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NORTH OF ENGLAND
CANCER NETWORK
ANNUAL CONFERENCE
Friday 20 September 2013
Stadium of Light
Colorectal Cancer
Mr Talvinder Singh Gill
Colorectal NSSG Chair
North of England Cancer
Network Annual Conference
20 September 2013
Colorectal cancer
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Colorectal cancer
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Colorectal cancer
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
To discuss….
• Incidence and Survival
• Early diagnosis and Prevention
• Recent advancements
• Future developments
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Incidence
• About one in 20 people in the UK will develop bowel cancer
during their lifetime
• Third most common cancer in the UK after breast and lung
• Second leading cause of cancer deaths
• Around 40,000 people are diagnosed every year
• About 16,000 deaths every year due to CRC
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Age specific incidence in UK
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Mortality trends
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Survival
• Five-year survival rates for colon cancer
Early 1970s
Mid 2000s
Male
22%
50%
Female
23%
51%
• Five-year survival rates for rectal cancer
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Early 1970s
Mid 2000s
Male
25%
51%
Female
27%
55%
NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Survival by stage
• Percentage of cases and 5 year relative survival by Dukes’ stage (1996 –
2002)
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Dukes’ stage
% of cases
Five year
survival
A
8.7%
93.2%
B
24.2%
77.0%
C
23.6%
47.7%
D
9.2%
6.6%
Unknown
34.3%
35.4%
NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Survival advantage
• Early detection and improved treatments
• Affluent patients have 5 to 9% survival
advantage over most deprived groups
• Over 2000 deaths would be avoided if
this difference is removed
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Two-week rule
• Less than 10% of patients referred by the TWR are eventually
diagnosed with CRC
• Of all CRC patients diagnosed
•
•
•
Less than 25% had been referred using the TWR
About 25% are admitted as emergency cases
More than 50% are referred using alternative routes
• There is no evidence to indicate that the TWR had resulted in
identifying CRC patients at an earlier, more treatable stage of
their disease
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
North Tees CRC
Number
5%
9%
35%
15%
15%
21%
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
TWR
Routine
Emergency
Screening
GP urgent
Other
Early detection
• The NHS Bowel Cancer Screening Programme
•
•
2% FOB +ve
Colonoscopy: 40% polyp, 10% cancer
• NHS bowel scope screening
•
43% reduction in bowel cancer mortality
• Maddams et al., 2008
•
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Up to 20,000 fewer deaths from bowel cancer over the next 20
years if just 60% of those eligible take up the invitation for bowel
screening
NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Early detection
• Public awareness
• Worrying symptoms
• Curable at early stage
• Denial and fear of cancer
• QOL
• Health professional awareness
• Risk assessment
• Willie Hamilton RA tools
• Screening
• Population screening
• For high risk groups
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Prevention
• General well being and healthy life style
• Diet
•
Fruits and fiber, 5 a day
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Reduction in red and processed meat
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Garlic, milk, Fish oil, Aspirin and calcium
• The seAFOod Trial (Bowel polyp prevention)
• Exercise
• Obesity
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•
Obese men have a 53% higher risk
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71% of men and 58% of women are overweight
NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Improvements in treatment
• Colonoscopy:
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•
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Chromo-endoscopy
Narrow-band imaging
CT colonography
• Staging:
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•
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CT and MRI scans
PET scan
Diffusion-weighted MR imaging
• Surgical access:
•
•
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Laparoscopic surgery
Single port surgery and Robotic Surgery
NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Open vs Laparoscopic surgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Open vs Laparoscopic surgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Robotic surgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Robotic surgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Single port laparoscopic surgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Single port laparoscopic surgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Improvements in treatment
• Surgical technique:
• Surgical tissue plane
• Total mesorectal excision (TME)
• Extra levator abdominoperineal excision (ELAPE)
• Treatment for metastases
• Surgery for Liver, Lungs and other organs
• Portal vein embolisation
• Thermal ablation
• Radiofrequency, Cryo, Microwave
• Radioembolisation
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Single port laparoscopic surgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Improvements in treatment
• Peri-operative management:
• Enhanced recovery programme
• Goal directed fluid therapy
• Local excision for rectal cancer
• Transanal Endoscopic Microsurgery (TEM/TEO)
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Transanal Endoscopic Microsurgery
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Adjuvant treatments
• Radiotherapy
• EBRT, schedule, technique
• Chemo-radiotherapy
• Selective internal radiation therapy
• Chemotherapy:
• 5FU, Oxaliplatin, Irinotecan etc.
• Various combinations and schedules
• Monoclonal antibodies:
• Cetuximab, Bevacizumab, Panitumumab
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Future developments
• TREC trial
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RTh and local excision for ERC
• FOx TROT trial
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Neoadjuvant CTh for locally advanced colon cancer
• CReST trial
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Role of stents in obstructing colon cancer
• Other trials
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Various oncological treatments
NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Role of Genetics
• CRC pathogenesis
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•
•
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Adenoma carcinoma sequence
More complex and multiple genes
69 genes related to pathogenesis
5% inherited and another 20% have family history
• KRAS gene test
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About 40% of patients with CRC have tumours with mutant KRAS.
EGFR inhibitors (Cetuximab) improves outcomes only in patients with
wild type (non-mutated) KRAS.
• Gene mapping
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Planning of resources
• Increase uptake of screening
• Awareness in socially and economically deprived
areas
• Reduce variability in the management
• Surgeon specific mortality data
• Research and trials
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Thank You
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NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
NORTH OF ENGLAND
CANCER NETWORK
ANNUAL CONFERENCE
Friday 20 September 2013
Stadium of Light