Screening, Surveillance And Diagnosis Of Colorectal Cancer

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  • 1. SCREENING, SURVEILLANCE AND DIAGNOSIS OF COLORECTAL CANCER Andrew Luck Colorectal Surgeon Northern Adelaide Colorectal Unit Adelaide, South Australia Honorary Secretary, Colorectal Surgical Society of Australia and New Zealand CSSANZ representative, National Bowel Cancer Screening Program Advisory Group CANCER SOCIETY OF NEW ZEALAND, WELLINGTON June 2009
  • 2.
  • 3. 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
  • 4. SYMPTOMS
  • 5. 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 Crohns colitis
    • Screening of the average risk population
  • 6. 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
  • 7. Quantifying risk of CRC (NHMRC Guidelines 2005) 1 in 25 1 in 25 80 1 in 15 1 in 20 1 in 30 1 in 65 70 1 in 20 1 in30 1 in 50 1 in 100 60 1 in 30 1 in 50 1 in 100 1 in 300 50 1 in 90 1 in 200 1 in 400 1 in 1200 40 1 in 350 1 in 700 1 in 2000 1 in 7000 30 20 years Over 15 years Risk 10 years 5 years If age is
  • 8. Quantifying risk based on family history of CRC (NHMRC Guidelines 2005)
            • RR
    • No family history of CRC 1
    • One 1 o relative CRC >55 2
    • One 2 o relative CRC 1.5
    • One 1 o relative CRC 55
  • 11. 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
  • 12.
  • 13. Category 2: Those at moderately increased risk
    • One 1 o relative CRC 1cm), or those with villous change
    • 4-6 years if none of above risk factors

22. 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

23. 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

24. 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

25. 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

26. 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!)

27. 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%

28. 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%

29. 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%

30. FOBT POSITIVITY

  • Asymptomatic 82.9%
  • Rectal bleeding (6/12) 6.5%
  • Change in bowel habit 3.0%
  • Iron deficiency anaemia 1.3%
  • Abdominal pain 3.4%

31. 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%

32.