Diagnosis ICD-10: Chapter II code: C18.9 for Malignant neoplasm of the colon. Patient presentationMr. F, an 85-year-old man, presented to his GP having noticed an increase in the frequency of his bowel movements and after finding that he had loose stool but no melina nor any signs of mucus in his stool. Upon presentation, he also admitted to being increasingly tired. After further questioning, he said he did not have any abdominal pain nor any tenesmus nor any dysphagia and haematemesis. Mr. F has no previous history of any of these of signs or symptoms. He has, however, a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, stage 2 chronic kidney disease and mild osteoarthritis all for which he is taking medication for. The patient does not remember any significant information regarding his family history.He is married to a wife and has 3 children. One of whom along with his wife he says has been extremely supportive. He does not smoke and on average drinks 9 units of alcohol per week. InvestigationsInvestigations following the 2-week pathway referral:13th of SeptemberGastroscopy Reached duodenum NADColonoscopySigmoid diverticular disease 2 sessile polyps on hepatic flexure (3mm and 8mm, endomucosal resection)7cm rectal carcinoma biopsy taken 2nd of OctoberMRI T3N0Mx Stool sampleFaecal calprotectin 235 (0-110 ug/g) therefore high FOB -veFBCHb: 120 g/L (130 – 180 g/L) therefore anaemicThe result of these investigations all complies with that of the diagnosis. Due to the consistency of the results with the diagnosis. the patient was then referred to the care of a general surgeon in order to develop a treatment plan. Sensitivity and Specificity of TreatmentThe current guidelines for NICE suggest the usage of colonoscopy as the gold-standard test in diagnosing any type of colorectal cancer. The screening procedures also utilise colonoscopy as its main method of detecting colorectal cancer. However, it does not specify which type of colonoscopy is best suited as there are several types and the procedures are being tweaked continuously to enhance its efficacy. Therefore for sake of comparison two procedures that have similar factors of comparison and are often close in comparison when it comes to which might be more beneficial for the patient. The CT colonoscopy overall sensitivity was 96.1% (CI 93.8 – 97.7%), the specificity of this procedure, however, was not mentioned. The optical colonoscopy sensitivity however was 94.7% (CI 90.4% – 97.2%). With CTC there was no heterogeneity detected although there was a moderate degree of heterogeneity present with OC (l(2) = 50%). It can be safe to say that in patients of suspected colorectal cancer, CTC is the preferred form of diagnostic tool(1) Disease detailsColorectal cancer is a disease in which you have the formation of malignant cells in the tissue of the colon (2). The are a lot of predisposing factors for colorectal cancer, these include; neoplastic polyps, IBD (Ulcerative colitis and Crohn’s disease), genetic disposition; FAP (familial adenomatous polyposis, HNPCC hereditary nonpolyposis colorectal cancer), a diet which is low in fiber and high in red and processed meat. In addition to this it there has been evidence of increased intake of alcohol and the usage of smoking adding to the risk (3). While many of these risk factors are quite poorly understood with regards to how they can lead to colorectal cancer it is generally understood genetic predispositions such as FAP and HNPCC are both inherited and autosomal dominant (4)(5). With regards to occupational factors a study (6) conducted in 1993 exploring ‘Do occupational factors influence the risk of colon and rectal cancer in different ways?’ found that there was a significant decrease in the occurrence of colorectal cancers (left-side of colon) in people who were involved in physically active for more than 20 years and those that were part of a sedentary work lifestyle for over 20 years (rectal cancers).PrognosisThe prognosis for colorectal is generally poor with an overall 5-year survival being roughly 50%. However, this figure may alter depending on the age of the patient and the stage of the cancer (3). A study (7) conducted in 1999 suggests that the progression of the adenomatous polyp to form a colorectal cancer has a natural history of 10-15 years. Complications of this may include bowel obstruction, cancer recurrence, metastasis, development of a second primary colorectal cancer(8). If the issue is not resolved the cancer will inevitably lead to the patient’s death. Population burden of diseaseIncidenceColorectal cancer ranks to be the 4th most common of all cancers (11% of all cancers) which are reported in the UK with 41,265 cases (55% of them being males and 45% females). This data was collected in the year 2014. The incident however for many of the other countries may differ in the number of occurrences of bowel cancer as there is a difference in the weighing of risk factors.(9) Colorectal cancer is, however, the 3rd most common of all cancers worldwide with nearly 1.4 million new cases having been diagnosed in the year 2012. These cases, however, are not equally distributed as 2/3rd of all newly diagnosed colorectal cancer cases happen in countries which are highly developed and/or have a high income.(10)PrevalenceThe prevalence of colorectal cancer has increased the recent years due to the introduction of screening programmes. Currently (as of data which can be accessed through the Macmillan website) there are roughly 290,000 (11).General practice morbidity data In 2007 the “Age-Standardised person prevalence rates per 10,000” for a “Malignant Neoplasm Colon” was 6/10,000. This was reported by The Royal College of General Practitioners. This number has stayed stable over the years between 2001 and 2007 with there being an increase of 2 on two occasions (2003, 2004 respectively)(12).Hospital inpatient data The Hospital Episode Statistics showed that there were 9,496 for a malignant neoplasm in the colon (as a primary diagnosis) between the years 2015-16 (13) while the total number of Finished Consultant Episodes was 10,465. Out of this population, 5,927 were males with the mean age of the whole population being 67 and 901 of these cases were emergency cases. The average length of the stay was 28 days. UK mortality data The number of deaths involving a malignant neoplasm of the colon being the underlying cause of death was 2,938 with the most number of cases being present in the age group 74-79.(14)Global trends in incidence and prevalence The colorectal cancer cases are on an increase and are expected to reach 2.2 million new cases (60% more) by the year of 2030. This data was found based on temporal patterns obtained from Cancer Incidence in Five Continents (CI5) volumes I-X and the WHO mortality database.(15)Treatment objectivesThe aim of the treatment and this report focuses on curing the disease all the while making sure that the patient retains a good quality of life post-surgery. Treatment given and the evidence baseThe treatment recommended for the current condition is TME (total mesorectal excision) along with APR (abdomino-perineal resection) as per NICE guidelines which were released in 2011 (16). However the advised surgery for the patient in question was a lower anterior resection which in this case was laparoscopic. There were 3 RCT’s (randomised control trials) comparing the operating times which showed a massive discrepancy (weighted mean difference WMD of 40 minutes 95% CI 32 minutes to 48 minutes). Another 4 RCTs also showed a shorter hospital stay (WMD of 2.6 days with 95% CI 2.0 to 3.1 days). A decreased trend in the number of lymph nodes retrieved through a laparoscopic resection (WMD of 0.4, 95% CI 1.4 to 0.6 according to 3 other RCTs)(17). A systematic review of 22 studies: 5 RCTs (n =1,085), 17 non-randomised trials (n=2,164). 10 of these trials were deemed to be of a high quality. The overall survival showed a difference of 4.4 years which is not significantly different (72% laparoscopic against 65% open, 11 trials, Cohen’s d=0.1, p=0.5) and neither was the mean local recurrence (7% against 8%, 16 trials, mean follow-up of around 35 months, Cohen’s d=0.1)(16). The Stouffer’s composite Z-value statistic was used to meta-analyse the studies (18). In Mr. F’s case, a laparoscopic approach was taken perhaps due to the age of the patient. As we were told the shorter hospital visit and recovery time would have played a vital role in choosing this option. An open surgery, in this case would have also exposed the patient to a higher risk of complication as the patient is a hypertensive and a type 2 diabetic. LeafletThis leaflet compasses all the questions one may wonder about bowel cancer ranging from what bowel cancer is to what the risks are. In addition to this, the leaflet also informs all its readers of the bowel screening programme that is going on. The leaflet also portrays information in the form of infographics which will keep new users interested in the content and will allow it to be absorbed in a friendly form. PreventionPrimary prevention – There has been a link made between the occurrence of colorectal cancer and the western lifestyle.There have been several studies which point out to an association between red meats, highly refined grains and starches and some sugars colorectal cancer. Therefore the replacement of this food by poultry, fish, and plant-based protein, unrefined grains and fruits would reduce the chances of getting colorectal cancer. Other factors which can be reduced to prevent (lessen the chance of) colorectal cancer is smoking and drinking and the reduction of weight (19)Secondary prevention – If some part of the colon still exists post surgery then the annual surveillance with colonoscopy will help prevent the cancer reoccurring. We can also target certain individuals for secondary prevention through genetic testing as some may have a familial link to colorectal cancer (20). Tertiary prevention – The patients still benefit from lifestyle changes such as exercising more and adjusting their food intake to suit a ‘mediterranean diet’. NSAIDs have shown, according to several studies, to be beneficial for tertiary prevention as it’s meant to improve survival in the survivorship period. It can be said although that while there might not be too many factors which contribute to tertiary prevention, there have been clinical trials conducted to test out the efficacy of 3-Hydroxy-3-MethylGlutryl-Coenzyme A Reductase Inhibitors, NSAIDs, Polyamine Synthesis Inhibitors which show a promising future for tertiary prevention (21). Possible future developmentshttps://www.clinicaltrials.gov had 1,806 studies which related to “Colorectal cancer” (which was the search term) that had been completed. Quite a lot of these studies are focusing on the usage of drugs to promote anti-tumor activity either to lessen the effect of any metastasis of the cancer or to maintain the disease for maintenance therapy so it does not progress anymore. “Progression free survival” is one primary outcome measure which is very common with regards to treatment. Hyperthermic Intraperitoneal chemotherapy has been an area of high interest as it reduces the risk of metastasis in the peritoneum. There has been increased research into this area as it has this allows for the mortality rate associated with metastasis to greatly decrease due to the current rate of metastasis occurring in the peritoneum. Several drugs are also being tested to improve the efficacy of this procedure. Famous casesThere have been several famous people who have been touched by colorectal cancer. Sam Simon who co-created “The Simpsons” passed away from the disease, Sharon Osbourne, Ronald Reagan, Audrey Hepburn are all famous cases whose lives were affected by CRC, however, they all lived to tell the tale one way or another. Ronald Reagan was in his presidency while he was battling his cancer and the reason for his passing was not his CRC but rather his Alzheimer’s disease at the age 93. An interesting fact: Sara Murray Jordon a popular gastroenterologist in her field diagnosed herself with CRC and passed away in the year 1959 at the age of 75 (21).