 26% 25% Dukes B (28) 24% 26% Dukes C (27) 23% 25% Dukes D (11) 10% 9%

Bowel Cancer Bowel Cancer

First 116 screen detected colorectal cancers at UCLH

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SLIDE 4

Bowel Cancer Bowel Cancer

Number UCLH 2007 UCLH 2008 UCLH 2009 UCLH 2010 Total Pilot

Colonoscopy

150 437 604 793

1984 (1.9%) 325 (2%)

Normal

66 (44%) 196 (45%) 335 (55%) 480 (60%)

1077 (53%) 162 (50%)

Polyps

72 (48%) 197 (45%) 243 (40%) 282 (36%)

794 (40%) 130 (40%)

Cancer

12 (8%) 44 (10%) 26 (4.7%) 31 (3.9%)

113 (5.1%) 33 (10%)

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SLIDE 5

Bowel Cancer Treatment Bowel Cancer Treatment

Early disease Early disease

Versus Versus

Advanced disease Advanced disease

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SLIDE 6

Bowel Cancer Treatment Bowel Cancer Treatment

Early Disease Early Disease

  • Open surgery

Open surgery

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SLIDE 7

Bowel Cancer Treatment Bowel Cancer Treatment

Early Disease Early Disease

  • Laparoscopic / Key

Laparoscopic / Key-

  • hole surgery (Concerns)

hole surgery (Concerns)

  • port

port-

  • site metastasis

site metastasis

  • prolonged operation

prolonged operation

  • lymph node harvest

lymph node harvest

cost study (USA) N Eng J Med May 2004 cost study (USA) N Eng J Med May 2004 clasicc clasicc trial (MRC) Lancet May 2005 trial (MRC) Lancet May 2005 color color trial ( trial (Eur Eur) Lancet ) Lancet Oncol Oncol July 2005 July 2005

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SLIDE 8

Bowel Cancer Treatment Bowel Cancer Treatment

Early Disease Early Disease

  • Laparoscopic / Key

Laparoscopic / Key-

  • hole surgery (benefits)

hole surgery (benefits)

  • cosmesis

cosmesis

  • rapid recovery (bowel/return to work)

rapid recovery (bowel/return to work)

  • less pain

less pain

  • decrease adhesions (SBO)

decrease adhesions (SBO)

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SLIDE 9

Bowel Cancer Treatment Bowel Cancer Treatment

Early Disease Early Disease

  • Laparoscopic anterior resection

Laparoscopic anterior resection

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SLIDE 10

Bowel Cancer Treatment Bowel Cancer Treatment

Early Disease Early Disease

  • Laparoscopic right

Laparoscopic right hemicolectomy hemicolectomy

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SLIDE 11

Case 1 Case 1

  • 69 year old male

69 year old male

  • Positive PFOBT

Positive PFOBT

  • Colonoscopy

Colonoscopy-

  • Sigmoid Cancer

Sigmoid Cancer

  • Laparoscopic left

Laparoscopic left hemicolectomy hemicolectomy

  • Histology 0/12 Nodes;

Histology 0/12 Nodes;

  • pT3 N0 M0 (Dukes B)

pT3 N0 M0 (Dukes B)

  • Routine Follow

Routine Follow-

  • up

up

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SLIDE 12

Bowel Cancer Treatment Bowel Cancer Treatment

Advanced disease Advanced disease

  • Chemotherapy

Chemotherapy

  • Combination chemotherapy

Combination chemotherapy (5FU / (5FU / oxaliplatin

  • xaliplatin /

/ Irinotecan Irinotecan /+/ /+/-

  • monoclonal antibodies)

monoclonal antibodies)

  • median survival = 24months!

median survival = 24months!

Tournigand Tournigand et al; J J Clin Clin Oncol Oncol 2004 2004

  • Challenges

Challenges

  • selective toxicity

selective toxicity ? ? -

  • benefit after curative surgery

benefit after curative surgery

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SLIDE 13

Bowel Cancer Treatment Bowel Cancer Treatment

Advanced disease Advanced disease

  • Radiotherapy

Radiotherapy

  • long / short course

long / short course

  • no benefit for colon cancer

no benefit for colon cancer

  • reduce local recurrence

reduce local recurrence Lancet MRC-CRO7 trial 2009

  • survival benefit

survival benefit

N Engl J Med May 1997

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SLIDE 14

Bowel Cancer Treatment Bowel Cancer Treatment

Advanced disease Advanced disease

  • Liver metastases (

Liver metastases (Resectable Resectable) )

  • delayed / synchronous

delayed / synchronous

  • < 4 metastasis

< 4 metastasis

  • confined to one lobe of liver

confined to one lobe of liver

  • major vessels not involved

major vessels not involved

  • no residual disease elsewhere

no residual disease elsewhere 40% 5yr survival 40% 5yr survival

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SLIDE 15

Bowel Cancer Treatment Bowel Cancer Treatment

Advanced disease Advanced disease

  • Liver metastases

Liver metastases – – (Non (Non-

  • Resectable

Resectable) )

  • radiofrequency ablation (RFA)

radiofrequency ablation (RFA)

  • RFA + resection

RFA + resection

  • Local disease control, ? Survival benefit

Local disease control, ? Survival benefit

  • Asymptomatic primary (controversial)

Asymptomatic primary (controversial)

  • Resection + Chemo

Resection + Chemo Vs

Vs Chemo +/

Chemo +/-

  • resection

resection

  • Survival benefit with resection

Survival benefit with resection

Bajwa et al; Eur J Surg Oncol 2009

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SLIDE 16

Bowel Cancer Treatment Bowel Cancer Treatment

Radionics, cooled tip RF electrodes

Advanced disease Advanced disease

RFA liver metastases RFA liver metastases

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SLIDE 17

Bowel Cancer Treatment Bowel Cancer Treatment

Advanced disease Advanced disease

RFA liver metastases RFA liver metastases

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SLIDE 18

Bowel Cancer Treatment Bowel Cancer Treatment

Advanced disease Advanced disease

  • Lung metastasis (surgical resection)

Lung metastasis (surgical resection)

  • 20

20-

  • 30% 5 year survival with resection

30% 5 year survival with resection

  • +/

+/-

  • RFA

RFA

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SLIDE 19

Bowel Bowel Cancer Treatment

Cancer Treatment

Advanced disease Advanced disease

  • Bone / brain metastasis

Bone / brain metastasis

  • disease incurable

disease incurable

  • irradiation / fixation of bone for pain

irradiation / fixation of bone for pain

  • irradiation / corticosteroids for brain

irradiation / corticosteroids for brain (reduce intra (reduce intra-

  • cerebral pressure)

cerebral pressure)

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SLIDE 20

Clinical developments in cancer treatment

  • Multidisciplinary team approach police and

execute evidence based best practice for each patient

Local Colorectal Cancer MDT Case Review Best Practise Early vs Advanced Treatment Options Discussed with Patient

? Patient Choice

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SLIDE 21

Clinical developments in cancer treatment

  • Combined multi-modality treatment
  • neoadjuvant therapy ( disease downstaging )
  • new surgical techniques +/- chemo-rad
  • Radiofrequency ablation +/- liver resection
  • Neo-adjuvant chemotherapy for colon cancer

(MRC –FoxTROT trial)

  • New surgical techniques for colon cancer

(total meso-colic excision)

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SLIDE 22

Colorectal cancer screening

Rationale

  • Natural history
  • Most cancers arise from benign adenomas

(adenoma-carcinoma sequence)

  • Adenomas removed / destroyed with

flexible sigmoidoscope / colonoscope

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SLIDE 23

Colorectal cancer screening

Types

  • Faecal occult blood testing *
  • Flexible sigmoidoscopy *
  • Double contrast barium enema
  • Colonoscopy – GOLD STANDARD!
  • Virtual colonoscopy ?

Future ?

  • Genetic markers in blood / stool

(Detection of colorectal cancer by DNA quantification of exfoliated colonocytes) Bajwa et al; DCR 2008

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SLIDE 24

Evidence (FOBT)

  • randomised trial (Nottingham / Denmark)
  • 150,000; 45-74yrs; 360 vs 420 deaths
  • 15% decrease in cumulative survival in

the non-screened population

Colorectal cancer screening

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SLIDE 25

Pilot Screening Statistics

  • 25,000 in screening population
  • 65% will return kit (16250)
  • 2% will be abnormal (325)
  • Of these

– 162 will be normal at colonoscopy – 130 will have polyps – 33 will have cancer

National colorectal cancer screening

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SLIDE 26
  • Once only (55

Once only (55-

  • 64yrs)

64yrs)

  • 190,000 (55%) responded

190,000 (55%) responded

  • 170,000 randomised (2 : 1)

170,000 randomised (2 : 1)

  • 57,000 assigned screening

57,000 assigned screening

  • 40,000 (flexible

40,000 (flexible sigmoidoscopy sigmoidoscopy) ) Results – 11.3yrs follow-up

  • * 33% (50) reduction – incidence
  • * 43% decrease – mortality

Atkin et al; Lancet 2010 Segnan et al, J Natl Cancer Inst. 2011

U.K flexible U.K flexible sigmoidoscopy sigmoidoscopy screening trial screening trial (UK FSST) (UK FSST)

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SLIDE 27

National bowel cancer screening National bowel cancer screening with flexible with flexible sigmoidoscopy sigmoidoscopy

  • Single flexible sigmoidoscopy at 55 years
  • Pilot trials – late 2012
  • National roll out 2014, complete by 2016
  • Age 60-74 (2 yearly FOBT screening)
  • Existing screening centres to oversee
  • New centres for FSST must be JAG accredited
  • Personnel (Nurses/ Medical / Surgical Registrars
  • Accreditation process for personnel unclear *
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SLIDE 28

UCLH & FSS

Where are we now?

  • Age extension (September 2012)
  • 2013 – proposals to pilot FSS
  • 2014 – FSS at UCLH / surrounding trusts
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SLIDE 29

Conclusion

  • Bowel cancer screening saves lives. 70% of screen detected

cancer is early stage disease potentially curable at endoscopy

  • r surgery.
  • UCLH is a leader in modern colorectal cancer therapy
  • ffering a multidisciplinary evidenced based approach to

patient management

  • Through research and pioneering work, UCLH has

contributed to some of the new exciting clinical developments in colorectal cancer.

  • Future introduction of FSS at UCLH will reduce the

incidence / mortality of this disease and improve overall UK survival in line with the best in Europe.