Clues to colorectal cancer presentation (silent killer) Direct access colonoscopy

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Clues to colorectal cancer presentation (silent killer) Direct access colonoscopy. Mr Shafi Ahmed PhD, FRCS, FRCS(Gen.Surg) Consultant Laparoscopic Colorectal Surgeon Clinical and MDT Lead for Colorectal Cancer B arts Health NHS Trust Associate Dean and Honorary Senior Lecturer - PowerPoint PPT Presentation

Text of Clues to colorectal cancer presentation (silent killer) Direct access colonoscopy

  • Clues to colorectal cancer presentation (silent killer)Direct access colonoscopyMr Shafi Ahmed PhD, FRCS, FRCS(Gen.Surg)Consultant Laparoscopic Colorectal SurgeonClinical and MDT Lead for Colorectal CancerBarts Health NHS Trust

    Associate Dean and Honorary Senior LecturerRCS Tutor and TPD Core surgery Civilian Advisor to the Armed ForcesAcademic Surgery UnitQueen Mary University of London

  • Who are we?


  • Patients treated 2012-2013

  • Oncology firm RLH

  • Bowel Cancer Related Research Portfolio (Colorectal Cancer Team Royal London Legacy Site)

    Laboratory Research:Colorectal Cancer:Hypoxic biomarkers to predict response to therapy in rectal cancer.Influence of telomerase length and hTERT expression in prognostication in CRC.Tissue microarray in CRC.MicroRNAs in CRC prognostication.Methylation markers in young age cancers in ethnic Bangladeshi population.Clinical and molecular profiling of Signet ring cell lower GI cancers Biomarkers of muscle damage in patients with parastomal hernia after bowel resection (cancer and non-cancer patients)

  • Anal CancerHPV related methylation markers in patients with anal intra-epithelial neoplasia and anal squamous cell carcinomaClinical Research including clinical trials:

  • Cancer Related:Randomised controlled trial comparing laser ablative therapy versus active observation to prevent development of anal squamous cell carcinoma in HIV positive MSM patients with high-grade AIN (LOPAC trial) NIHR-HTA funded.Development of a multi-modal therapy including exercise and cognitive interventions for improving quality of existence in cancer survivors (SURECAN) NIHR programme development grant funded study.Epidemiology of anterior resection syndrome and validation of LARS scoring system in UK population.A clinical, molecular and functional study on discriminants of sphincter preserving restorative surgery in patients with low rectal cancer.An International, longitudinal cohort study of safety and feasibility of APPEAR technique in ultra-low rectal resections.RCT comparing SMART vs. conventional surgery for prevention of parastomal herniaPilot, feasibility study of functional outcomes after laser ablative therapy of high grade AIN in HIV positive patients

  • Technology/Innovation Research:Development of a novel locomotion technology for active colon capsule endoscopy proof of concept study (QM Innovation funded).Evaluation of a novel combined laser and plethysmography probe to assess intra-operative bowel perfusion in patients undergoing restorative large bowel resectionDevelopment of a humanoid arm/hybrid robotic system for laparoscopic and open pelvic/rectal surgery.

  • Presentation

  • Traditional teaching of presentation of colorectal cancer 2 week wait referrals

    Right sided lesionsFe deficiency anaemiaPalapable massLeft sidedChange in bowel habitLooser more frequent stoolsRectal bleedingRectumRectal bleedingTenesmus

  • Two week wait referrals1078 per year22 referrals per yearIncreasing every yearPeaks with health campaign

    However only 10-15% of cancers diagnosed by 2ww

  • London Cancer emergency auditA and E admissions with new onset cancer25% of all patients presenting with colon cancerBowel obstructionPerforationsElective mortality 30%AnaemiaIncidental findings

  • The problem10-15% 2ww25% acute admissionScreening 10-20%

    Therefore approx 50% are through other routesHow to identify?

  • Direct Access Colonoscopy

  • After consultationColonoscopy >90%Flexible sigmoidoscopyCT PneumocolonPlain CTDischarged

  • Direct access colonoscopyPrevious direct access flexible sigmoidoscopyObsolete2 week wait referrals to reduce the burden of 2 week waitReduce the lead time for test and improve 31 and 62 day target

  • QUIP - 2013Full management suppportTo reduce the burden of OPD clinicsTelephone triageNurse led2 pilot clinics

  • Problems facedLanguageBowel preparationAssessment of suitabilityTime dependent on CNSNeed support staff at RLH

  • Whipps cross led by Ed Seward (Consultant Gastroenterologist)150 patients2week and 18 week wait referralCurrent waiting times8 weeks clinic appt4- 6 weeks for colonoscopy20min slotsNurse ledDNA rate 1%

    Outcome50% reduction in pathway for 2ww67% for 18 week

    Shortlisted for BMJ prize for service innovation

  • Flexible sigmoidoscopy

  • Once only flexible sigmoidoscopy55-64113 000Control and intervention groupColorectal cancer incidence in the intervention group was reduced by 23%mortality by 31%

  • Bowel ScopePilot 2012South of Tyne (Queen Elizabeth & South Tyneside) West Kent (West Kent & Medway) Norwich St Marks (London) Wolverhampton Surrey (Guildford)

    Roll out in 2014