Detection
	Bowel Cancer or Haemorrhoids?
	Screening
	Diagnosis
	Treatment
	NlCE guidelines
	Follow up
	FAQ's

DETECTION

Early detection of bowel cancer can lead to a greater chance of long-term cure. Patients who report with bowel symptoms should have a history taken, including a detailed account of the type of symptoms, the severity and the length of time since onset. They should also undergo an appropriate clinical examination taking into account any jaundice or pallor, an abdominal examination and a
digital rectal examination. Although bowel cancer commonly affects people of a slightly older age group, alarm symptoms in the younger patient should also be dealt with urgently particularly if there is family history of the disease.

RECTAL BLEEDING AND HAEMORRHOIDS

GPs will be well aware that it is important not to rule out the possibility of bowel cancer when considering a
haemorrhoids diagnosis. This is especially true if the patient is presenting other high-risk symptoms. However, if piles are confirmed and a surgical treatment is considered, GPs should look at whether Procedure for Prolapse and Haemorrhoids (PPH) would be suitable. PPH (also known as a stapled haemorrhoidectomy or a stapled anopexy) is a minimally invasive surgical treatment. It uses a circular stapling device to cut out the prolapsed tissue and reposition the haemorrhoids to their normal anatomical position, rather than the traditional surgical method of cutting the haemorrhoids away. As a result, people who have undergone PPH report little post-operative pain, a shorter and more comfortable recovering period 1 and a quicker return to normal activities compared to a Milligan-Morgan haemorrhoidectomy procedure.3 The surgery can be performed under a local, general or regional anaesthetic.1 As with any surgical procedure, there are risks accompanying PPH and patients should be encouraged to discuss them with their GP.

For more information please call the PPH InfoLine on 0800 028 2231 or visit www.allaboutpph.co.uk

	Click here to order FREE packs of our Bowel Cancer and Piles leaflets (available in packs of 20 - please state the quantity you require in your email)
	Click here to download the Bowel Cancer and Piles leaflet
	Click here to download the Reference Card: 'Early Detection of Colorectal cancer'

Patients who present with alarm symptoms can be urgently referred via the two-week rule which will ensure that a hospital appointment is booked within two-weeks of the referral being received. Each Cancer Network has developed an urgent suspected colorectal cancer proforma.
This is usually available in each practice and can be faxed through to a designated line in the hospital. The appointment is then made and the date/time faxed back to the G.P. If it is not already known it is worth finding out from the local hospital the number of the designated telephone
fax line. This proforma should only be used for patients where there is a high grade of suspicion of colorectal cancer and not as a method of 'fast-tracking’ routine patients.

In order to make an appropriate referral the following guidelines can be used to help determine the urgency at which the referral needs to be made.

Click here to download the referral guidelines for suspected cancer.

NHS Bowel Cancer Screening Programme (England: 60-69 years)

As promised, April 2006 finally saw the Government's official commitment to a national screening programme for bowel cancer, with the news that funding (£10m) has been released for the first phase of the three year initiative.

A programme of this scale will take time to be effectively implemented across the whole country. The Government initially set out a three year phased roll out which will see the whole of the eligible population (people aged between 60 and above) covered by the end of 2009.

Screening centres currently open are listed on the Cancer Screening Website.

Patients living in these areas, and aged between 60-69 and registered with a GP, will receive an invitation for screening via the post.

Read more in the Information for Primary Care Booklet. and the Information for Primary Care Leaflet.

We will update our website regularly as and when new centres open, and all information is also available on the NHS Screening Programmes website at www.cancerscreening.nhs.uk

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Scottish Bowel Cancer Screening Programme (Scotland: 50-74 years)

A Scottish Bowel Cancer Screening Programme commenced in March 2007. The programme will offer men and women aged 50 to 74 years a FOB test every two years.

The screening programme will be phased in gradually over a three year period giving Health Boards time to prepare and allocate resources. The programme will cost £19.5 million in its first three years of roll-out from 2007-08 to 2009-10. This funding will be met from existing NHS Board allocation increases.

Following the successful pilot in NHS Tayside, Grampian and Fife, testing kits will be posted to 650,000 people in the target age range every year. These tests are completed at home and are then returned for screening. Patients will receive results within two weeks.

Welsh Bowel Cancer Screening Programme (Wales: 50-74 years)

This programme will commence in March 2008, as per the Scotland programme.

Screening for high-risk patients

There are however screening programmes in place for families with certain hereditary conditions or those with a family history of colorectal cancer. In around 30% of colorectal cancer cases there is a family history of the
disease. 5% of these cases have an inherited condition, which makes them genetically predisposed to colorectal cancer such as Familial Adenomatous Polyposis (FAP) and Hereditary Non-Polyposis Colorectal Cancer(HNPCC).The remaining 25% of cases are patients who have a
strong family history of the disease, which occurs too frequently to be considered coincidental but is not consistent with the previously mentioned hereditary forms of the disease (Information from Public Health Genetics
Unit at www.phgu.org.uk last updated November 2004).

Genetic Risk

Familial Adenomatous Polyposis (FAP) – this condition where numerous polyps are formed in the bowel is an autosomal dominant hereditary condition. Once diagnosed in an individual, the family are referred to a regional genetics centre and screened for the condition. If diagnosed with FAP, the treatment is a prophylactic colectomy as the mean age for cancer onset is 39 years. In some cases, due to personal reasons, surgery is deferred. In these cases (for patients who have the documented APC gene mutation) screening should take the form of 6 monthly flexible sigmoidoscopy and annual colonoscopy but surgery should be strongly recommended before the age of 25.

Hereditary Non-Polyposis Colorectal Cancer (HNPCC) – this condition is diagnosed either through the fulfilment of certain criteria (Amsterdam Bethedsa Criteria) or by the pathogenic mutation in one of the DNA mismatch repair genes. (Information from Clinical Molecular Genetics Society at www.cmgs.org). Again patients and their families with HNPCC are referred to regional genetics centres for counselling and screening. HNPCC families are screened via total colonic surveillance every 2 years starting at the age of 25 or 5 years below the age of the first cancer
case in the family and should continue until the age of 75.

Family History

In this group of patients colorectal cancer occurs too frequently to be considered coincidental but does not accurately fulfil the criteria for an hereditary condition. In this group of patients current guidelines are a screening colonoscopy 10 years below the age at which the youngest
family member was diagnosed.

Patients presenting with a family history of bowel cancer should be referred to the local colorectal specialist for a full assessment of risk and referral for appropriate screening.

Staging

Once colorectal cancer has been diagnosed pre-operative staging of the tumour must take place prior to any treatment. Pre-operative imaging such as CT and MRI scans can, as accurately as possible, determine the exact site of the tumour as well as identify any local infiltration of the disease or distant metastases. Staging can help determine if it is appropriate to administer radiotherapy (in the case of rectal cancers) prior to surgery or just to proceed directly to an operation. If the cancer was not diagnosed at colonoscopy wherever possible a completion colonoscopy should be performed to exclude any synchronous tumours or adenomatous polyps. If this is not possible pre-operatively then a full colonoscopy should be performed within
6 months from the time of surgery.

Surgery

The first line treatment for many cases of colorectal cancer is surgery. Even in cases where metastases are present it is now widely considered that, if the patient is fit enough, surgery to remove the primary tumour should be carried out as response to palliative chemotherapy for secondary disease is generally improved.

Surgery involves resection of the segment of the bowel containing the tumour as well as some surrounding tissue and lymph nodes. Where possible the bowel is rejoined providing continuity of the colon and a stoma is avoided. In the case of low rectal tumours or in some emergency procedures a temporary or permanent stoma is unavoidable.

Along with open surgery, The National Institute of Health and
Clinical Excellence has recently issued new guidance that laparoscopic, or keyhole surgery, (including laparoscopically assisted resection) is a recommended alternative. Laparoscopic colorectal surgery should be performed only by surgeons who have completed appropriate training in the technique and who perform the procedure frequently enough to maintain competence. The decision about which of the procedures (open or laparoscopic) is undertaken should be made after an informed discussion between patient and surgeon. In particular, the suitability of the lesion for laparoscopic resection should be considered, along with the
risks and benefits, and the experience of the surgeon, for either procedure. Whilst patients will discuss this with their
surgeons, they may also require advice and guidance from their GPs.

Click here to download the list of recommended colorectal centres offering laparoscopic surgery.

TEMS procedure (transanal endoscopic microsurgery)

This is a minimally invasive procedure for rectal tumours in which the surgeon removes the tumour through a scope placed in the anal canal.This procedure has the advantage of a quicker recovery time and potentially fewer complications. It is potentially suitable for those
patients with very early stage tumours although the possibility of nodal invasion needs to be discussed. It is also suitable for some non-malignant polyps. Patients with advanced rectal cancers may undergo this procedure to improve quality of life.

Radiotherapy

Radiotherapy is only administered in the case of rectal cancers. It can either be given neo-adjuvantly i.e. prior to the operation in an attempt to ‘downstage’ the tumour before resection or post-operatively (if final histological grading shows a T4 tumour or there is circumferential margin involvement) to try to reduce the chance of recurrence in the
future.

Chemotherapy

Chemotherapy is generally given after surgery, particularly if the histology report confirms the presence of involvement of any of the lymph nodes removed in the specimen. Chemotherapy can be given in combination with radiotherapy post-operatively in the case of rectal
cancers.Chemotherapy can also be given, in smaller doses, with radiotherapy in the pre-operative setting as it helps enhance the action of the radiotherapy.

Methods of follow-up include:

Clinical Examination: the patient is seen in clinic and questioned about any recent symptoms. A clinical examination is performed including observing for signs of jaundice or anaemia, abdominal examination and in the case of rectal cancers a rigid sigmoidoscopy to check the anastomosis can also be performed.

Blood Tests: Tumour markers in the blood can rise in the presence of active tumour and two indicators if possible recurrent cancer are Carcinoembryonic Antigen(CEA) and CA19-9. Generally a rising CEA or CA19 –9 can be indicative of recurrent cancer and so if one or
other is raised on blood testing further investigations may be requested to determine if there is recurrent disease.

CT Imaging or Ultrasound: These can be done as part of the hospitals’ follow-up protocol for patients who have had surgery for bowel cancer or may be requested in the presence of abnormal symptoms or elevated tumour markers. Scans may initially concentrate on the area of surgery as well as common areas for metastases such as the liver and lungs.

Colonoscopy: Current guidelines recommend that all patients with colorectal cancer undergo a complete colonoscopy at the time of diagnosis. If this is not possible due to the presence of an obstructing lesion a completion colonoscopy should be carried out within 6 months
of surgery. After that repeat colonoscopy should be performed every 5 years until the age of 75 (providing no polyps are found – refer to BSG guidelines on polyp follow-up).

For all guidelines refer to the British Society of Gastroenterology at www.bsg.org.uk

The current debate surrounding the most appropriate method of follow-up has been brought about by the lack of hard evidence to support one method of surveillance over another. In addition the cost of follow-up per life year gained is uncertain and therefore a case for intensive follow-up cannot be adequately argued. At present follow-up practices
vary widely between Trusts and is very often dictated by each individual consultant’s personal preference.

In attempt to answer the question of the benefit of follow-up there is currently running in the UK a multi-centre randomised controlled trial looking at the cost-effectiveness of intensive versus no scheduled follow-up in patients who have undergone resection for colorectal cancer
with curative intent (FACS Trial). Details of this can be found on the National Cancer Research Network Website www.ncrn.org.uk

Other articles addressing this issue are;
Renehan AG, Egger M, Saunders MP, O’Dwyer ST. Impact on survival of intensive follow-up after curative resection for colorectal cancer: systemic review and meta-analysis of randomised trials. BMJ 2002;324: 813

Renehan AG, O’Dwyer ST, Whynes DK. Cost effectiveness analysis of intensive versus conventional follow-up after curative resection for
colorectal cancer. BMJ 2004; 328: 81

If it is not known what the current follow-up practice is in your local hospital it may be worth contacting either the Consultant Colorectal Surgeon or the Colorectal Nurse Specialist so that you are aware of
what regime is followed.