SCREENING, SURVEILLANCE AND

DIAGNOSIS OF COLORECTAL CANCER

Andrew Luck

Colorectal SurgeonNorthern Adelaide Colorectal Unit

Adelaide, South Australia

Honorary Secretary, Colorectal Surgical Society of Australia and New ZealandCSSANZ representative, National Bowel Cancer Screening Program Advisory Group

CANCER SOCIETY OF NEW ZEALAND, WELLINGTON June 2009

DIAGNOSING COLORECTAL CANCER

• Symptomatic– Rectal bleeding– Change in bowel habit– Abdominal pain and/or mass– Unexplained loss of weight– Anaemia– Symptoms due to metastases

• All symptoms should be investigated, especially in over 40 year olds

SYMPTOMS

DIAGNOSING ASYMPTOMATIC CRC

• Serendipity

• Screening of high risk groups– Familial syndromes

• Familial adenomatous polyposis• Hereditary Non-polyposis colorectal cancer

– Family history

• Surveillance of high risk groups– Past history of CRC or adenomatous polyps– Long standing ulcerative or Crohn’s colitis

• Screening of the average risk population

SCREENING VS SURVEILLANCE

• Screening– Assessment of asymptomatic individuals with NO

personal past history of colorectal polyps or cancer

– Screening program will vary depending on risk

• Surveillance– Assessment of asymptomatic individuals WITH a

personal past history of colorectal polyps or cancer or a disease known to increase risk

– Surveillance program will vary depending on nature of previous disease

Quantifying risk of CRC(NHMRC Guidelines 2005)

If age is 5 years

Risk

10 years

Over

15 years 20 years

30 1 in 7000 1 in 2000 1 in 700 1 in 350

40 1 in 1200 1 in 400 1 in 200 1 in 90

50 1 in 300 1 in 100 1 in 50 1 in 30

60 1 in 100 1 in 50 1 in30 1 in 20

70 1 in 65 1 in 30 1 in 20 1 in 15

80 1 in 25 1 in 25

Quantifying risk based on family history of CRC

(NHMRC Guidelines 2005)

RR• No family history of CRC 1• One 1o relative CRC >55 2• One 2o relative CRC 1.5• One 1o relative CRC <55 3-6• Two 1o or one 1o and one 2o relative

CRC at any age 3-6

Quantifying risk based on family history of CRC

(NHMRC Guidelines 2005)

If age is 5 years

Risk

10 years

Over

15 years 20 years

30 1 in 7000 1 in 2000 1 in 700 1 in 350

40 1 in 1200 1 in 400 1 in 200 1 in 90

50 1 in 300 1 in 100 1 in 50 1 in 30

60 1 in 100 1 in 50 1 in30 1 in 20

70 1 in 65 1 in 30 1 in 20 1 in 15

80 1 in 25 1 in 25

Category 1: Those at or slightly above average risk

• No personal history of bowel cancer, advanced adenoma or chronic ulcerative colitis

• Either no close relatives with CRC or one 1o OR 2o relative diagnosed >55

Screening recommendation for Category 1 patients

• Faecal occult blood testing (FOBT) every second year from the age of 50 years (NBCSP)

– ie NOT all patients with a first degree relative with CRC qualify for colonoscopic screening

Category 2: Those at moderately increased risk

• One 1o relative CRC <55

• Two 1o relatives or one 1o and one 2o

relative on the same side of the family CRC diagnosed at any age

Screening recommendation for Category 2 patients

• Colonoscopy

• Every 5 years

• Starting at age 50, or ten years younger than the age of first diagnosis in the family, whichever comes first

Category 3: Those at potentially high risk

• Three or more 1o and 2o relatives on the same side of the family with CRC (suspect HNPCC)

• Two or more 1o and 2o relatives on the same side of the family with CRC and one or more of the following features– Multiple cancers in one person– CRC before the age of 50 years– Another relative(s) with related malignancy

• Endometrium, ovary, stomach, small bowel, renal pelvis, ureter, biliary tract or brain

Category 3: Those at potentially high risk

• At least one 1o relative with a large number of adenomas throughout the large bowel (suspected FAP)

• A relative in whom the presence of high risk mutation in the adenomatous polyposis coli (FAP) or one of the mismatch repair genes (HNPCC) has been identified

Screening recommendations for Category 3 patients

• FAP suspected– Flexible sigmoidoscopy annually (+/- dye spray

chromoendoscopy or narrow band imaging) from 12-15 years to 30-35 years

– Genetic testing for mutation on Chromosome 5q

• If positive, – prophylactic total colectomy and ileorectal anastomosis or

restorative proctocolectomy and ileal pouch anal anastomosis

– Annual endoscopy of upper GI and Rectum or pouch for life

Screening recommendations for Category 3 patients

• HNPCC suspected– Genetic testing for HNPCC

• Immunohistochemistry or MSI testing of family members’ cancers and polyps, then gene testing if positive

• If gene mutation established, genetic testing of family members

• If positive– Yearly colonoscopy– Regular assessment of other organs– If cancer found, change of surgical approach

• More extensive colectomy– ? Prophylactic colectomy

• If negative, ??

SURVEILLANCE OF OTHER HIGH RISK GROUPS

• Past personal history of CRC, repeat colonoscopy to be performed

– If colonoscopy incomplete before surgery, between 3 and 6 months post op

– If colonoscopy complete pre-op, 3 years after surgery (?? 1 year)

– Every 3 years unless symptoms or adenomatous polyps found

SURVEILLANCE OF OTHER HIGH RISK GROUPS

• Past personal history of adenomatous polyps, repeat colonoscopy at

– 1 year if multiple polyps, poor bowel prep or potentially incomplete resection of adenoma

– 3 years if large adenoma (>1cm), or those with villous change

– 4-6 years if none of above risk factors

SURVEILLANCE OF OTHER HIGH RISK GROUPS

• Long standing ulcerative colitis

– Colonoscopic surveillance every 2 years with multiple biopsies (for dysplasia) starting ~8 years after diagnosis

SCREENING OF THE AVERAGE RISK POPULATION

• Faecal occult blood test every 2 years starting at age 50– Immunological test (tests for human

haemoglobin)

• National Bowel Cancer Screening Program

NATIONAL BOWEL CANCER SCREENING PROGRAM

• 2003

• Pilot– Mackay, Queensland– North East Melbourne– South West Adelaide

• Via electoral role FOBT sent to all people turning 55 or 65 in a 10 month period– Reminder letter at 8 weeks

NATIONAL BOWEL CANCER SCREENING PROGRAM

• If positive, recommended to visit GP to organise colonoscopy via public or private systems (Usual care model)

• If negative, recommended to repeat FOBT in 2 years

NATIONAL BOWEL CANCER SCREENING PROGRAM

• On basis of pilot result, in the 2005-6 federal budget, the Howard government

• $45 million

• FOBT kits to all Australians turning 55 or 65 between 1/7/06 and 30/6/08

• Rescreening kits for pilot participants• Reinvitation to pilot invitees who did not participate in pilot• Some infrastructure

– Data managers etc– $6.60 to fill out forms!!– Not colonoscopy or pathology services (Usual Care Model!)

PARTICIPATION RATES

• Crude rate 38.4% (as at Feb 2009)– 593,929 from 1,545,528 invitations

• Kaplan-Meier assessment (Dec 2008)– Australia 42.9%– States

Tas 48.4% Qld 43.6%

SA 47.1% Vic 43.0%

WA 47.1% NSW 40.0%

ACT 45.6% NT 34.6%

PARTICIPATION RATES

Subgroups

• 55 year olds 39.9%• 65 year olds 47.7%• Males 39.2%• Females 46.7%

• Pilot participants 83.0%• Pilot invitees (who declined 2002) 21.0%

FOBT POSITIVITY

• Persons 7.5% 27,342/362,477

– 55 6.4%– 65 9.0%

• Males 8.9%– 55 7.5%– 65 10.6%

• Females 6.4%– 55 5.5%– 65 9.0%

FOBT POSITIVITY

• Asymptomatic 82.9%

• Rectal bleeding (<6/12) 5.2%

• Rectal bleeding (>6/12) 6.5%

• Change in bowel habit 3.0%

• Iron deficiency anaemia 1.3%

• Abdominal pain 3.4%

REFERRAL FOR COLONOSCOPY

• GP visits* 43.2% » Likely data collection issue

• Queensland 58.1%• NSW 37.9%

• Referral for colonoscopy 90.7%

• Reasons for non referral– Colonoscopy within 18/12 42.5%– Medical co-morbidities 35.4%– Patient declines 34.3%

COLONOSCOPY RESULTS

• Cancer 752 5.1%

• Polyps* 7739 53.8%– Adenoma 1784 12.4%– Awaiting path 5595 41.4%

• Normal 5938 41.1%

COLONOSCOPY RESULTS Cancer (%) Polyps (%)

• Persons 5.1 53.8– 55 4.0 52.2– 65 6.1 57.3

• Males 5.5 62.9– 55 4.4 61.0– 65 6.3 64.6

• Females 4.7 45.3– 55 3.6 42.7– 65 5.8 47.9

• Pilot Rescreeners 6.0 47.0

RESECTION RESULTSPersonal results 2007/2008

ACPS stage

NBCSP Other Total

O 8 8 16A 7 7 14B 4 24 28C 5 14 19D 2 11 13

Total 26 64 90

2008/9 FEDERAL BUDGET

• 87.4 million dollars (until end 2010)

– Add 50 year olds to 55 and 65– Nurse pathway coordinators

• BUT– No rescreening– No money in forward estimates

LESSONS FROM AUSTRALIAN PROGRAM

• Lives can be saved

• Start out with the full program in place– Staged invitations– Rescreening in place from outset

• Robust data collection– Doctors will not fill out forms without good reason

• Screening centres a la Breast Screen Australia• Electronic collection from GP/colonoscopy unit/pathologist• Link data collection to remuneration for procedure• Collect data on resection results