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The impact of colorectal cancer

Colorectal cancer (CRC) is the fourth most common cancer in the UK with over 40,000 people diagnosed each year. It is the second deadliest cancer, accounting for more than 15,700 deaths annually and affecting both genders almost equally, although the lifetime risk of developing CRC in men is now 1:14 but 1:19 for women.1 The majority of patients diagnosed will be over the age of 50, although 2,100 people below this age are diagnosed every year, often at a much later stage of their disease trajectory.2 We know that there is a strong correlation between diagnosis, stage and outcome which is why the NHS Bowel Cancer Screening Programme (BCSP) was introduced in 2006 and has been rolled out to all four nations. To date 81,950 cases of polyps have been treated and 15,511 colorectal cancers diagnosed. Unfortunately, national uptake is less than 60% and much lower in some areas.3 However, developments in surgical techniques, neo and adjuvant therapies are enabling patients to live longer post treatment, but often with long-term or late effects. 

In spite of the BCSP and the Department of Health (DH) national awareness campaign, Be Clear on Cancer, 25% of all patients are still presenting as emergencies.4

The challenge for nurses in primary care is how to make every healthcare contact into a health improvement opportunity. Therefore the key to health interventions that will have the greatest impact is an awareness of the signs and symptoms of CRC, an understanding of who is at greatest risk and a working knowledge of the BCSP.

What symptoms are significant?

One or more symptoms may be present and include:

  • Rectal bleeding - either mixed up in the faeces or noticeable on the toilet tissue when wiping.
  • A change in bowel habit lasting three weeks or more (often a much looser stool) but a definite change to the person's normal habit.
  • Unexplained weight loss - extreme tiredness for no obvious reason, or abdominal pain or lumps. 

People may experience one, some or none of these symptoms, however if someone has any concerns or if things just don't feel right, then this should trigger an appointment with the doctor.5 

It could be argued that these symptoms are attributable to benign bowel disease or perianal conditions, which of course they could be, but given its high mortality rates, CRC should be ruled out early in the diagnostic process. 

Understanding the risks

The exact cause of CRC is not known but there are some risk factors, or a combination of risk factors, which may increase the chances of developing it. These include the following:

Age

The majority of patients will be over the age of 50, but if a person under this age presents with any of the previously mentioned symptoms, CRC needs to be positively ruled out rather than not being considered at all.2

Family history

There is a greater risk of CRC if several family members - often in different generations - are diagnosed at a much younger age. 

One first-degree relative (FDR) diagnosed with CRC under the age of 50. (FDRs are mother, father, brother, sister, child).

Two FDRs (or in a first-degree kinship, eg. mother and aunt) diagnosed with CRC at any age. 

If this applies, referral to a family history clinic should be considered.7

Inherited conditions

Some inherited conditions increase the risk of developing CRC. Examples are Lynch Syndrome (formerly known as HNPCC) and Familial Adenomatous Polyposis (FAP). Many members in a single family can be affected. Genetic counselling/testing and regular surveillance has to be a high priority.8 However if only one family member over the age of 50 has been diagnosed with CRC, then the risk of developing it in the future is no greater than that of the general population.9

Inflammatory bowel disease (IBD)

This may increase the risk of developing CRC due to the long-term inflammatory processes. Any patient that has a diagnosed IBD should be on a surveillance programme.10

Type 2 diabetes

In men this is associated with an increased risk of incidence of CRC, whether or not insulin is used.11 The challenge for those in primary care is to find ways to raise awareness within the practice population to ensure that CRC is diagnosed early enough to make a real and positive difference to the long-term outcome.

Reducing risk

Lifestyle modifications, such as reducing the intake of red and processed meat; maintaining a healthy weight, exercising regularly, eating five portions of fruit and vegetables daily, stopping smoking and keeping to the government recommended limits for alcohol consumption will all help to reduce the risk of developing CRC.12

Bowel cancer screening 

Encouraging your practice population to participate in the BCSP is fundamental to reducing the risk of developing CRC in an asymptomatic population. From the age of 50 in Scotland and 60 in England, Wales and Northern Ireland a faecal occult blood test (FOBt) will be sent to everyone registered with a GP every two years until the ages of 74 in England (although you can opt to stay on the BCSP over the age of 74), Wales and Scotland and 71 in Northern Ireland. The BCSP aims to detect bowel cancer at an early stage in people with no symptoms. It can also detect polyps which can over time become malignant, but if removed, the risk of CRC developing decreases. Studies have shown that those eligible for screening are much more likely to complete their BCS kits if the programme is seen to be endorsed by their doctor or nurse.13 Asking the question “have you done your kit?” at each face-to-face consultation could have a significant impact on the uptake of the BCSP.

Survival rates following a diagnosis

If CRC is diagnosed in the early stages (Dukes' A) then there is a 93% chance of being alive five years on. If diagnosed at the later stage (Dukes' D), survival at five years is only 7%. Presently only 9% of patients are diagnosed at Dukes' A. As CRC progresses and becomes more invasive then the treatment also becomes more complicated, frequently requiring a combination of neo and adjuvant therapies, with the possibility of either the formation of a temporary or permanent stoma. Incredibly only 15% of patients who are alive five years following their treatment will not have any long-term or late effects associated with it.1

 

Conclusion 

There is a direct relationship between stage at diagnosis, long-term outcome and associated quality of life issues following treatment. The BCSP is slowly starting to have an effect, but emergency admissions remain high. Being aware of the signs and symptoms of CRC, identifying the patient groups most at risk and encouraging and endorsing participation within the BCSP will in time help to reverse this trend. Primary care nurses are pivotal to this and by making every healthcare contact into a health improvement opportunity is a challenge that will have the greatest impact on this tumour group.

 

Resources

Bowel Cancer UK

0800 840 3540

support@bowelcanceruk.org.uk

www.bowelcanceruk.org.uk

 

References

1. Cancer Research UK. Bowel cancer mortality statistics. 2013. Available

   at: www.cancerresearchuk.org

2. Cancer Research UK. Bowel cancer mortality statistics. 2013. Available at: www.cancerresearchuk.org/cancer-info/cancerstats/types/bowel/mortality/u...

3. NHS Bowel Cancer Screening Programme. Available at: www.bcsp.nhs.uk

4. ACPGBI. National Bowel Cancer Audit Supplementary Report 2011. 2012. Available at: www.acpgbi.org.uk/news/announcements/national-bowel-cancer-audit-supplem...

5. NICE. CG27 Referral for suspected cancer: information for the public. 2011. Available at: www.nice.org.uk/nicemedia/pdf/CG027publicinfo

6. Cancer Research UK. Bowel cancer mortality statistics. 2013. Available at: www.cancerresearchuk.org.

7. The Family History of Bowel Cancer Clinic. Available at: http://familyhistorybowelcancer.wordpress.com/tag/kevin-monahan

8. Cairns et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups. GUT 2010; 59:666-9. 

9. Bowel Cancer UK. Bowel Cancer: Family History Summary of guidelines for bowel cancer screening and surveillance in moderate-high risk groups. 

10. Cairns et al, Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups. GUT 2010; 59: 666-9.

11. Diabetes.co.uk. Complications: Diabetes and colon cancer. Available at: www.diabetes.co.uk/diabetes-complications/colon-cancer.html

12. World Cancer Research Fund. Cancer prevention: bowel cancer. Available at: www.wcrf-uk.org.

13. Damery S, et al. Evaluating the effectiveness of GP endorsement on increasing participation in the NHS Bowel Cancer Screening Programme in England: study protocol for a randomized controlled trial. Trials 2012;20(13):18.

14. Cancer Research UK. Statistics for Bowel Cancer. Available at: www.cancerresearchuk.org/cancer-help/type/bowel-cancer/treatment/statist...