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Colorectal Cancer

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					    Colorectal Cancer                                             Aims
                                           • Update on National Bowel Cancer Screening
                                             Program: myths and fallacies
                                           • Red book vs government recommendations:
                                             What do GP’s do?
               Frank Chen                  • Where does bowel cancer sit in relation to
         Head: Colorectal Surgery            other cancers?
             Eastern Health                • Prevention and risk reduction




   Aims: RACGP Colorectal
                                                   Aims: RACGP module
   Cancer Education Module
• List risk factors                          • Who is eligible for the NBCSP
                                             • Who should be screened for bowel cancer,
• Describe symptoms                            when and how often
• Be aware and have information re: risk     • Sensitivity and positive predictive value of the
  category and recommended screening           FOBT
  schedule                                   • Manage those ineligible for the NBCSP
• Compare management strategies for          • Duty of care of the NBCSP participants
                                             • Strategies to meet the increased demand for
  patients with -ve and +ve FOBT               colonoscopy




          Demographics
• 2nd most common cancer in Australia
  (2003)
• In Vic 2005: 3441 new cancers, 1173
  deaths
• Prostate Cancer in 2003 became the
  most common
• Breast>Melanoma>Lung




                                                                                                  1
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Colorectal Cancer Number
                                                            Incidence of CRC by State
         By State
                        VIC




              NSW




Cancer Incidence Vic 2005
                                                            Cancer Incidence Vic 2005
  Incidence                                     Mortality




                                                                                                      2
    Cancer Incidence Vic 2005
     Incidence                     Mortality
                                                           Cancer Rate and Mortality




                                                  Rate= Standardised incidence/mortality rate per 100000 persons




                 Colon Cancer                                             Colon Cancer
•   5 year survival is 63%                            • 2004 Incidence
                                                      • ICS regions
•   Survival M=F                                         – Southern                                       1396
•   Older age of diagnosis= worse survival               – Western and Central                            726
                                                         – North Eastern                                  1169
•   Survival Melb Metro=Country                          – Barwon                                         478
•   Improvements over 15 years 47%-63%                   – Grampians                                      267
    from 1990 (Chemo, early detection?)                  – Loddon Mallee                                  362
                                                         – Hume                                           280
                                                         – Gippsland                                      318




                 Rectal Cancer                                           Rectal Cancer
• The 5 year survival is 63%                          • 2004 Incidence
• The survival is lower for men 61% vs 66%            • ICS regions
                                                         – Southern                                       679
• Older age is associated with reduced survival
                                                         – Western and Central                            415
  68% <45yrs vs 53% >75 yrs
                                                         – North Eastern                                  643
• Survival improvements in 15 years from 1990            – Barwon                                         216
  50-63% (chemo RT?, early detection?)
                                                         – Grampians                                      126
• No survival differences between metro Melb             – Loddon Mallee                                  179
  and Country centres                                    – Hune                                           153
                                                         – Gippsland                                      159




                                                                                                                   3
                         Oesophagus



 Anatomic Distribution of Colorectal Cancer
                         Anatomy                                                                       Presentation
                                      Stomach
                                                                             •       Position dependent
                   Duodenum                                                  •       Maybe asymptomatic or
                                                                             •       Multiple symptoms
                                 10%               7%                        •       Rectal Bleeding*
                   12%                                                       •       Mucus PR
                                     Small                                   •       Altered Bowel Habit*
                                     Bowel
     Right Colon                                        Left Colon           •       Abdominal Pain*
                     22%                                                     •       Mass
                                              18%                            •       Anaemia
                                                                             •       Overlap With Other Conditions
            Appendix          31%         Rectum
                                                                             •       Fobt+ve
                                             Pelvic Floo r
                              Anus




    Aetiology Of Bowel Cancer                                                           Aetiology of Bowel Cancer
                                                                                                           Food/Lifestyle
     • Most Cases Have No Obvious Cause                                          •    Energy Intake                           3
                                                                                 •    Dietary Fat/ Cooking methods            3
     • In Others, These Factors May Apply                                        •    Fruit and Vegetables                    3
          -Low Fibre, High Fat Diet                                              •    Fibre                                   3
                                                                                 •    Calcium                                 3
          -“Lifestyle”
                                                                                 •    Selenium                                2
          -Family History Of Bowel Cancer (15%)                                  •    Antioxidants                            3
          -Bowel Polyps                                                          •    Anti-inflammatory & cholesterol drugs   3
          -Previous Bowel Cancer                                                 •    Physical activity                       3
          -Colitis                                                               •    Smoking                                 3




                                                                                           The adenoma-carcinoma sequence
                       Prevention
                                                     NHMRC
• “Eating Healthy                     •   <2500 kcal/d Men
  Diet and exercising                 •   <2000 kcal/d Women
  regularly could                     •   <25% energy as fat
                                      •   5 or more portions of vegs+fruit
  prevent 66-75% of                       daily
  cases”                              •   Consume poorly soluble cereal
                                          fibres
www.cancerscreening.gov.au            •   Calcium intake 1000-1200 mg
                                          /day
                                      •   Regular exercise
                                      •   Restrict alcohol
                                      •   Do not smoke




                                                                                                                                  4
                Prevention of Colorectal Cancer
                                                                                Who is at risk of Bowel
                                                                                      Cancer?




                              Basis for screening




                        Risk Factors
                                                                                    Incidence Vs Age
                • Age                                                                           Incidence/100000

                • First Degree Relatives                                900

                                                                        800
                • Hereditary
                                                                        700
                     – FAP                                              600

                     – HNPCC                                            500
                                                                                                                              Incidence/100000
                                                                        400
                     – Cancer Families
                                                                        300
                • History Of Carcinoma, Adenoma                         200

                                                                        100
                • Westernized Society
                                                                          0
                • Polyps/IBD/radiotherapy
                                                                        20 9

                                                                        25 4

                                                                        30 9

                                                                        35 4

                                                                        40 9

                                                                        45 4

                                                                        50 9

                                                                        55 4

                                                                        60 9

                                                                        65 4

                                                                        70 9

                                                                        75 4

                                                                        80 9
                                                                            4

                                                                            +
                                                                          -1

                                                                          -2

                                                                          -2

                                                                          -3

                                                                          -3

                                                                          -4

                                                                          -4

                                                                          -5

                                                                          -5

                                                                          -6

                                                                          -6

                                                                          -7

                                                                          -7

                                                                          -8
                                                                         85
                                                                        15




                                                                              Absolute Risk of Colorectal Cancer
       Number new cases vs Age                                                                Risk over the next

                                                                        Age       5 years       10 years           15 years   20 years
         120

         100
                                                                        30        1 in 7000     1 in 2000          1 in 700   1 in 350
           80                                                           40        1 in 1200     1 in 400           1 in 200   1 in 90
           60

           40
                                                                        50        1 in 300      1 in 100           1 in 50    1 in 30
           20
                                                                        60        1 in 100      1 in 50            1 in 30    1 in 20
            0
                 <20    20-   30-   40-   50-   60-   70-   80-   90-   70        1 in 65       1 in 30            1 in 20    1 in 15
                        29    39    49    59    69    79    89    99
                                          Age                           80        1in 50        1 in 25
Personal data 2003




                                                                                                                                                 5
   Risk Factors: Family History                                                                         Risk Factors
  Degree Of Risk Of Developing Colorectal Cancer According To
                                                                         •    Age
          Number Of Family Members With The Disease
                                                                         •    First Degree Relatives
                                                                         •    Hereditary
    1 First Degree                                              1-17*           – FAP
    1 First, 1 Second Degree                                    1-12            – HNPCC
                                                                                – Cancer Families
    1 First Degree<45 Yrs                                       1-10
                                                                         •    History Of Carcinoma, Adenoma                      QuickTime™ and a


    2 Parents                                                   1-8.5
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                                                                         •    Westernized Society
    2 First Degree                                              1-6
    3 First Degree                                              1-2
                                                                         • Previous Polyps
                                                                         •    IBD
                                                                         •    Radiotherapy
    *Age and Family History- Categories of risk: Basis for identifying
      patients who should be screened
    # only 15% have a family history




                               Risks                                                                              Risks
         Polyps                                                                        Polyps
 • Malignant potential                                                       • Polyp 1cm risk of CRC
   related to                                                                  is 10% over 15 years
 • size > 1 cm                                                               • Or 1.5-3.6X control
                                                                               population
 • High grade                                                                • X2 with multiple polyps
   dysplasia                                                                   or villous morphology
 • Villous features




                      Risks Polyps                                                                      Risk Factors
• What to do after?             • Within 1 year if incomplete
                                                                               •   Hereditary or Family History
• NHMRC                         • Within 3 years for                           •   Age
                                      large ademonas > 1 cm,                   •   Previous Polyps
• Adenomas                        high grade dysplasia or villous
                                                                               •   Radiotherapy

                                  change,                                                                                                   QuickTime™ and a




                                                                               • Previous Carcinoma,
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                                  >2 polyps,
                                      those with a family history or           • Westernized Society
                                  >60 years                                    • Inflammatory Bowel
                                • 4-6 years for single adenomas                  Disease
                                  <1cm




                                                                                                                                                                       6
                      Risks                                                  Risks
                                                        Inflammatory Bowel
  Previous colorectal
                                                               Disease
         cancer
                                                    •   4-20X increase risk
• 2.1-3X average risk                                                                                QuickTime™ and a



                                                    •   20-30 years younger
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• Increase in risk of
  ovarian, breast and                               •   >Right sided
  endometrial cancer                                •   Age, pancolitis
                              Synchronous cancers




                                                             Why Screen For Bowel
                      Risks                                        Cancer?
• Westernized Society                                          WHO Criteria For Population Screening
• Adaptation
• 20-30 years to
  assume risk and                                        • Disease Must Represent A Major Health Problem
  distribution profile of
  indigenous population                                  • Early Diagnosis Improves Survival

                                                         • Existence Of A Safe Inexpensive Screening Test




                                                              Methods Of Screening
                                                        • Faecal Occult Blood
                  Screening                               Testing (FOBT)
                                                        • DRE and
                                                          sigmoidoscopy
                                                        • Flexible
               Asymptomatic                               Sigmoidoscopy
                                                        • Barium Enema
                                                        • Colonoscopy
                                                        • Virtual Colonoscopy




                                                                                                                                 7
                                                                                 Recommendations for Population
    NHMRC Screening Guidelines*                                                      Screening: Category 1
     Population Screening on the Basis of Family History                              NHMRC: Gov                                                Red Book

• Category 1: at or slightly above average risk
                                                                               • FOBT annually from age                             • FOBT every 2 years
• 98% of the population                                                          50                                                   from age 50
• No personal or family history of CRC or MUC                                  • Consider sigmoidoscopy
• One 1st degree relative or 2nd degree relative diagnosed                       preferably flexible every 5
  at age 55 or older                                                             years from the age of 50
• Risk may be 2X the average risk, expressed after the age                     • Consider one off
  of 60                                                                          colonoscopy


      *1999, rescinded 2005: Guidelines are in a constant state of evolution




                                                                                  Recommendations for Screening:
    NHMRC Screening Guidelines
                                                                                          Category 2
                      Category 2                                                        NHMRC/Gov                                               Red Book
    • 1-2% of the population
                                                                                 • Colonoscopy every 5                              • = (sigmoidoscopy+DC
    • One 1st degree relative with CRC                                             years starting age 50 or
      diagnosed < 55 yrs                                                                                                              Ba enema acceptable if
                                                                                   at an age 10 Yrs
                                                                                                                                      CSPY unavailable)
    • Two 1st degree or second degree relatives                                    younger than the age of
      on the same side of the family diagnosed                                     first diagnosis of CRC in
      with CRC at any age                                                          the family whichever is
                                                                                   first.
    • No high risk features:                                                     • Consider FOBT in the
    • Risk is 3-6X                                                                 intervening years




    NHMRC Screening Guidelines
                              Category 3

• Those at potentially high risk, <1% of the
  population
                                                                                                                     QuickTime™ and a
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• > or = 3, 1st/2nd degree relatives on the same
  side of the family with CRC any age
• 2 or more 1st/2nd degree relatives on the same
  side of the family with CRC including any of the
  following high risk features: multiple cancers in
  one person, cancer < 50 yrs, at least one relative
  with endometrial or ovarian cancer                                                                                   FAP




                                                                                                                                                               8
                                                                         Recommendation for Screening:
NHMRC Screening Guidelines
                                                                                Category 3
                        Category 3                                             NHMRC/ Gov                                 Red Book/ Gov
                                                                    • Screening at risk members of                • Consider referral to familial
                                                                      proven HNPCC families should be               cancer clinic
• At least one 1st or 2nd degree relative with CRC with               by annual or 2 yearly                       • Ref to bowel cancer
  a large number of adenomas throughout the large                     colonoscopy, at 25 years. Annual              specialist for appropriate
  bowel.                                                              screening should be offered to                screening
                                                                      patients carrying a germline                • HNPCC=NHMRC+ 5 yrs
• Somebody in the family in whom the presence of a                    mutation                                      before youngest member
  high risk mutation in the APC or MMR genes has                    • FAP-flexible sigmoidoscopy                    whichever is first
  been identified.                                                    annually from age 10-15 years to            • FAP=NHMRC+ every 3
                                                                      30-35 years. APC genetic testing.             years after 35 years
                                                                                                                  • FOBT alternate years




Anatomic Distribution of Colorectal Cancer
                                                                                  Methods of Screening
                                     Stomach
                  Duodenum                                                    Faecal Occult Blood Testing: No Symptoms

                                                                                            +ve Rate%         PPV%     Dukes A&B Cancers %
                  12%          10%                7%                                                          Ad & Ca Screened     Control
                                                                       Goteborg                 1.9             22       65          33
                                    Small                              Nottingham               2.1             53       90          40
                                    Bowel                              New York^                1.7             30       65          33
    Right Colon                                        Left Colon
                                                                       Minnesota^               2.4             31       78          35
                    22%                                                Fuhnen                   1.0             58       81          55
                                             18%
                                                                       *Faecal Occult Blood Testing
                                                                       ^Survival Benefit Demonstrated
           Appendix          31%       Rectum                          Colonoscopy Essential Component To Each Trial

                                            Pelvic Floo r
                             Anus




                        FOBT                                                                            FOBT
• Fobt Each Year                       5.8 Deaths / 1000                                   Population Screening

• Fobt Each 2 Years                    8.3 Deaths / 1000            • Detects 40-80% of cancers
                                                                    • Up to 15-40% reduction in mortality in screened
• No Testing                           8.8 Deaths / 1000              population
  (Control Group)                                                                          BUT
                                                                    • Recommendations FOBT every 2nd year* in
                                                                      asymptomatic >50 yrs without FH CRC
                                                                     *Cancervic, NBCSP




                                                                                                                                                    9
                                   FOBT                                               National Bowel Screening
     Guaiac tests                                  Positive test                                                        Issues
                                                                                  • Recognition of the
                                                                                    problem                   • Fed-State transition
• Detects 40-80%                             • 1 in 14
                                                                                                              • Funding of designated
• 20%-50% miss rate                          • 30-45% chance of a                 • Simple Population test      centres by DHS
                                               benign polyp                       • Target population: 55     • Referal patterns not
                                                                                    and 65                      taken into account.
   Immunochemical*                           • 3-5% chance of
                                                                                  • Rolled out in 2007        • Cancer “Centres”
• 80-90% detection rate                        cancer                                                           designated by
                                                                                  • 10 years to capture
                                             • Always investigate                                               Governments not=
                                                                                  • ?<55 years, >65 years?      centres of excellence
                                               further                            • Rotary Bowel Screen

                      Saves lives: cheap $6-$30                                                      A Good Thing




                       FOBT: process                                                                   Pitfalls
• Invitation to participate
• Turning 50, 55 or 65 between Jan 08 &                                           • False -ve: misses 10-25% of cancers
  Dec 10 (currently)                                                              • False +ve: unnecessary tests and possible
• Medicare, DVA card only                                                           complications and anxiety
• Within 2-6 months of b’day                                                      • Collection: unsavory
• Kit sent                                                                        • Nonresponders 30% OS vs 75%? Better now?
• Return to lab within 24-72 hrs                                                  • Responders ?more health conscious, less likely to
• Notification of result                                                            have positive results
• GP referral
• Designated centres                                                              • Outside NBCSP: No medicare rebate but available
• Paperwork-feedback and follow up
• Treatment




                      FOBT+ve or -ve
   • -ve              Need FOBT every 2 yrs (Cancervic)
                      See doctor if symptoms
                      specifically blood pr
                                                                                          Alternatives to FOBT
   • +ve              See doctor-colonoscopy*




   *Cancervic: statement that public patients may have to wait several weeks or
            months for the procedure




                                                                                                                                        10
            DRE+sigmoidoscopy                                                Flexible sigmoidoscopy
   • Reaches 35% of
     rectal cancers                                                     • Reaches 50-55% of
   • 10% of all colorectal                                                cancers
     cancers                                                            • No RCT’s with mortality
   • Office procedure                                                     as endpoint
   • Limited by stool                                                   • Requires preparation,
   • Adjunct to staging                                                   sedation?
     and assessment of                                                  • Perforation <2 in 10000
     rectal cancer
                                                                        • Role in screening?




                 Barium Enema                                                       Barium Enema

• Sensitivity is 90% (65-95%)
                                                                   •    5-10% unsatisfactory
• Rectum, rectosigmoid and
  caecum often difficult areas                                     •    Requires preparation
• 70-95% polyps <1 cm                   QuickTime™ and a
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                                                                   •    No sedation
  detected                                                         •    Complications 3/10000
• Reports vague due to
  technical or medicolegal
                                                                   •    Mortality 3/100000
  issues




                   Colonoscopy                                                       Colonoscopy
                                                                               Quality issues
• Sensitivity for cancer is                                            • Caecal intubation rate
  95%                                                                    >95% (54%-98%)
• Allows for biopsies                                                  • 5% caecal polyps alone
• Miss rate of polyps <                                                • Training, practice,               QuickTime™ and a
                                                                                                       TIFF (LZW) decompressor




  1cm is 15%,
                                                                                                    are needed to see this picture.




                                                                         experience
• >1 cm is 6%                                                          • Caecum and splenic
                                                                         flexure difficult areas
• Needs preparation                                                    • Polyp pick up rate 25%
• Needs sedation                                                       • Withdrawal time 9 min




                                                                                                                                      11
                     Colonoscopy                                                                   Virtual Colonoscopy
          Complications                                                                 • 33 studies: 6393 pts
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                                                                                        • Sensitivities = size of
                                                                                          polyps
•   Diagnostic= 0.14%
                                                                                           – < 6mm 48%
•   Therapeutic 2%                                                                         – 6-9mm 70%
•   Perforation 1 in 1000*                                                                 – >9mm 85%
•   Haemorrhage 3 in 1000                                                               • Specificities 92-97%
•   Mortality 1-3 in 10000
                                                             QuickTime™ and a
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                                                                                        • Cancers=colonoscopy




              Virtual Colonoscopy                                                        Screening: What should GP’s Do?
    •   Need Prep                                                                         • Be aware of guidelines NHMRC, Red Book
    •   Expensive
    •   Cannot Biopsy
    •   Labour intensive                                                                  • Have Resources printed material

    Indications                                                                           • Treat the individual not the population
    • Strictures to look
       beyond
    • Failed colonoscopy                                                                  • Offer the “best test”, base decisions on best
    • Anaesthetic                                                                           practice not economics
       contraindications




        Diagnosis Of Bowel Cancer                                                            Diagnosis of Bowel Cancer
                                                                                                       Staging the Disease
               Establishing the Diagnosis
                    in the Patient with                                                 Why? Individualise treatment & avoid unnecessary
                        Symptoms                                                         surgery

                                                                                        1/ How locally advanced is it?     •   Clinical Exam
              • Colonoscopy +bx,                                                                                           •   MRI
                exclusion of synchronous
                                                                                                                           •   Ultrasound
                lesions
                                                                                        2/ Any evidence of spread?         •   CT Scan
                                                                                                                           •   Pet Scan




                                                                                                                                               12
                                                          MRI
                      CT Scans




Exclude liver metastases, contiguous organ involvement




                         MRI                             Ultrasound


         Prostate
                                      bladder


                                                                    QuickTime™ and a
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           Cancer
                                      rectum


                                     Lymph node



           Contiguous organ involvement                                                                   Rectal Cancer ERUS




   Liver metastasis
                                     Sacral               Laparoscopy & Colorectal Surgery
                                     metastasis

                                                                                               Benefits

                                                                                      Keyhole Surgery
                                                                                      Cosmesis
                                                                                      Reduced Postoperative Pain
                                                                                      Reduced Length Of Stay
                                                                                      Earlier Return To Work
                                                                                      ? Fewer Complications
                       CT PET Scan




                                                                                                                               13
 Laparoscopy & Colorectal Surgery                  Laparoscopy & Colorectal Surgery
                                                         What Colorectal Operations ?
                    “Costs”                                    Diagnostic
                                                               Bowel Resection
             Cost of equipment
                                                               »“Diverticulitis”
             Longer operating time
                                                               »Inflammatory Bowel
             ? Cancer cure as good                              Disease
             ? Complications                                   »Cancer
                                                               Rectal Prolapse
                                                               Stoma Formation




      Laparoscopy & Colorectal                     Laparoscopy & Colorectal Surgery
              Surgery
  • 3 RCT: no cancer survival differences                           Conclusions
  • All multicentre                                    Laparoscopic Surgery Is Feasible
  • Control arm results (open surgery)                 Do Benefits Outweigh Costs?
    arguably not gold standard                         Should It Be Done In Cancer Cases?
  • Poll of laparoscopic surgeons? Most                Answers Still Not Available At This Time
    would have their operation open
  • Questions for your surgeon? Role of
    advocate?                                         FC 1993




Treatment
                                                     Treatment Of Bowel Cancer
                                                                                 Aims
                                                                      • To Remove The Segment
                       QuickTime™ and a
                                                                        Of Bowel And Lymph
                  Photo - JPEG decompressor
                 are needed to see this picture.                        Nodes Before The Cancer
                                                   Surgery Is The       Has Spread
                                                    Only Cure         • To Relieve The
                                                                        Symptoms Of Bowel
                                                                        Cancer
                                                                      • To preserve Quality of life




                                                                                                      14
Surgery                             Surgery




 Surgery
                                          Cure Rate of Bowel Cancer
                                    A/Confined To Bowel Wall 95%

                                    B/Through Bowel Wall                  75%

                                    C/In Lymph Glands                     50%

                                    D/Spread To Distant Sites <5%




      Advances In Surgery For
          Rectal Cancer                                         Surgical Staplers
                      1950   1998                Stapler inserted pr
                                              and pushed to staple line

   • Ability To       65%    98%
     Remove Cancer

   • Mortality From   8%     <2%
     Operation

   • Need For A       80%    <10%
     Colostomy




                                                                                    15
                Follow Up                                                                  Follow Up
• Rationale                                                                •   Second Primary
• Detection of second primaries                                            •   3X the average risk
• Detection of Recurrence                                                  •   7.7% at 4 years
                                                                           •   62% adenoma rate at 4 years
                                                QuickTime™ and a
                                      TIFF (Uncompressed) decompressor
                                                                           •   Adenoma-Cancer sequence
                                         are needed to see this picture.




                                                                           •   Lifelong surveillance




                Follow Up                                                                  Follow Up
• Recurrence
                                                                           • CEA 3 monthly for 2 years
• 1 in 3 will develop
                                                                           • 6 monthly till 5 years
• Usually in first 2 years
• Detection in asymptomatic ?resectable                                    • Colonoscopy 1 year, 3 years till aged 80 or
  for cure                                                                   medically unfit
• 1% will benefit
                                                                           • Most patients express a strong preference for
                                                                             follow up




         Outstanding Issues                                                        Multidisciplinary Care
• Ask the expert
• Outcomes: pathology, surgeon                                             •   ICS Establishment 10 cancer groups
• Caseload, training, “experience”                                         •   Purpose: “improved care”
• CSSA membership helpful
                                                                           •   Establishment of Specialist Units
• Ask the right questions, Biogrid participation,
  mortality, complication rate:                                            •   MDT meetings: Attendees
• RACS not equal to ATO for CPD                                                – standardise treatment
• Dept Health and Ageing recognition-ICS                                       – More rapid referral
                                                                               – Discussion of more complex cases




                                                                                                                             16
                                       Biogrid database                                                                                               Resources
• Privately funded colorectal cancer database                                                                                          • Anticancer council of Victoria:
              • Quality Assurance                                                                                                        www.cancervic.gov.au
         • State government backing                                                                                                    • National Bowel Cancer Screening Program:
         • Voluntary participation but                                                                                                   www.cancerscreening.gov.au or 1300 738
                                                                                                                                         365, 1800 118 868
   • Now CSSANZ requirement to remain
                   members                                                                                                             • RACGP Red Book Guidelines and education
                                                                                                                                         modules
           • Powerful research tool
                                                                                                                                       • NHMRC 131120
                                                                                                                                       • Colorectal Surgical Society of Australasia and
                                                                                                                                         New Zealand




                                                    QuickTime™ and a
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                                             are needed to see this picture.




   Colorectal Surgical Society of
   Australia and New Zealand
                                                                                     Microscopic invasion through muscularis propria




            QuickTime™ and a                              QuickTime™ and a
   TIFF (Uncompressed) decompressor             TIFF (Uncompressed) decompressor
     are needed to see this picture.               are needed to see this picture.




                                                                                                                                                                                          17

				
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