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
Barts Health NHS Trust
Associate Dean and Honorary Senior Lecturer
RCS Tutor and TPD Core surgery
Civilian Advisor to the Armed Forces
Academic 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
Operations in 2012/13
Mr Ahmed
Mr Thaha
Total
44
(includes joint
procedures
between Mr
Ahmed and
Mr Thaha)
20
64
Bowel Cancer Related Research Portfolio
(Colorectal Cancer Team – Royal London Legacy Site)
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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:
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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
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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
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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
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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
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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