Category Archives: Bowel Cancer

FIT visual abstract

Guest Plain English summary: Worried about symptoms of bowel cancer? A simple stool test may help.

Kai Sheng Saw, Chen Liu, William Xu, Chris Varghese, Susan Parry, Ian Bissett

Have you ever worried if you or a loved one has bowel cancer? Bleeding from the rectum, changing bowel habits, unexplained weight loss, abdominal pain and bloating are symptoms associated with bowel cancer, warranting a visit to the doctors. However, studies have demonstrated that presence of these symptoms are poor predictors of colorectal cancer diagnosis.(1)

Currently, when these symptoms are raised with your doctor, it is very likely that the next step would be a colonoscopy or colonography. This involves clearing your bowel with bowel preparation laxatives for the test, and the discomfort of having a medical instrument inserted into one’s back passage. These colonic investigations also carry small but significant procedural risks.

The faecal immunochemical test, or FIT, is a simple and non-invasive test for patients who present to their doctors with symptoms concerning for bowel cancer. It is stool test that can reliably detect minute amounts of human blood in faeces that is not always visible to the naked eye. Most bowel cancers bleed to varying degrees into the colon and mix with faeces. FIT has been widely used in bowel cancer screening programmes but surprisingly it is only with COVID constraining access to healthcare that interest to expand its clinical use for patients with bowel cancer symptoms has taken hold.

We hypothesised that the FIT test could measure the amount of blood in faeces of patients presenting with concerning symptoms and categorise them into different colorectal cancer risk groups to help doctors determine the need for and urgency of recommending further invasive colonic investigation.

At the end of August 2021, we looked at over 9600 relevant academic publications on this topic, selected 15 high quality studies that were best designed to answer the question and combined their results for further analysis.

Our analysis showed that at the lowest possible detectable faecal blood by FIT (≥2 microgram Hb/g faeces), a positive FIT test would detect approximately 96 out of 100 colorectal cancers. In two of the largest studies conducted in the UK (2, 3), up to 63% of patients who under current standards would undergo an invasive colonic investigation because of reported symptoms, would be able to avoid one. 

When settings are adjusted to be in line with current National Institute for Health and Care Excellence (NICE) recommendations (≥10 microgram Hb/g faeces), a positive FIT test would pick up approximately 88 out of 100 colorectal cancers. If one has a negative FIT test at this setting, it is estimated that approximately only 1 in 243 patients undergoing invasive colonic investigation would have a cancer detected, meaning by contemporary practices, 242 patients would undertake the risk of a colonoscopy despite not having bowel cancer. (2,3)

Conversely, if FIT detects higher levels of blood in faeces (such as at ≥100 or ≥150 microgram Hb/g faeces), approximately 1 in 3 patients will have bowel cancer diagnosed. 

For patients with symptoms, these results indicate that when very low levels of blood are detected in stool by FIT, the chances of having bowel cancer are adequately low, hence invasive investigation may be avoided. Conversely, if relatively higher levels of blood are indicated by FIT, the probability of an existing bowel cancer is very high and urgent colonic investigation would be ideal to detect and treat the cancer as soon as possible.

No test is perfect. The currently accepted gold standard, colonoscopy, is estimated to miss 5 in 100 cancers.(4) With the correct settings, our analysis suggests that FIT approximates this diagnostic accuracy while being non-invasive, accessible and cheap.  While colonic imaging tests have an irreplaceable role in the diagnosis of bowel cancer, it may be more optimal for patients, clinicians, and health care systems to rationalise the use of colonoscopy and colonography to avoid delays in diagnosis and treatment for those who are deemed to be at highest risk of bowel cancer.

There are more intricacies related to this question and areas requiring further research, hence, for more information, we invite you to read our Open Access article that was recently published in BJS

References

1.         Vega P, Valentin F, Cubiella J. Colorectal cancer diagnosis: Pitfalls and opportunities. World J Gastrointest Oncol. 2015;7(12):422-433.

2.         D’Souza N, Georgiou Delisle T, Chen M, Benton S, Abulafi M, Group NFS. Faecal immunochemical test is superior to symptoms in predicting pathology in patients with suspected colorectal cancer symptoms referred on a 2WW pathway: a diagnostic accuracy study. Gut. 2021;70(6):1130-1138.

3.         Turvill JL, Turnock D, Cottingham D, Haritakis M, Jeffery L, Girdwood A, et al. The Fast Track FIT study: Diagnostic accuracy of faecal immunochemical test for haemoglobin in patients with suspected colorectal cancer. British Journal of General Practice. 2021;71(709):E643-E651.4.         Pickhardt PJ, Hassan C, Halligan S, Marmo R. Colorectal cancer: CT colonography and colonoscopy for detection–systematic review and meta-analysis. Radiology. 2011;259(2):393-405.

Calculator

Guest blog: “Are you a gambler or an accountant?”

Permanent stoma rates after anterior resection for rectal cancer

Authors: E Back, J Häggström, K Holmgren, M M Haapamäki, P Matthiessen, J Rutegård, M Rutegård

Anterior resection for rectal cancer is a beautiful operation. Whether with hand-held electrocautery or robotic scissors, uncovering the mesorectal package in embryological planes is a most satisfying moment, especially when followed up by a nice, tension-free and well-perfused anastomosis; when all goes well, of course. Unfortunately, anastomotic breakdown is a far too common and dangerous event, tripling the risk of early death1. Quite often, such an event also leads to reoperation and a permanent stoma2. No wonder then that, after decades of research on the merits of defunctioning stomas preventing anastomotic leakage3, there’s a near ubiquitous use in low anterior resection4 (though recent reports challenge this dogma5). The caveat, it seems, is that even temporary stomas cause problems6 and might never be reversed7, questioning the sphincter-saving procedure itself. Moreover, the spectre of severe low anterior resection syndrome rears its ugly head even when a textbook outcome is accomplished8; on the other hand, quality of life might be worse for patients with a permanent stoma9, and this was reported even in the stoma-friendly Scandinavian environment.

The problem is insurmountable, it seems. Do you choose bowel dysfunction and the risk of a leak, or do you opt for a permanent stoma at the get go? Would you dare omit the defunctioning stoma? In short, are you a gambler or an accountant?

In any case, information on an individual patient level is sorely needed for such an important discussion. We’ve recently published a prediction study using pre-operative variables collected from the Swedish Colorectal Cancer Registry, where an attempt has been made at forecasting the risk of a permanent stoma at two years after anterior resection for rectal cancer. While close to five thousand patients contributed data in the analysis, using the ensemble method SuperLearner to develop and validate a moderately accurate prediction model, the real thrust from this study lies in the on-line calculator. The input is shown in Figure 1, where the key predictors can be varied to reflect the patient at hand.

Figure 1. Variables included in the logistic forward-backward selection model can be varied, reflecting the individual patient.

There are certainly more variables of importance out there, and the experienced surgeon will surely add some data to a mental recalculation; smoking, on-going inflammation, continuous immunosuppressive medication, as well as a weak sphincter might decrease the chances of a stoma-free outcome even more. The output can be seen in Figure 2, where the risk of a permanent stoma is depicted in a cross-tabulation of defunctioning stoma use and laparoscopy use; those factors are the only ones that can be altered at a preoperative consultation. Importantly, the output is a predicted risk with measures of uncertainty, providing lower and upper bounds of the permanent stoma risk. Consistently, there is a higher risk of a permanent stoma with the use of a defunctioning stoma, which recently was shown using mediation analysis4.

Figure 2. Output from the prediction model with corresponding measures of uncertainty.

We urge all fellow surgeons to play around with the calculator – it’s actually quite addictive. Perhaps it can be informative in a patient-centred approach to anterior resection, as it seems that, stoma avoidance has the same priority as cure of cancer in some patient populations10. While at it, we can also recommend the internationally validated prediction model for low anterior resection syndrome, POLARS11. While all these prediction models can be improved, it is certainly worthwhile for both surgeon and patient to have some idea of the expected results after anterior resection. 

References

1 Boström P, Haapamäki MM, Rutegård J, Matthiessen P, Rutegård M. Population-based cohort study of the impact on postoperative mortality of anastomotic leakage after anterior resection for rectal cancer. BJS Open. 2019 Feb; 3: 106–111. 

2 Holmgren K, Kverneng Hultberg D, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study. Colorectal Dis. 2017 Dec; 19: 1067–1075. 

3 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007 Aug; 246: 207–214. 

4 Holmgren K, Häggström J, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer. Colorectal Dis. 2021 Jul 26; 

5 Talboom K, Vogel I, Blok RD, Roodbeen SX, Ponsioen CY, Bemelman WA, et al. Highly selective diversion with proactive leakage management after low anterior resection for rectal cancer. Br J Surg. 2021 Jun 22; 108: 609–612.

6 Gessler B, Haglind E, Angenete E. A temporary loop ileostomy affects renal function. Int J Colorectal Dis. 2014 Sep; 29: 1131–1135. 

7 Jørgensen JB, Erichsen R, Pedersen BG, Laurberg S, Iversen LH. Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study. BJS Open. 2020 Dec 2; 4: 1162–1171. 

8 Emmertsen KJ, Laurberg S, Rectal Cancer Function Study Group. Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer. Br J Surg. 2013 Sep; 100: 1377–1387. 

9 Näsvall P, Dahlstrand U, Löwenmark T, Rutegård J, Gunnarsson U, Strigård K. Quality of life in patients with a permanent stoma after rectal cancer surgery. Qual Life Res. 2017 Jan; 26: 55–64. 

10        Wrenn SM, Cepeda-Benito A, Ramos-Valadez DI, Cataldo PA. Patient Perceptions and Quality of Life After Colon and Rectal Surgery: What Do Patients Really Want? Dis Colon Rectum. 2018 Aug; 61: 971–978. 

11        Battersby NJ, Bouliotis G, Emmertsen KJ, Juul T, Glynne-Jones R, Branagan G, et al. Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut. 2018 Apr; 67: 688–696. 

External aspect of the operative field: DaVinci™ robotic system docked to the patient

Guest blog: What advantage does robot-assisted and transanal TME have over laparoscopy?

Authors: Jeroen C. Hol, Colin Sietses

Contact: j.c.hol@amsterdamumc.nl

Correspondence to: “Comparison of laparoscopic versus robot-assisted versus TaTME surgery for rectal cancer: a retrospective propensity score matched cohort study of short-term outcomes

Image source: Robinson Poffo et. al. Robotic surgery in Cardiology: a safe and effective procedure. https://creativecommons.org/licenses/by/4.0/ under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The emergence of minimally invasive surgery has led to the development of three new surgical techniques for oncological rectal resections: laparoscopic, robot-assisted and transanal TME (TaTME). When we compared the three techniques executed in expert centres, we expected to find an advantage for one of the three techniques in terms of reduced complication rates. But contrary to our expectations, no difference was seen. There was one striking difference however, when comparing these techniques, though it might be something different than you might have thought. We shine a light on all three techniques to explain their advantages. 

Laparoscopy: minimally invasive surgery

In the 1980’s, Heald introduced the total mesorectal excision (TME) principle, which comprises excision of the rectum and its surrounding fatty envelop with preservation of the autonomic nerves [1]. TME has become the golden standard for surgical resection for rectal cancer and helped dropping local recurrence rates drastically. The past decades laparoscopy has been introduced and gradually replaced open surgery. Laparoscopy offers short term benefits of minimally invasive surgery, such as faster recovery and reduced complication rates [2, 3]. It offers similar long-term outcome as open surgery [4]. But laparoscopy is technically demanding because it is difficult to work with rigid instruments in the narrow and confined area of the pelvis. Therefore, conversion rates to open surgery of more than 10% were seen [5]. Conversion is linked to increased morbidity and worse oncological outcome [6]. In order to overcome those technical limitations of laparoscopic TME, new techniques have been introduced; robot-assisted TME and TaTME. 

Robot-assisted TME: the same, but different

Robot-assisted TME comprises the same approach as laparoscopy, but with the use of a surgical robot. The surgical robot provides a stable platform with supreme vision and supreme instrument handling. Surgeons thought this technique might improve results in terms of reduced complication rates and reduced conversion rates. However, the largest randomized trial so far comparing robot-assisted and laparoscopic TME failed to show any difference in these outcomes [7]. This might have been the result of a methodological flaw, because the robotic surgeons in that trial were not as experienced as their laparoscopic colleagues [8]. In our study, we tried to eliminate this by only selecting experienced centres that were beyond their learning curve. However, we did not see reduced complication rates or reduced conversion rates after robot-assisted TME compared to laparoscopy.

Transanal TME: a different approach

TaTME comprises a different approach to address the most difficult part of the dissection. In TaTME the most distal and difficult part of the rectum is dissected from below using a transanal insufflator port. However, this is a technically demanding technique and has a long learning curve [9]. Some initial series showed high loco regional recurrence rates, which even led to a halt of TaTME in Norway [10, 11]. The potential learning curve effect is now part of an ongoing debate about the oncological safety of this technique. Most initial results however looked promising and showed consistently good quality specimen and lower conversion rates [12, 13]. In our study, conversion rates, number of complete specimen and morbidity rates did not differ from the other laparoscopy and robot-assisted TME. 

Technological advantage 

The results of our study showed similar and acceptable short-term results for all three techniques in expert centres. The most striking difference was that in centres with robot-assisted or TaTME, more primary anastomoses were made. The technological advantage of the two new techniques could have contributed to higher restorative rates. Both robot-assisted and TaTME provide better access and visibility to the distal rectum, enabling surgeons to complete the TME dissection safely and create an anastomosis. Robot-assisted TME could overcome technical limitations of laparoscopy in the narrow pelvis thanks to the use of 3D vision, lack of tremor, and superior instrument handling, thereby facilitating safe creation of an anastomosis [7, 14]. TaTME does not need multiple staple firing to transect the distal rectum and without requiring conversion to open surgery [13]. In fact, TaTME does not need cross-stapling at all, preventing the creation of dog-ears which are prone to ischemia [15]. 

Patient’s perspective

In conclusion, the technological advantage of robot-assisted TME and TaTME manifests itself in higher restorative rates. Each technique seems to be equally beneficial in terms of oncological outcomes and morbidity. However, anastomosis creation, quality of life and functional outcome are becoming of great importance to patients. It seems to be that an increasing proportion of patients is now in pursue of an anastomosis. The overall anastomosis rate of more than 84% for robot-assisted and TaTME in our study was higher than the anastomosis rate of 50% in a previous national study [16]. A note of caution should be added, as an anastomosis might not be always better in terms of functional outcome and quality of life. Patients with a low anastomosis are at risk of developing severe low anterior resection syndrome (LARS) symptoms. Severe LARS symptoms can have a detrimental effect on quality of life [17].  Further research should be undertaken to investigate whether a higher anastomosis rate is beneficial in terms of quality of life and functional outcome and whether this higher anastomosis rate actually leads to increased patient satisfaction. 

References

1.         Heald, R.J., E.M. Husband, and R.D. Ryall, The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg, 1982. 69(10): p. 613-6.

2.         Stevenson, A.R., et al., Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA, 2015. 314(13): p. 1356-63.

3.         van der Pas, M.H., et al., Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol, 2013. 14(3): p. 210-8.

4.         Bonjer, H.J., et al., A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer. N Engl J Med, 2015. 373(2): p. 194.

5.         Chen, K., et al., Laparoscopic versus open surgery for rectal cancer: A meta-analysis of classic randomized controlled trials and high-quality Nonrandomized Studies in the last 5 years. Int J Surg, 2017. 39: p. 1-10.

6.         Allaix, M.E., et al., Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival? World J Gastroenterol, 2016. 22(37): p. 8304-8313.

7.         Jayne, D., et al., Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial. JAMA, 2017. 318(16): p. 1569-1580.

8.         Corrigan, N., et al., Exploring and adjusting for potential learning effects in ROLARR: a randomised controlled trial comparing robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection. Trials, 2018. 19(1): p. 339.

9.         Koedam, T.W.A., et al., Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve.Tech Coloproctol, 2018. 22(4): p. 279-287.

10.       Larsen, S.G., et al., Norwegian moratorium on transanal total mesorectal excision. Br J Surg, 2019. 106(9): p. 1120-1121.

11.       van Oostendorp, S.E., et al., Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation. Br J Surg, 2020.

12.       Detering, R., et al., Three-Year Nationwide Experience with Transanal Total Mesorectal Excision for Rectal Cancer in the Netherlands: A Propensity Score-Matched Comparison with Conventional Laparoscopic Total Mesorectal Excision. J Am Coll Surg, 2019. 228(3): p. 235-244 e1.

13.       Grass, J.K., et al., Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery. Eur J Surg Oncol, 2019. 45(4): p. 498-509.

14.       Kim, M.J., et al., Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer: A Phase II Open Label Prospective Randomized Controlled Trial. Ann Surg, 2018. 267(2): p. 243-251.

15.       Penna, M., et al., Four anastomotic techniques following transanal total mesorectal excision (TaTME). Tech Coloproctol, 2016. 20(3): p. 185-91.

16.       Borstlap, W.A.A., et al., Anastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study. Ann Surg, 2017. 266(5): p. 870-877.

17.       Emmertsen, K.J. and S. Laurberg, Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg, 2012. 255(5): p. 922-8.

zebras

Bowel cancer is not just a disease of older people

A young surgeon’s experience as a patient with bowel cancer

If you ask any clinician, becoming a patient is an unusual experience. When you couple that with the naivety of youth, embracing the role of a patient is particularly challenging. 

“We are taught that we when we hear hoof beats, we should think horses, not zebras.”

As part of surgical training, and even in medical school, there are specific red flags that are taught to all of us. ‘Bowel habit change’ and ‘per rectal bleeding’ are not a great combination. We are also taught that we when we hear hoof beats, we should think horses, not zebras. So when I developed these symptoms I just assumed that I probably had a benign cause of bleeding. I assumed this for six weeks while I worked in a high volume liver and kidney transplant unit until I decided it was bothersome. I picked up the phone to one of my mentors, a colorectal surgeon. She subsequently performed my low anterior resection.

My story is different. I class myself as one of the lucky ones. I was aged 33, with no significant family history, only stage 3. I underwent a low anterior resection, fertility treatment and then 6 months of adjuvant FOLFOX. FOLFOX was not very kind. I didn’t require neoadjuvant radiotherapy, had clear margins and only 2 positive nodes. It is amazing how different your perspective is after such an unexpected life interruption. My life changed completely in one single moment.

From the beginning I called myself a lucky unlucky person. I had encountered young people with colorectal cancer in my surgical training, however, in clinics with 30-50 people being followed up in our public health system, it was still a rarity. When I was diagnosed in 2018 I only really began to appreciate the growing trend of young people being diagnosed with colorectal cancer. People that are not considered at risk. People under the age of 50. Where screening programs exist, all of these people would be too young to be screened. The age for screening in the United States has recently been lowered. It is still not practical for many reasons to extend population based screening to include those who are even younger. While the figures are alarming us all and steadily climbing, they still don’t meet criteria to support population based screening. 

“Becoming a patient reveals so much more about patient care and management.”

What is practical and even more alarming is these people’s stories. Bowel Cancer Australia and Bowel Cancer UK frequently highlight individuals who I never thought I would relate to. I am one of many in a long list of patients who are only too happy to tell their story in hope that someone might not have to go through and live with the effects of cancer. Becoming a patient reveals so much more about patient care and management. The anxiety relating to waiting, having scans, and to having your first operation as such a major one. The knowing too much, from the very beginning. After I was told that my surgeon found a cancer, I know I asked where it was. I meant anatomically. I asked this as I knew what the next investigations would be and what treatment (if I wasn’t metastatic) was being considered. It’s not a normal opening question from any other patient.  

It is really encouraging to see increasing attention being paid by researchers and surgical journal editors to the rising rate of colorectal cancer in young people, because it means that the message is being delivered regarding the need to investigate symptomatic people. This is separate to any screening argument. I have been part of the #Never2Young campaign and consider myself obliged to advocate for such awareness campaigns not only as a health professional, but as a colorectal cancer patient. I have become a statistic. I am one of those people diagnosed with a left sided colorectal cancer in the age group 20-49. 

Publishing real data and real stories and disseminating them will reach our communities and our clinicians working on the front line, trying to sort through who to investigate further or not. The message is becoming clearer for them now. Symptomatic people need investigating. I have seen firsthand only too many young people who have dismissed their own symptoms or had them dismissed by all levels of care. There are barriers to appropriate investigation with colonoscopy for many reasons. We need to make sure patients are better supported. 

Cancer does not discriminate.

I have completed treatment. I have had highs and lows within my surveillance already. I am lucky enough to have returned to work finishing my time in general surgical training. Navigating through life post treatment has days of uncertainty and sadness. I never stay sad too long. I constantly get reminders of just how lucky I am to still have this life that could have so easily been taken from me.

Cancer does not discriminate. It will choose anyone at any time. Anyone with symptoms needs to be investigated, as sometimes those hoof beats are actually zebras.

Katherine Goodall is a general surgical registrar from Queensland Australia