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
Bowel Cancer Bowel Cancer National U.K Figures U.K survival (45%), U.K survival (45%), but note ! but note ! France - - 50% 50% France Germany - - 60% 60% Germany Nearly 60% of symptomatic patients present with advanced disease
Bowel Cancer Bowel Cancer First 116 screen detected colorectal cancers at UCLH 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 Number UCLH UCLH UCLH UCLH Total Pilot 2007 2008 2009 2010 Colonoscopy 150 437 604 793 1984 325 (1.9%) (2%) Normal 66 196 335 480 1077 162 (44%) (45%) (55%) (60%) (53%) (50%) Polyps 72 197 243 282 794 130 (48%) (45%) (40%) (36%) (40%) (40%) Cancer 12 44 26 31 113 33 (8%) (10%) (4.7%) (3.9%) (5.1%) (10%)
Bowel Cancer Treatment Bowel Cancer Treatment Early disease Early disease Versus Versus Advanced disease Advanced disease
Bowel Cancer Treatment Bowel Cancer Treatment Early Disease Early Disease • Open surgery Open surgery •
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 trial (MRC) Lancet May 2005 trial (MRC) Lancet May 2005 clasicc color trial ( trial (Eur Eur) Lancet ) Lancet Oncol Oncol July 2005 July 2005 color
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) -
Bowel Cancer Treatment Bowel Cancer Treatment Early Disease Early Disease •Laparoscopic anterior resection Laparoscopic anterior resection •
Bowel Cancer Treatment Bowel Cancer Treatment Early Disease Early Disease • Laparoscopic right Laparoscopic right hemicolectomy hemicolectomy •
Case 1 Case 1 • 69 year old male • 69 year old male • Positive PFOBT • Positive PFOBT • Colonoscopy- -Sigmoid Cancer Sigmoid Cancer • Colonoscopy • Laparoscopic left hemicolectomy hemicolectomy • Laparoscopic left • Histology 0/12 Nodes; • Histology 0/12 Nodes; - pT3 N0 M0 (Dukes B) pT3 N0 M0 (Dukes B) - • Routine Follow- -up up • Routine Follow
Bowel Cancer Treatment Bowel Cancer Treatment Advanced disease Advanced disease • Chemotherapy Chemotherapy • - Combination chemotherapy Combination chemotherapy - (5FU / oxaliplatin oxaliplatin / / Irinotecan Irinotecan /+/ /+/- - monoclonal antibodies) monoclonal antibodies) (5FU / - median survival = 24months! median survival = 24months! - Tournigand et al; J J Clin Clin Oncol Oncol 2004 2004 Tournigand • Challenges Challenges • - selective toxicity selective toxicity - ? - - benefit after curative surgery benefit after curative surgery ?
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
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
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) • Vs Chemo +/ Resection + Chemo Vs - Resection + Chemo Chemo +/- - resection resection - - Survival benefit with resection Survival benefit with resection - Bajwa et al; Eur J Surg Oncol 2009
Bowel Cancer Treatment Bowel Cancer Treatment Advanced disease Advanced disease RFA liver metastases RFA liver metastases Radionics, cooled tip RF electrodes
Bowel Cancer Treatment Bowel Cancer Treatment Advanced disease Advanced disease RFA liver metastases RFA liver metastases
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 -
Bowel Cancer Treatment Cancer Treatment Bowel 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- -cerebral pressure) cerebral pressure) (reduce intra
Clinical developments in cancer treatment • Multidisciplinary team approach police and execute evidence based best practice for each patient Local Colorectal Cancer MDT Case Review Early vs Advanced Best Practise Treatment Options Discussed with Patient ? Patient Choice
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)
Colorectal cancer screening Rationale • Natural history • Most cancers arise from benign adenomas (adenoma-carcinoma sequence) • Adenomas removed / destroyed with flexible sigmoidoscope / colonoscope
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
Colorectal cancer screening Evidence (FOBT) • randomised trial (Nottingham / Denmark) • 150,000; 45-74yrs; 360 vs 420 deaths • 15% decrease in cumulative survival in the non-screened population
National colorectal cancer screening 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
U.K flexible sigmoidoscopy sigmoidoscopy screening trial screening trial U.K flexible (UK FSST) (UK FSST) • 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
National bowel cancer screening National bowel cancer screening with flexible sigmoidoscopy sigmoidoscopy with flexible • 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 *
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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