Bowel Cancer Treatment

hello, i'm norman swan. welcome to this programon beating bowel cancer - prevention, detection, treatment. we're coming to youon rural health channel 600. nearly 300 people a weekare diagnosed with bowel cancer and tragically for a diseasethat can be detected when it's curable, bowel cancer still hasa very high mortality rate, especially for people livingin rural and remote australia. this program will help youto reduce delay in diagnosis

in your patientsand reverse the appalling statistics in rural and remote communities. we'll also clarify additions to the national bowel cancerscreening program from the new 2012 budget. this is a professionally accreditedprogram from the rural health educationfoundation. as usual, there are a number ofuseful resources available on the rural education healthfoundation's website - rhef.com.au.

let's meet our panel. cameron bell is a consultantgastroenterologist at royal north shore hospitalin sydney. - welcome, cameron.- good evening. cameron is also directorof bowel cancer australia, a memberof the program advisory group of the national bowel cancerscreening program and chair of the working party on clinical practice guidelinesfor surveillance colonoscopy

for cancer council australia. john bronger is a communitypharmacist with over 30 years' experience. - welcome, john.- thank you, norman. john was the national presidentof the pharmacy guild for 11 years, and is currently president of the pharmaceutical society ofaustralia, nsw branch committee. sally cockburn is a gpand health advocate with many years' experience,

currently workingin suburban melbourne. - welcome, sally.- thank you. sally is involved incommunity health issues, health policyand education at many levels. she is a presenter on melbourne radio3aw with talking health, and is an ambassadoron bowel cancer, aren't you? we'll see an example of thatlater on. tammy farrell is an experiencedregistered nurse and nurse adviserfor bowel cancer australia.

- welcome, tammy.- thank you, norman. tammy has qualificationsin nutrition and is managing directorof core health consulting and authorof the real man's tool box. what's insidethe real man's toolbox? the real man's tool boxis a diy health manual for men. right. and the main tip is? the main tip is to look afteryourself, and to see your gp. right. and - ignore man flubut not anything else.

tammy works with rural and remotemining communities and blue-collar industries asa health consultant for employees. james st johnis a gastroenterologist interested in population screening for bowel cancerand familial cancer. - welcome, jim.- good evening, norman. jim was directorof gastroenterology at the royal melbourne hospital,a senior clinical consultant in the national cancer controlinitiative

and has been based at cancercouncil victoria since then. jim is a pioneer of national bowel cancer screeningfrom its inception, has been pushing hardall the way through. welcome, jim, in particular.welcome to you all. where does bowel cancer sit, jim,in terms of mortality? it's just ridiculous.it's up second or third. it's second.lung cancer causes most deaths followed by bowel cancer.

- it's outrageous.- over 4,000 deaths each year. what should it be? if we were actually doing our job getting early detection goingaccording to current technology, what could we get it down to? i'm an optimist. i believe we could reduce themortality down to 2,000 or 1,000. it's going to depend onparticipation. whatever the program is -the population screening,

the special programsfor people with increased risk, families with very special risk. but this is a cancerthat lends itself to screening. we can detect these cancersat a curable stage with screening testswell before they cause symptoms. and cameron,why the rural disparity? is it late diagnosis? i don't think that's clear, norman. i'm sure that access to resourcesis an issue.

i'm not sure, james, about participation in the bowelcancer screening program, whether that's substantiallydifferent in rural... participation in the outerand inner regional area is higher than in the major cities. the difference is... but the survival ratesare very different. there's a gradation from ruralto city. it may well be ready accessto specialised services

at least as one factor. and indigenous communities, cameron? the incidence of bowel canceris lower than in non-indigenous communities. there are a coupleof confounding things. there's a higher rateof cancer of unknown primary in indigenous australians. i suspect thata goodly proportion of that is bowel cancer that goes undetectedand unlabelled.

norman: and uninvestigated, presumably. potentially uninvestigated, yes. sally, the risk factors? the risk factors are beingover 50, having a family history, conditions like ulcerative colitisand crohn's disease, and being australian,living in australia. i thought crohn's diseasedidn't raise the risk? no, it does. crohn's diseaseand ulcerative colitis are two determining factorsthat we want to watch for.

it's not as much of a risk factoras ulcerative colitis, but in the segmentsthat are affected, so anybody with more thanabout a third of their colon affected by crohn's disease and patients withsevere anorectal crohn's disease are at an increased risk. what about lifestyle factors, tammy? lifestyle factors - physical inactivity,high alcohol consumption

and standard dietary guidelinesthat people follow can put a person at riskby around 70%. i thought the vegetable story, the roughage story,had been disproven? no, fibre is important. but we're finding thathigh red-meat intakes... so it's more that vegetablesmean a reduction in red meat? that's right. that's whatgoes with the red meat as well. we'd be looking attrying to limit

to around 500g of red meatper week. sorry, jim? - smoking, tammy?- yes. smoking is one of the big factorsthat we're trying to reduce in terms of bowel cancer. and obesityand type-2 diabetes as well? exactly right. and that's a growth-factorphenomenon, jim? yes.

it's a little bit unknown. teasing out what's obesity,what's insulin resistance and what's a consequence of the metabolic syndrome itselfis difficult. norman: and gender split? it's a common misconceptionthat it's a male disease. it is slightly more commonin men, but by age 75, 1 in 17 australian menwill have developed bowel cancer. it's 1 in 27 australian women.

but by age 85,it's 1 in 12 australians will develop bowel cancer. 1 in 10 for men, and it's nowi think 1 in 15 for women. it used to be 1 in 14.the figures changed a little bit. it's the second commonest internalfemale cancer, the second commonest male cancer, the second commonestcancer killer and it certainly kills more australiansthan die on our roads. tell me about the genetics, jim,associated genetic problems.

the genetics are criticallyimportant in a small group. when you look atall bowel cancer, about 3% or 4% of cases turn outto be members of families with either lynch syndrome,what we refer to as hnpcc - hereditary nonpolyposiscolorectal cancer - or families withfamilial polyposis. this is a situation where we can now do genetic testingin many families. once the family-specific mutationhas been found,

you can offer predictive testingto other members of the family to see whether they inheritedthe faulty gene or not. it's a major problemin a small number of people. and if you have the gene? if you have the gene,with lynch syndrome, because they get cancerat an early age, we recommend colonoscopystarting at the age of 25 or even earlier in some families. they get fast-track cancers,

and they need a colonoscopyevery year. it's a critical situation for them. they get multiple cancers. some people opt forprophylactic colectomy simply because of the disastroushistory within their families. familial polyposis -total colectomy? normally total colectomy, yes. tell me about lynch syndrome. lynch syndromeis a very complex diagnosis.

it's based on family history. it's based on several generationsbeing involved. it centres around at least oneof the people in the family affected by bowel cancerbeing young, either 45 or 50 depending on which set of guidelinesyou're trying to stick to. bowel cancer is a very importantcomponent of it but it also involves othergastrointestinal cancers like small-bowel cancer, stomachcancer, hepatobiliary cancer. also gynaecological cancers,endometrial and ovarian.

and then transitional cell cancerof the renal tract. it's a complex diagnosis. it's something wherefamilial cancer services are often crucially importantin terms of sorting out whether someone's family historyis consistent with it being lynch syndrome. what's your practicein general practice, sally, in terms of detectingthese families, or is it just opportunistic?

in general practice, it's important to have thatconversation with the patient, but sometimes they don't know whattheir family history is - granny died of something.you didn't talk about it then. it is a detective game. we do need to utilise our births,deaths and marriages. a few of my patientshave discovered that their father died of bowel cancerand no-one told them. a question has come infrom micheline, who asks,

'is there a biochemical marker that could be usedfor early detection?' well, they're being worked on. faecal biomarkersare being developed. was it carcinoembryonic antigenat one point or have i got that wrong? that's a testfor more advanced cancer. it's used to look forrecurrence of cancer rather than early diagnosis.

this is a real problem. patientsread about those in the glossies, and think,i want one of those blood tests. to explain to them, no, we're using these as markersof progression, is really hard. let's go toour first case history. 52-year-old brenda has just celebrated five years of post-breast cancer survival. she reckons she's neglected

the rest of her health. she read an article that there may be a risk of other cancers, and she wants to know if she's at increased risk of bowel cancer. she comes to you, sally, 'cause you're the ambassador. i'd congratulate her for thinkingabout the rest of her body. you can understand,she's been staring down the barrel

of breast cancer,and that's scary. she's 52, she would have receivedsomething in the mail at 50, but she ignored it. this is somethingwe have to take into account. some of these people throw awaytheir screening tests. to talk to herabout what's her risk... there are misconceptionsabout the brca gene, and i'd like to throwto my esteemed colleague on the brca gene situation 'causea lot of people worry about that.

is there an associationwith bowel cancer with brca? short answer - no. norman: long answer is?- well, it's complicated, like everything in medicine. only 5% to 10% of breast cancersare brca-positive. in those families,the studies are divided between whether there's anyincreased risk or not of bowel cancer. ashkenazi jews have got the terriblejewish diet to deal with.

- that complicates it.- hard to tease that out. before we get off the genetics, it's important to rememberthe non-fap, non-lynch people. in sporadic bowel cancer, it's been estimated that 30%of it has a genetic basis, but it's a very complicatedgenetics. it's not simple autosomal-recessive or autosomal-dominant. - and multigene?- yeah.

we know more about riskin those families than what the genetic basis is. coming back to brenda, she's a 52-year-old womanwho has survived breast cancer and she should slot intorecommendations for people over 50. take a history, examine her,if she's got no symptoms, i'd get her havinga faecal occult blood. it is one of the misconceptions

that breast cancer is a risk factorfor bowel cancer and a risk factor for the family. what are the current recommendations,jim? where are we at with screening? our national guidelines are that all australianswho are in good health should bein a population-screening program based on faecal occultblood testing, unless they have specialrisk factors.

we've discussedulcerative colitis and crohn's, lynch syndrome and familial polyposis. clearly,with a strong family history, where there's no definitegenetic basis, we base screening on colonoscopy. for 98% of the population,we'd say they should be havinga faecal occult blood testing every two years. if the test is positive,they should have that investigated.

that's normally doneby colonoscopy. that's the evidence base,based on randomised controlled trials which show a 30% reductionin mortality. level-1 evidence, randomised controlled trials,many other studies. but we don't havean evidence-based - national screening program, do we?- we're moving towards it. it's a huge task to set up a national programfor five million people,

to make sureyou have high quality, that you're gatheringall the data to show what the outcomes are,how efficient the program is. so the decision was madeto start with people turning 55 and 65, then to roll out the program from there. in 2008, it was decided to include 50-year-olds.

you mentioned the budget in may. it was announced that 60-year-olds would be introduced into the program next year. people turning 60 from 1st january will receive invitations from 1st july. norman: that's at five-yearly intervals? jim: yes. in 2015, people turning 70

will join the program. then in 2017, there will be a start of a two-yearly rollout. the first thing is, we'll have screening every 5 years from 50 to 70. these things are so obviousyou forget - why fob testing? there's a good reason.

back in the mid-1960s,a surgeon in the united states was doing screening for rectalcancer using sigmoidoscopy. he said he wasn't finding enough. it wasn't productive. he suggested thatwe should use a test for blood in the bowel action. cancers tend to havelow-grade bleeding. because of that,there was this interest in faecal occult blood testingfor population screening,

a simple test to see who should behaving colonoscopy. randomised trials were startedin the 1970s, early 1980s. by 1996,we had this level-1 evidence. australia moved very quickly. we adopted this as our nationalguideline by the nhmrc in 1998. it was recommended thatthere should be a pilot to look at the practicality,the feasibility and the acceptability of thisin the australian population. we ran a pilot from 2002 to 2004.

then we had the startof the national program in 2006. one thing we found in the pilotwas that there were 1,270 people who hada positive faecal occult blood test and 67 of themturned out to have cancer. 5.3% it waswhen they had their colonoscopy. in the pilot, it was decided that people who hada strong family history or who had symptomssuggestive of bowel cancer as assessed by their doctorsshould also have a colonoscopy

even though their test was negative. in that group, there were 530.only 2 had cancer. so the likelihood of finding cancerwhen the test was positive was 14 times greater thanwhen it was negative, even though those people hadwhat we would regard as strong risk factors. it depends on the age, but it was between a 10 and 20,almost 30-fold increase in likelihood of finding cancerif your test is positive

compared to havinga negative test. it's a remarkable screening test. we've gone beyond - you don't brush your teethand you don't eat red meat? the test we useis an immunochemical test. norman: do a show-and-tell for us. it's an immunochemical testfor human globin. it only detects bleedingfrom the large bowel. if you brush your teeth,as you say, that globin is digested.

it isn't recognisable. norman: show us what happens. people receive this kitin the mail. this is the package. it includes a letter of invitation. they receive a pre-invitation letterseveral weeks before to alert themthat this is about to arrive. and to encourage themand enhance participation. to encourage themto talk to their doctors

if they're not sureit's appropriate for them. say they've had bowel canceryears before, they're already having colonoscopy. they should see their doctorsand discuss it, and almost certainly phonethe information line and opt out. they receivean information booklet. they receive a registration formand a consent form. in addition, they receive the test kit. this is the kit currently being usedin the national program.

people worry about stool tests. we keep saying,once you've done it once, it's easy. when they do it, they say,no problem. they worry about smell, they worry aboutthe faecal aspect of it. this is where, in general practice,we can be useful. we can tell them in advance, you won't have to handle it,you won't have to touch it. it's up to us to do that.

how do they collectthe bowel action? this is a collection sheet, which is placed above the waterin the toilet bowl. it's methylcellulose. it's waterprooffor two or three minutes. it's biodegradable. - they have to collect samples...norman: two samples? - two samples.norman: from separate stools? jim: yes. there's no diet needed,no need to change medication.

all they have to dois collect the samples. they have a probe.you will see there's a red line there. they have the tube, whichcontains a buffer, a liquid. having passed the bowel actiononto the collection sheet, they insert the probedown to that depth, swipe two or three timesand then simply insert. when that's inserted, that locks. there's a transport tubeto protect it. then it's putin a zip-locked bag.

norman: then you put that somewhere cooluntil the next time. jim: yes. next bowel action, the same. they collect the sampleand in it goes, into its tube. that is returnedin a reply-paid envelope. with the forms. sally: who do the results go to?- to the participant, and they normally nominatea general practitioner, so to the general practitioner, and a copyto the central register.

- they'll know to come to us?jim: yes. it's terribly importantthat people are aware that it is so simple. currently less than 40% of peoplewho receive those kits do anything about it. 60% of them end up in the bin,and that's a tragedy - it's a lost opportunity. what are the numbers comingto pharmacies for the kits, john? it depends on whether rotaryhas got a promotional period

or it's a bowel-screening week,but they do come in. or whether a local personhas had bowel cancer. these are all the triggers. that's when we fieldlarge numbers of inquiries. you have an immunochemical testas well? yes. the one we currently useis this one. norman: tammy,show us how this one works. basically, they will purchasethis kit from a pharmacy. inside the envelope,there will be two blue plastic bags,

two brushes. these plastic bagshave a different function from the plasticwe saw jim showing us? tammy: yes. there's quite a good,in-depth instruction manual, full of pictures, so it's easy to use. going to the toilet, you would put your used toilet paperin the blue plastic bag. then get the paintbrush and swirlthat around in the toilet water.

you don't have to swirl itinto the stool itself. the occult blood will attachfrom the toilet water onto the bristles of this brush. then you take the sample cardin here, and still number one,you would wipe that on this test strip, put this in the blue plastic bag,put it in the bin, seal that over. then the second timeyou go for your next stool, you would take out the second brushwith the second square,

wipe this on here, seal that over,place this in the bin also. then you would put thisin the envelope that is returnedto the pathology unit. the results will come backtwo weeks later to the gpwhich the patient has requested and to the patient themselves,in order to follow up whether the test was positiveor negative. the bowel screen is something thatbowel cancer australia set up in collaboration withthe pharmacy guild

and the supplier of the test kitas a simple alternate pathway for people who weren't receivingkits from the government. we haven't found many customers,patients, having difficulty with the process. it's very easy to follow. we haven't had people saying, 'i messed it up,can i have another kit?' we also find that 83%of those who have done the test would do it again becausethey realise how simple it is.

the majority of my patients,when i press them, say, 'i didn't do it'cause i didn't want to know whether i had to touch it.' may i ask a question?we've got the five-yearly screening. but isn't the nhmrc practice thatwe do it every two years over 50? do we do it in between? the national programis moving to two-yearly. but meanwhile, we in generalpractice should do it two-yearly? yes, they're advised to have thatdone every two years.

is the colonoscopy that follows a positivefaecal occult blood test free? no. in the national program,the test is free, but then it's usual care. they can be referred toa public hospital or privately. it's up to the general practitionerto decide. sally, access to colonoscopy? it's hard enough in the city but in rural areasit must be very difficult,

especially in the public system. many of my patientscan't afford to go private and can't afford to waitto go public. it's a problem. at bowel cancer australia, we geta lot of inquiries from patients who have beenon the screening program. their concern isthat if they are remote, they're on a three- or four-monthwaiting list when they've had a positive test. a question from robert - 'how longdoes it take for colon cancer

to develop from a harmless polypto the first stage?' give us a senseof the natural history. people are focused on polyps. not all polyps are worrying. no, not all polyps are worrying. there's a histological typeof polyp which can almost be dismissed. small, distal hyperplastic polypscan almost be ignored. and are not an indicationfor a colonoscopy?

not for a repeat colonoscopy. if that's all that's foundat a colonoscopy, that patient goes back to beingthe risk they were before that polyp was removedand analysed. an adenoma, that type of polyp,adenomatous polyps, generally take at least something in the order ofeight to ten years if they're going tobecome a cancer. we've got to remember thatnot all polyps will.

a rough estimate would be thatin good hands, a colonoscopywill detect adenomatous polyps in probably as high as 50% or 60%of people. but over their lifetime, only 5% to 8% of australianswill get bowel cancer. so we just have totake polyps off without knowingwhether that was the polyp that was going tobecome a cancer. another question from craigfrom broome asks,

'is there any connection betweendiverticulitis and colon cancer?' and janet,a nurse from newcastle asks, 'can the symptomsof diverticulitis confound the diagnosisof bowel cancer?' there's no link betweendiverticulitis and bowel cancer. and yes, like a lot of othergastrointestinal conditions, including irritable bowel syndromeand haemorrhoids, there's huge symptomatic overlap. jim: i mentioned before thatthe tests are colon-specific.

many people who havea normal colonoscopy as part of their investigationare then advised to have a gastroscopy. it is entirely inappropriate. like the colonoscopyhasn't gone that far? if the bleeding is only arisingfrom the large bowel, it's quite inappropriatewith an immunochemical test for them to have a gastroscopy. it's an unnecessary burdenfor them

obviously unlessthey've got symptoms. you've found bleeding, you don't find anythingin the colonoscopy, and they say, maybe there's somethingin the tummy which there won't bebecause it would be degraded. jim: we assume it's bleedingfrom haemorrhoids or diverticular diseaseor some other innocuous cause. norman: damien is 47.he's the only lawyer in a small rural town.

he comes to you, sally, wanting a check-up. he's got no symptoms. a family history of ischaemic heart disease but no family history of cancer. he wants bowel cancer screening. sally: bowel cancer screening?norman: yes, doctor, and now. by the way,he's a litigation lawyer.

he used to work foran ambulance chaser so i'm told. i'm not going toplay defensive medicine, i'm going to treat him properly. he's 47,and the national guidelines say i should start my screening at 50if he's got no family history. but i treat people,not national guidelines. i see no skin off his or my nose to prescribea faecal occult blood test. i would not advise himto have a colonoscopy,

but i would advisea faecal occult blood despite the factthat he's not 50. what if he says, sally,that it's an inaccurate test. it's got false positivesand false negatives? he wants the real thing. i want to dothe faecal occult blood first. let's discuss it after that. you would say also that colonoscopy has false positivesand false negatives.

not by the good dr bell's hand. but it's a good point, norman.james is right to bring it up. people presume thatcolonoscopy is perfect, and it's not. we've known for at least 15 years that there is a thingcalled missed lesion. it should be discussed with everypatient having a colonoscopy as one of the potentialcomplications of the procedure. damien then says to you, sally, 'but i get some itchingon my bottom

and there's bloodon the toilet paper and sometimes a spatteringin the pan.' i would examine him. i would get on the gloves and do as the goodsir edward hughes taught me - put my finger inbefore i put my foot in, as long as he didn't have pain. with the spattering, the itch,he's probably got abrasions. i would treat clinical signsthat i saw.

norman: but you might not see anything. that's true, isn't it, sally? there's nothing to feel,you can't see anything, there might be somehaemorrhoids there. there's no fissure. and he's a litigation lawyer. he'll have a bit of excoriationfrom scratching. what's the commonest causeof perianal itch? pruritus ani -latin for itchy bum.

norman: that's a nice fancy description. it's usually due to overvigoroususe of toilet paper and irritation of perianal skinfrom paper particles. we'd treat that first, then get himto do his faecal occult. but get rid ofthe possible causes. norman: buy a bidet, then move on.- that's it. at the same time,you'd want him to understand that his risk for bowel canceris rising progressively as he gets older.

if he starts screening now, he should continueon a regular basis. do you want to look atthe absolute risks at this age? we've got a graphicof absolute risk. at 45, 50, it's about 1 in 300. man 1: he's almost at 50. man 2: in the next five years. man 1: his likelihood of getting bowel cancer in the next 5 years

is 1 in 300. in the next 10 years, 1 in 100. sally: are you saying he'll pressure us for a colonoscopy? i'm trying to get to the point where,my understanding is that if you've got symptoms,you don't proceed to fob testing, you proceed to colonoscopyor sigmoidoscopy. not in the case where we've gotsymptoms we can treat. if he's got somethingwe can treat

and get rid of the symptoms,then check faecal occult blood. give him anti-itchand anti-haemorrhoid cream, then test his fob. i'd also seeif he was iron-deficient. some people who have symptomsdo need to have investigation for the symptoms,right through to colonoscopy. but once that's been sorted out, he would then need to haveongoing screening. in his case, it would be based onfaecal occult blood testing,

unless you found an advanced adenomaat the colonoscopy or some special risk factor. it's important to differentiateinvestigation of his symptoms - history and physical examinationto begin with and whatever else - and the issue of screening. they're two separate discussions. i'd also call on tammy to look athis primary-prevention program. what are you going to do for him, having been reminded,thank you very much?

considering he's a solicitor and possibly sittingfor the majority of his day, i'd want to be looking at... well, he's fidgeting'cause he's got an itchy bum. true. moving on the seat. looking at what his average daylooks like. what's his dietary intake like? how sedentary is his lifestyle?is he a big drinker? does he smoke?

looking at the parameterswe could change to minimise his risk. if it is haemorrhoids,are you drinking enough water? are you having too much fibre? if you're not hydratedwell enough, causing potential haemorrhoids. speaking of his risk factors,we did know he has a family historyof ischaemic heart disease. we could suggest helping bothhis risk factors with aspirin.

i believe there's work donein aspirin. there's mounting evidencethat low-dose aspirin - 75mg or 100mg per day -reduces the likelihood of the development of adenoma,of cancer itself and of death from bowel cancer andalso other cancers, interestingly. but bowel cancerseems to be the one where there's the greatest effect. won't that cause problems withthe faecal occult blood test? no, not with an immunochemical one.

if bleeding is gastric, that blood will be broken downand won't be recognised. do you get people asking forlow-dose aspirin for cancer, john? not really. but we find a lot of peopleover 45 now are taking low-dose aspirinas a prophylactic, certainly to prevent stroke and other areasassociated with their health. it's a common feature now.

angela,a general practitioner registrar from mount beautyin victoria asks, 'if we screen biannuallybetween government tests, is this covered bythe general rebate with medicare or is the patient out of pocket? or can the gp order the testlike a normal pathology test?' i order itlike a normal pathology test and i haven't had complaintsfrom patients so i presume they geta medicare rebate.

you send them to the pathologistand they give you an fob kit? no, i have it in my cupboard. can i make a point? they have a use-by date on them.sometimes it's short. if the patient doesn't do itfor six to eight months, they can pass its use-by date. you've got it in your cupboard,it's sent to the pathologist - and they bulk bill?sally: yeah. leo from mount beauty -

i presume the gp supervisorof angela - asks, 'what's the false-negative ratefor bowel cancer screening?' for faecal occult? with the immunochemical testwe're using, the sensitivity for canceris of the order of 85% to 90%. it's far more sensitivethan the guaiac tests we used in the randomised control trials. they missed about 50%of the cancers. - sensitivity or specificity?jim: sensitivity.

and the specificity? i always get this wrong. specificity is false negative,isn't it? clinical epidemiology question. you shouldn't have asked it. it's for performance in peoplewho don't have disease. so, how often does someonewho's healthy get a positive test? it's in the order of 2% or 3%with the test we're using. this is a test for blood

and we're talking aboutdetection of neoplasm. i think leo's askinghow many cancers are missed. what proportion of cancersare missed? in the national program,we'll have to wait to see what happensover the next few years. but it's of the order of 10%,we believe. the next case study is joe,who goes to see you, john, at his pharmacy to buy an fob kit. he's heard he should get tested.

he's worried because his grandmother had bowel cancer when she was 45. i'd say there's no disadvantage in selling him a test kit. of course, at 45,he doesn't meet the criteria, but there's still abouta 1 in 600 chance. they're better odds than lotto, and a better prizeif he's found he's got a problem.

he's got a family history of it. maybe cameronwould have a better idea of it. how do you make senseof this family history, cameron? you'd want to look into it. his grandmother was only in hermid-40s when she got bowel cancer and that's regarded as -no bowel cancer is good - but in terms of the significancefor other family members, 55 is the cut-off. norman: if indeed she had bowel cancer.

if she had bowel cancer.that would need to be verified. then it would bevery interesting to know what joe's parent,the grandmother's child, had - whether there had beenpremature death from cardiovascular disease, or whether they might have hadcolonoscopies and had large polyps removed, which would change the whole thing. that's then somebody who potentiallyhas two bowel cancers

in his family history. norman: if they'd had screening,they would have had it. yeah. we just don't know. we can never say to somebodywho's had a polyp removed, 'well, that was a cancer prevented.' there are some timeswe think that's pretty likely. but if you went intothe family history a little bit more, his family historymight become more significant. would you take the family historyin the pharmacy, john?

you don't take the family history because we're involvedin the screening. the advice i would give him ifhe was concerned about buying it, which he isn't, but if he was, i'd tell him to have a discussionwith his gp. i'd let the gp take the history. if someone comes inat 45 years of age, i'd say, 'well, what's the downside of him buyinga bowel-screening kit anyhow?'

the odds still increase of bowelcancer over 40 years of age, even thoughit's not the guidelines. - sally?- i was going to say, if he has a negative result but you've just found his motherwas screened and had polyps, he goes on to have a colonoscopy. we don't know about the mother.the grandmother died at 45. he's negative, and he's 45.what do we do with him then? we don't knowwhat his family history is.

you would probably at the very leastbring him back when he's 50 and do faecal occult blood testingevery one or two years. norman: make sure he's not missed. that he doesn'tfall through the cracks. what's the story withflexible sigmoidoscopy? i noticed a randomised trial in the new england journala couple of weeks ago suggesting it was more effectivethan fob testing. there are huge logisticaland infrastructure ramifications.

it's different. there's been a lot of interestin using flexible sigmoidoscopy perhaps at the age of 55,or even every 5 or 10 years as a screening method. it's not competingwith faecal occult blood testing. you can combine the two together. in the english screening program,they're suggesting they should have flexiblesigmoidoscopy performed at 55, then occult blood testingfrom 60 through to 74.

what proportion of cancers occurin the left side of the colon? about 60%. the percentages are changing slightly. they've shown in three trials,in england, the plco trialin the united states and the score trial in italyhave all shown in volunteers that flexible sigmoidoscopywill reduce the incidence and the mortalityfrom bowel cancer in general, but very much soin left-sided bowel cancer.

- but these are volunteers.- not randomised. how would our population react tothis? would they accept the test? james is saying, you've got tomultiply that success rate in detecting advanced adenomasor cancers by the participation rateif it's offered to a population. norman: it becomes diluted.- it's of great interest. watch this space. i meant to ask you earlierabout information sources, places people can gofor information, jim.

one obvious siteis the cancer screening website: there are a number of thingswhich can be downloaded. all the lettersand all the instructions for the national program. a summary of the nhmrcnational guidelines. information on family history,again, nhmrc-endorsed and developed bycancer council australia. and i think i showed you before,the booklet used in the program. there's a lot of information there.

so it's cancerscreening.gov.au there's a coupleof other cancer sites - bowel cancer australiaand cabrini, melbourne. i also say, norman, thatgeneral practitioners are asked to send information backto the national program when they see patientswith positive faecal occult blood tests. it's a very simple form,and it can be completed online or you can ringthe information line in hobart, the medicare information line,to get hard copies

or you can print copiesof the report and complete them manuallyfrom the website. all you have to put in is... checktwo or three boxes, essentially, then return it to the program. we touched on family historyseveral times, but i thinkwe should make the point that the nhmrc guidelinesstratify the risk of your family history. for example, if you havea single first-degree relative

whose cancer developedover the age of 55, they regard thatas a low increase in risk. the guidelines suggest that those people be treated asaverage-risk individuals and start screening at age 50. the intermediate-risk category is somebody whose first-degreerelative was younger than 55 or who has two family memberson the same side of the family, whatever their age was,affected by bowel cancer.

for those people,the recommendation is colonoscopy at ten years younger thanthe youngest affected relative. then there are the fap people andthe lynch syndrome people, whose... starts at an earlier age. ..colonoscopy is more intenseand rigorous. you're watching a rural healtheducation foundation program on preventing and early detectionof bowel cancer. we'll be back after this. a home fob testcould save your life.

i wish i'd done it earlier. fob testing is so important. all of these people have hada long battle with bowel cancer. it's a conditionthat kills around one australian every two hours. yet a simple home fob test kitcan help prevent it. please purchasea home fob test kit. it could save your life too. - i recognised her.- it was me, indeed.

those were peoplewho volunteered their time. and having someone as high-profileas cocksie was magnificent. people have seen that in movietheatres. it's scary to think. it would put you offyour choc bomb. 25-year-old glen is a fitter and turner in a factory. one of his mates was diagnosed with bowel cancer, and they were talking about how

it's different if caught early. he saw this ad on tv and is looking for advice, but he's scared because he's had bleeding and pain around his anus and has been constipated. no family history of bowel cancer. what will you do for him, ambassador? i need to take his concern seriously

and to fob him off,if you'll excuse the pun. but he's got symptoms,and i need to investigate these, examine him and see if i can seeevidence for his bleeding. at 25, his risks are very low. if he's got pain,and it sounds like an anal fissure, i'm not going to stick my finger inbecause it's too painful. he's another examplewhere i would treat his symptoms and get him backand talk about it again. i'd also give him informationon bowel cancer.

cameron, take me throughthe history-taking of bleeding - what's worrying, what's not.when you can relax, when you can't. - well, it's a minefield, basically.norman: a red one! at the lower endof the concern spectrum is small amounts offresh, bright-red blood on the toilet paper only,not mixed in with the stool, particularly if a patient tells you it's been happening on and offfor years and years, unchanged. at the other end of the spectrumis heavier bleeding,

particularly if it'sdark maroon-coloured blood, suggesting that it's notfrom low down in the anorectum, particularly if the bloodis mixed in with the stool and particularlyif it's a recent development. it's a minefield, though. but a low cancer willgive you fresh bleeding that looks like a haemorrhoid. absolutely. as sally said,no-one should be fobbed off.

unless her symptomatic patient joe responds immediately to treatmentfor his anal fissure, i'd have a low threshold toinvestigating someone like that with sigmoidoscopy. he doesn't deserve a colonoscopy? i wouldn't colonoscope himbecause he's got symptoms that all sound as if they'rewithin reach of a sigmoidoscope. if he was a litigation lawyer? exactly the same.i'd treat him like he were my brother.

i'm just getting a little nervous that you're all a bit relaxedabout bleeding. no, i'm not relaxed. but i think in somebody like him, where there is no issueabout bowel cancer screening, we're talking now abouta symptomatic patient and flexible sigmoidoscopyis adequate investigation of this guy's symptoms. fob is not an option in him.

he's got bleeding. he's 25. if i'm in downtown,suburban sydney or melbourne, i can send himfor a sigmoidoscopy. but if i'm in a rural area,he's 25, a fitter and turner... it looks like an anal fissure,it smells like an anal fissure, it cracks like an anal fissure,i'd treat that, then get him back and review him,and say, 'any more anal bleeding withoutthe anal fissure and off you go.' to what extent do youonly get bleeding once

and that's the only signyou've ever got? and have bowel cancer?that can occur. many bowel cancers are silent until you've reachedan incurable stage. once you've got bleeding, are youlikely to only have one episode? i know what you're getting at. - it's possible.- thanks for that. investigating symptomatic people,i'm talking about. notwithstanding the low riskof finding something.

i fully agreewe do have to take this seriously. sally: yeah, but logistically...- most early-stage cancer causes no bleeding, no symptoms.it's silent. but a 25-year-old guy, i mean,where do you draw the line? what are we saying to peoplein remote areas? i'm talking abouta 65-year-old guy. this is another misconceptionfrom both the general public and as health professionals - we are seeing young peoplewith bowel cancer.

a lot of young peoplecoming to bowel cancer australia are telling us,'we have visible bleeding. we thought it was haemorrhoids,so we didn't worry about it.' they were pumping weights,taking a lot of protein. we really need toget the message out there that young people can have bowel cancer. we've got to put it in perspective. if every year,14,000 australians get bowel cancer, of that 14,000,1,000 are younger than age 50

and less than 80are younger than age 35. at 25, you just don't lose themto follow-up. you presume it's an anal fissureunless there's bleeding - i'll be clear -but you get them back. you don't lose them to follow-up. make sure your receptionistreminds you in a month's time to phone him upand find out how he's going. he's young. he might haveinflammatory bowel disease. if he's 55, even though you thinkit's an anal fissure?

i'd think about his symptoms,and if they were still distal, to investigate his symptoms,i'd do a sigmoidoscopy. but if he's an average-risk guy, if it's going to make faecal occultblood testing impossible, and i'm not sure you can relyon the fact that the visible blood disappears. it's possible,after a fissure heals or if someone has haemorrhoids, it's possible to havebleeding-related

anorectal pathologyto make the fobt unreliable. do you meanflexible sigmoidoscopy? so examinationof the rectum, the sigmoid colon and into the descending colon. my point was,if this was a 55-year-old guy where you can't assumethe disappearance of visible blood means he can have an fobt, thenprobably he needs a colonoscopy. very quickly, colonoscopy,current bowel preps and so on. give us a flavour, so to speak.

norman: what they do now.- they've improved, but they're still not ideal. generally, there's several daysof avoiding high-roughage things, particularly things with seeds. while they're good for the bowelnormally - muesli, multigrain breads,et cetera - avoid those forthree or four days beforehand. clear fluids the day before, then a bowel preparationthat's two or three sachets.

it depends on ageand absence of comorbidities like heart and renal disease, but for most peopleunder the age of 70, two small-volume doses and a large-volume dose,is my standard preparation. we've got some graphics of polypsso you can see what happens. what are we looking at there? on the left of the screenis a sessile polyp that's not particularly big.

on the rightis a pedunculated polyp. both of thosewould be easily removed. at the colonoscopythey were detected at, they could be removedwith a snare. that's a straightforward procedure. they should always be collected and they should all be sent forhistopathology. a couple of case studies - a 52-year-old womancomes to see you, sally.

she's back from looking afterher sister, who's a year or two older, who's just had surgeryfor bowel cancer. that's easy. she's got a familyhistory. her sister is young. i'd send her fora colonoscopy and bypass fob. another case is a 65-year-old womanwho's living in queensland who comes to see youfeeling very unwell. she's overweight, a smoker, drinks alcohol on a regular basis.

she's been suffering from diarrhoea, bloating and cramps, feeling fatigued and vomiting for a week. sally: there's so many things she could have. i'll have bowel cancer on my list of differential diagnoses, but i'd need a full work-upwith her.

you'd probably include iron studies. if she's iron deficient,in premenopausal women, there's a bit of roomfor manoeuvre. but in a postmenopausal womanor in a male, iron deficiency is a red flag. if she has cancer,it's not good news in her. if her symptoms are due to bowelcancer, her prognosis is worse than if she's foundto have an asymptomatic cancer, say, as a result of screening.

are we still intodukes' classification? no, we've moved on. there's a tumour nodemetastasis classification that yields stage 1 to 4 that roughly correspond to the a, b, c and d of the old dukes' classification. the a and the b are variably involving bowel wall only.

c, or stage 3, involving nodes. stage d or 4 involving metastasis to distant organs. norman: and the outcome of surgery? cameron: in the first stageis very good, as is illustrated on the graphic. in stage 1 disease, 5-year survival rates are around 90%.

they progressively fall as the tumour involves deeper into the wall, then the lymph nodes. by stage 4, with metastases present, the 5-year survival is 5% to 8% only. norman: gps need to know this

because they're pleasedshe's going to come back - adjuvant chemo is routine now? its clearest roleis in stage 3 disease, so when lymph nodes are present. it's unnecessaryin stage-1 disease, and it's more controversialin stage-2 disease. so where the cancer is furtherthrough the bowel wall but not yet involving lymph nodes. that's a complex decision.

i know we're running out of time.two or three quick questions. carol from tamworth asks, 'ischronic constipation a risk factor - for bowel cancer?'- no. april from toowoomba asks, 'does a vegetarian dietprotect you from bowel cancer?' no, not necessarily. you're not eating red meat. that's right. it's a limiting... i thought seventh-day adventists

had a lower incidenceof bowel cancer? i can't tell you on that one.cameron: i think they do. i know vegetarianswho have had bowel cancer, so it's somethingyou can't rule out. norman: sure. we were saying exercise, but many people who exerciseget bowel cancer. right.but it is reducing the risk by minimisingyour red-meat intake. andrew from alice springs asks,'is there any evidence

that an infective agentcan contribute to the development of bowel cancer?'not a silly question. i'm not awarethat there is an infection that increases the riskof bowel cancer. sally: are we starting to get intoepigenetics? not necessarily. we said there's no chance of itin stomach cancer and we know that h-pylori is related. it's not a silly question.

but common bowel infections, things like salmonella,campylobacter, shigella don't predispose to subsequent... thank you all very much.it's been fascinating. sorry it's been rushedtowards the end. we don't want to get to the stageof that lady at the end, where she's got spread, and you're strugglingto get to a good result at all. what are your take-home messages?jim?

with the national bowel cancerscreening program, we know from the biogrid study,which has been run with the colorectalsurgical society of australia, that people diagnosedthrough the program are far more likelyto have stage-1 disease - 40% if not more with stage-1 - compared to those who presentwith symptoms, where it's 14%. with distance spread, very few,3% had metastatic disease compared to about 15% in thosewho presented with symptoms.

we're getting early-stage cancers... norman: it's a powerful story.- ..which should translate into better survival. norman: tammy?- two points. for those listening, don't underestimatemodifiable lifestyle factors. taking the time to talk to peoplein terms of what they're doing and changesthey could possibly make to improve their healthis important.

also - talk, test and tell. talk about bowel cancer. test for itif you're within the age groups or if there are symptoms. and tell your familyif it is in the family. norman: sally?- as general practitioners, it's up to us to sell the messagethat this is an insurance policy, the only cancer we can prevent other than cervical cancer,with the vaccination.

and work in partnershipwith our pharmacy colleagues. together, we should be ableto make sure people live. in rural areas,it's often hard to see a gp, so they can pick the test upat the pharmacy, and if they're positive,they're referred back to their gp. that's the arrangement. in that age group, you don'thave to have the symptoms to have the start of a cancer,so get tested often. norman: cameron?- everyone over the age of 50

should do something to reducetheir risk of bowel cancer. if they're asymptomaticand have no family history, a faecal occult blood testevery two years. if they've got symptoms,get them investigated. if they've got a strong familyhistory, have a colonoscopy. thank you all very much. i hope you've got a lotfrom this program on bowel cancer. let's get those mortality rates down. if you're interested inobtaining more information

about the issues raised,there are a number of resources on the rural health educationfoundation's website: you can go to the beating cancer -prevention, detection, treatment program web pageand click the resources link. if you're a health professional, don't forget to completeand send in your evaluation forms, which can be found on the website. you will receive a certificateof attendance and if eligible, cpd points.

thanks to the australian government's department of health and ageingfor making the program possible and thanks to you for taking time to attend and contribute. for more information aboutthe rural health channel on 600, you can find thaton the foundation's website: i'm norman swan.i'll see you next time. captions bycaptioning & subtitling international

funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�