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

Mr Shafi Ahmed PhD, FRCS, FRCS(Gen.Surg)Consultant Laparoscopic Colorectal SurgeonClinical and MDT Lead for Colorectal Cancer

Barts Health NHS Trust

Associate Dean and Honorary Senior LecturerRCS Tutor and TPD Core surgery

Civilian Advisor to the Armed ForcesAcademic Surgery Unit

Queen Mary University of London

Who are we?

NCBRSI

Patients treated 2012-2013

Treatment type Total treatment

Chemotherapy 30

Chemo-Radiotherapy 31

Surgery 59

Radiotherapy 15

Palliative Care 7

Active Monitoring 8

Total 150

Oncology firm RLH

Mr Ahmed Mr Thaha Total

Operations in 2012/13

44 (includes joint

procedures between Mr Ahmed and Mr Thaha)

20 64

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.• MicroRNA’s 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 Cancer• HPV related methylation markers in patients

with anal intra-epithelial neoplasia and anal squamous cell carcinoma

• Clinical 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 hernia

• Pilot, 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 resection

• Development 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 lesions

– Fe deficiency anaemia– Palapable mass

• Left sided– Change in bowel habit

• Looser more frequent stools– Rectal bleeding

• Rectum– Rectal bleeding– Tenesmus

Two week wait referrals

• 1078 per year• 22 referrals per year• Increasing every year• Peaks with health campaign

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

London Cancer emergency audit

• A and E admissions with new onset cancer• 25% of all patients presenting with colon cancer• Bowel obstruction• Perforations

– Elective mortality <10%– Emergency mortality >30%

• Anaemia• Incidental findings

The problem

• 10-15% 2ww• 25% acute admission• Screening 10-20%

• Therefore approx 50% are through other routes

• How to identify?

Direct Access Colonoscopy

• After consultation– Colonoscopy >90%– Flexible sigmoidoscopy– CT Pneumocolon– Plain CT– Discharged

Direct access colonoscopy

• Previous direct access flexible sigmoidoscopy– Obsolete– 2 week wait referrals

• to reduce the burden of 2 week wait• Reduce the lead time for test and improve 31

and 62 day target

QUIP - 2013

• Full management suppport• To reduce the burden of OPD clinics• Telephone triage

– Nurse led– 2 pilot clinics

Problems faced

• Language• Bowel preparation• Assessment of suitability• Time dependent on CNS• Need support staff at RLH

Whipps cross led by Ed Seward (Consultant Gastroenterologist)

• 150 patients• 2week and 18 week wait referral• Current waiting times

– 8 weeks clinic appt– 4- 6 weeks for colonoscopy

• 20min slots• Nurse led• DNA rate 1%

• Outcome– 50% reduction in pathway for 2ww– 67% for 18 week

• Shortlisted for BMJ prize for service innovation

Flexible sigmoidoscopy

• Once only flexible sigmoidoscopy• 55-64• 113 000• Control and intervention group• Colorectal cancer

– incidence in the intervention group was reduced by 23%

– mortality by 31%

Bowel Scope

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

• Roll out in 2014