Bowel cancer screening and prevention

Victorian Cancer Registry 2012

Cancer Incidence and Mortality Victoria 2012

0

1000

2000

3000

4000

5000

6000

Prostate Breast Bowel Lung

IncidenceMortality

Cancer Type

Num

ber

Incidences = 29,387

Mortality =

10,780

New cases and deaths in 2012 for the leading cancers in Victorian men

4764

19201573

1278790 735

1161

0

1,000

2,000

3,000

4,000

5,000

6,000

Prostate Bowel Lung Melanoma

New

case

s/de

aths

in

2009

Type of Cancer

New cases

Deaths

210

Victorian Cancer Registry 2012

New cases and deaths in 2011 for the leading cancers in Victorian women

Victorian Cancer Registry 2012

1713

1003883

698 616765

1050

1,000

2,000

3,000

Breast Bowel Lung Melanoma

New

cas

es/d

eath

s in

200

9

Type of Cancer

New casesDeaths

3748

Signs and symptoms CRC

• Most early bowel cancers don’t produce obvious signs or symptoms

• Symptoms often typical of several common conditions • Most common presenting symptoms: - Bleeding from the rectum, mixed with or separate from faeces - Persistent change in bowel habit - Symptoms of anaemia - Colicky lower abdominal pain - Unexplained weight loss

Pathogenesis of colorectal cancer

• Adenomatous polyp that grows inside large bowel

• Slow growing (10+ years), many never progress

• Benign adenomas may become malignant over time

• Usually removed when observed through colonoscopy

Flat adenoma

Polyp on long stalk

Risk factors CRC Non-modifiable: • aged 50 years+ • inflammatory bowel disease • strong family history of bowel cancer Modifiable: • diet • obesity • smoking • high alcohol intake • physical inactivity

Familial risk factors for CRC

Familial Adenomatous Polyposis (FAP) • Usually due to a mutation in one of two copies of a tumour suppressor gene • Hundreds of adenomas throughout the colon and rectum - can develop into cancer, often at early age - consider prophylactic surgery • May appear as teenager/ young adult

Hereditary Non-Polyposis Colorectal Cancer (HNPCC) Lynch Syndrome • Inherited mutation in a copy of one of a group of DNA mismatch repair genes (MMR) • Usually strong family history of colorectal cancer - early age onset, usual diagnosis before age 50 - multiple colorectal cancers • Association with endometrial, ovarian etc cancers

Potentially high risk (FAP, HNPCC)

• Three or more 1st degree relatives or a combination of 1degree/2 degree relatives on the same side of the family • Two or more 1degree/2degree relatives on the same side of the family plus any of the following high risk features: - Multiple bowel cancers in a family member - Bowel cancer before the age of 50 - Family member who has/had an HNPCC related cancer • At least one 1degree/2degreee relative with suspected FAP (i.e. hundreds of polyps in the large bowel) • Member of a family identified with a high risk gene mutation

Evidence-based guidelines

• NHMRC and RACGP recommend Faecal Occult Blood Testing every two years for all men and women aged 50 and older

• It is important for GPs to remind patients to present if they develop signs or symptoms i.e. population screening may be inappropriate for these patients

NHMRC Guidelines http://www.nhmrc.gov.au/guidelines/publications/cp63

National Bowel Cancer Screening Program

(NBCSP)

Benefits of screening with FOBT

• Can detect CRC at early stage, with 90% chance of curing it • Reduces the risk of dying from bowel cancer by at least 15-

33% • Most bowel cancers take up to10+ years to develop, so having

an FOBT every 2 years is an appropriate interval • Detects both pre-cancerous polyps as well as adenomatous

polyps that may develop into cancer over time • Bowel cancer has a defined natural history that makes

screening by iFOBT appropriate for early detection • iFOBT has an 85-90% sensitivity for lower GI bleeding • FOBT can be done in the privacy of the home

Limitations of screening with FOBT

• Positive FOBT requires further investigation, usually colonoscopy. Most people who have a colonoscopy will not have cancer. Although rare, there are risks associated with colonoscopy.

• Not all bowel cancers detected by screening can be successfully treated

• Participants may be anxious waiting for results; however, NBCSP patients with a positive FOBT are fast-tracked to investigative colonoscopy

• The test involves faecal testing which some find unpleasant • A negative result is not 100% conclusive because some bowel

cancers don't bleed, or do so intermittently

Types of FOBT

Cons: Dietary changes e.g. no red meat, eliminate certain vegetables Medication changes e.g. no Vit C, aspirin, iron supplements Not specific to human haem 50% sensitivity for bowel cancer Subjective visual result reading

Pros: Low cost Accessibility

1. Guaiac (pseudoperoxidase activity of haem)

Types of FOBT, cont.

Cons:

• Greater cost

• Limited availability for some programs

Pros: No diet or medication changes 80-90% sensitivity Specific for lower G-I bleeding Easy, hygienic, user-friendly Immediate stabilisation of Hb Automated lab processing High throughput for population screening Test recommended by national guidelines

2. Immunochemical tests (antibodies to human globin)

Cons:

Greater cost

Limited availability for some programs

Correct storage for iFOBT

• Complete and post the test within 10 days of collecting the first sample

• Samples should be stored in a cool dry place, preferably between 2-10 degrees

• Can be stored in the refrigerator if necessary • Avoid posting on hot days, or post the envelope in an

indoors mail box, or post just prior to collection times

Positive FOBT i.e. low grade bleeding

NBCSP (data from Qld public sector) • FOBT positivity rate 7.7% • PPVs for: - bowel cancer 4.3% - advanced adenoma 23% - non-advanced adenoma 25% i.e. 52% of people with a positive FOBT will have some sort of cancer or adenoma • 10 - 20 times more likelihood of finding bowel cancer with

positive FOBT than with negative FOBT

M. Appleyard et al (2011)

Referral for colonoscopy

• The patient should be referred for colonoscopy within four weeks if symptoms are highly suggestive of bowel cancer

• Ideally refer to a physician or surgeon who has Conjoint Committee recognition of their training in colonoscopy

Who should have a colonoscopy?

Targeted Colonoscopy

Symptoms Strong Family History

Past Bowel Cancer or AA

Positive FOBT

Why colonoscopy inappropriate for screening

Colonoscopy: • Low yield • Lack of high level

evidence for benefit outweighing harm

• Inappropriate for population screening of 5 million Australians

• Cost • Patient inconvenience/

compliance

• Potential complications: - difficulties with preparation - anaesthetic complications - perforation of colon (1/2000-4000 cases) - bleeding following procedure (1/500 cases) - death (1/10,000 cases) - ~ 5% are not completed

Colonoscopy reports what to look for

• Look Quality of bowel preparation • Length of bowel examined and action to take if caecum

could not be reached • Withdrawal time • Size, type, number and site of any adenomas or cancers • Suggested repeat procedure interval • Biopsy comments

NBCSP participation rates

National Bowel Cancer Screening Program monitoring report: phase 2, July 2008-June 2011

Key Messages (Two ways to screen)

NBCSP National Bowel Cancer Screening Program Screen in between

FOBT kits provided by the government for males and females turning 50, 55, 60 and 65 years, who have no symptoms or family history of bowel cancer

Recommended every 2 years for all people aged 50+ who have no symptoms or family history of bowel cancer

Can be done in the comfort and privacy of your own home. Involves taking samples from 2 bowel motions using a test kit

Can be done in the comfort and privacy of your own home. Involves taking samples from 2 bowel motions using a test kit

Samples sent to the lab are tested for invisible blood in the bowel motion

Samples sent to the lab are tested for invisible blood in the bowel motion

If blood is found, further tests are needed. This is likely to be a colonoscopy

If blood is found, further tests are needed. This is likely to be a colonoscopy

Full biennial (every two years), implementation of the National Bowel Screening Program should be in place by 2020.

Tests are available by visiting the cancer council website, Calling 132011 and from some pharmacies and health organisations.

Role of general practice

• Determine appropriateness of screening for individual patients

• Assess and manage high-risk individuals according to NHMRC guidelines

• Receive FOBT results where nominated by a participant • Manage participants with a positive FOBT • Notify NBCSP central registry of outcomes where applicable • Recognise and assess individuals with symptoms that could

be related to cancer, and in whom diagnostic investigations (rather than screening) are required

Recommendation from a GP is shown to enhance participation rates in FOBT screening

Bowel screening intervals

FOBT 2 yearly screening after age 50 recommended NHMRC, for all asymptomatic people The program should be fully implemented as biennial screening by 2020 NHMRC guidlines http://www.nhmrc.gov.au/guidelines/publications/cp63

Notification of the register of +ve results

• Important that GPs notify the register (on-line or hardcopy form) • Allows for:

– Follow up of patients with a positive FOBT result – Accurate data collection

• Which leads to: – Accurate evaluation of the program

Successful program = more lives saved

Follow-up of a +ve FOBT

The Register will issue follow up letters and make follow up phone calls to participants and GPs if: • No GP visit is recorded within 8 weeks of a positive FOBT

result • No GP visit is recorded within 6 months of a positive FOBT

result • No colonoscopy is recorded 4 months after a positive result • No colonoscopy is recorded 6 months after a positive result

Duty of care

• Legal advice was obtained by DoHA

• Advice indicated that there was no additional duty of care imposed on medical professionals in regard to the National Program

• Practices will fulfill their duty of care by acting in accordance with existing professional standards and best practice

More information: www.cancerscreening.org.au

Where patients can get an FOBT

• Free kit from National Bowel Cancer Screening Program for 50, 55, 60 and 65 year olds currently. With two yearly implementation by 2020

• Purchase InSure kit from Cancer Council Victoria on 13 11 20 or www.cancervic.org.au/boweltest for $32.50

• Purchase InSure kit from Enterix on 1800 55 65 75 or www.enterix.com.au for $39.95

• GPs; some local pathology services • Some pharmacies – see www.bowelscreenaustralia.org for

participating suppliers Note - screening FOBTs are not Medicare rebatable unless doctor has given a pathology form and recommended the test be done

Key messages

• Regular screening using an FOBT can significantly reduce the number of Australians who die each year from bowel cancer

• It is estimated that the National Program has the potential to save 1000 – 2000 lives per year

• General practice support of the program is integral to its success

For more information

• National Bowel Cancer Screening Program:

www.cancerscreening.gov.au (including multilingual information)

Information Line 1800 118 868

FOBT Helpline 1300 738 365 • Cancer Council Victoria:

www.cancervic.org.au/generalpractice

Helpline 13 11 20