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An Australian survey has shown that a high proportion of adults never examine their stools, the toilet paper, or the toilet bowl adequately to be able to identify whether blood is present. 3 Prompt medical attention for rectal bleeding facilitates diagnosis of Colorectal Cancer. 3 Rectal bleeding requires investigation, especially when it is of recent onset (within the previous 6–12 months). People over 40 years of age should be encouraged to look for blood with their bowel motions on a regular basis. 5.1.1 Investigation Investigation must be tailored to the circumstances. Recent onset of symptoms in a patient over 40 years of age raises the index of suspicion for Colorectal Cancer and investigation is important in this situation. In all patients, a thorough examination of the anus, rectum and colon should be performed including digital rectal examination. Proctosigmoidoscopy is recommended, as this enables haemorrhoids to be more easily identified. However, failure of symptoms to settle should lead to full colonoscopic examination 4-9 barium enema or CT Colonography, which is becoming preferred to barium enema (see Sections 8.1.3, 8.1.4 and 8.1.5). This in spite of evidence that the prevalence of Colorectal Cancer in patients with colonic symptoms who have no evidence of bleeding ‘is low and is comparative with the prevalence in an asymptomatic population’. 10 Complete colonoscopy has been shown in a two-cohort study to exhibit a high level of accuracy. A cohort of 8 486 patients had a clear colonoscopy. Of these, 496 had repeat studies with an average of 3.1 years follow up. Subsequent malignancy was observed in 0.6%. 4 This degree of accuracy can be achieved very safely in diagnostic colonoscopy. 5 It should also be recognised that with flexible sigmoidoscopy, colonoscopy and double contrast barium enema it is possible to miss a cancer during the examination. Should there be a deficiency of ‘correlation between clinical and investigational findings’, the matter should be carefully reviewed. 11 What investigations need to be included? Guidelines — Investigation Level of evidence In symptomatic patients aged over 40 years, referral to a specialist should be considered and consideration of full examination of the colon with colonoscopy is recommended. 5.2 The patient with iron deficiency anaemia Practice recommendation Refs III-3 Equivocal 4-8 There is always a cause for iron deficiency and, in non-menstruating patients, gastrointestinal bleeding is the most common cause. 7 It is usually occult. In non-menstruating patients over 40, Colorectal Cancer is a common pathology. 8 It is important to confirm iron deficiency before embarking on gastrointestinal investigation. An isolated low serum ferritin is not adequate evidence, 7 and it needs to be confirmed by microcytosis or low iron saturation and other abnormalities in iron studies. Investigation of patients with iron deficiency must include full colonic evaluation. Colonoscopy is preferred, as lesions such as angiodysplasia are not recognisable by radiology. If colonoscopy is incomplete or unavailable, a double contrast barium enema is required 8 , or CT Colonography The patient with symptoms 55
considered (see 8.1.5). Double contrast barium enema has a known false-negative perception error which has been shown to be effectively reduced if the images are submitted to multiple radiologists for reading 11 (see Section 8.1.4). 56 The prevention, early detection and management of colorectal cancer
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Clinical Practice Guidelines FOR TH
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© The Cancer Council Australia/Aus
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2.11 Conclusions...................
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11.2 High ligation ................
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17.4 Cost effectiveness of follow u
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Table 14.3 Pathological TNM staging
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Executive Summary • Colorectal Ca
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STRENGTH OF RECOMMENDATIONS 2,3 The
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Should red meat intake be altered t
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Chapter Recommendations 4 COMMUNICA
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Chapter 8 Recommendations How shoul
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Chapter Recommendations Should bowe
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Chapter Recommendations When should
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Chapter 17 Recommendations What pos
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Section I Early Colorectal Cancer
Page 33 and 34: Adenomatous polyps (adenomas) are b
Page 35 and 36: 17. South Australian Cancer Registr
Page 37 and 38: CHAPTER 2 PRIMARY PREVENTION Studie
Page 39 and 40: Colorectal adenomas, especially adv
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Page 43 and 44: mustard greens, swedes and turnips)
Page 45 and 46: for protection against Colorectal C
Page 47 and 48: Does selenium supplementation reduc
Page 49 and 50: the optimal duration of use, and ad
Page 51 and 52: References 1. Jass JR. Pathogenesis
Page 53 and 54: 34. Kushi L, Giovannucci E. Dietary
Page 55 and 56: 67. Fearon ER, Vogelstein B. A gene
Page 57 and 58: 100. Il'yasova D, Hodgson ME, Marti
Page 59 and 60: 133. Meyskens FL, Jr., Gerner EW. D
Page 61 and 62: CHAPTER 3 POPULATION SCREENING FOR
Page 63 and 64: studies also demonstrate that age i
Page 65 and 66: • symptoms • family medical his
Page 67 and 68: Should screening be recommended? Gu
Page 69 and 70: Box 3.3 Screening Pathway used in t
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Page 73 and 74: 33. Alexander F, Weller D. Evaluati
Page 75 and 76: CHAPTER 4 COMMUNICATION WITH THE PA
Page 77 and 78: 4.6 Coordination of care Treatment
Page 79 and 80: • assistance with and care of chi
Page 81 and 82: 17. National Breast Cancer Centre,
Page 83: CHAPTER 5 THE PATIENT WITH SYMPTOMS
Page 87 and 88: 58 The prevention, early detection
Page 89 and 90: diagnoses prove difficult to confir
Page 91 and 92: What recommendations are there for
Page 93 and 94: References 1. Woolf CM. A genetic s
Page 95 and 96: 34. Australian Health Technology Ad
Page 97 and 98: CHAPTER 7 HIGH-RISK FAMILIAL COLORE
Page 99 and 100: offered predictive genetic testing.
Page 101 and 102: endoscopically uncontrollable numbe
Page 103 and 104: mutation carriers. 52 There is also
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Page 107 and 108: added to transvaginal ultrasound. 8
Page 109 and 110: category 2, see Chapter 6) but may
Page 111 and 112: What screening is recommended for e
Page 113 and 114: References 1. Vasen HF, Griffioen G
Page 115 and 116: 33. Giardiello FM, Hamilton SR, Kru
Page 117 and 118: international criteria for the dete
Page 119 and 120: 96. Burt RW, Jass JR. Hyperplastic
Page 121 and 122: 8.1.2 Sigmoidoscopy: rigid versus f
Page 123 and 124: For radiological imaging of the lar
Page 125 and 126: 8.2.3 Staging for distant metastase
Page 127 and 128: The feelings and fears of the patie
Page 129 and 130: 18. Rex DK, Cutler CS, Lemmel GT et
Page 131 and 132: 52. Liu SK, Church JM, Lavery IC, F
Page 133 and 134: 104 The prevention, early detection
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strong family history of Colorectal
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A screening interval of 4-6 years i
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BRAF mutation, particularly when mu
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18. Jass JR, Young J, Leggett BA. E
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52. Jass JR, Young J, Leggett BA. H
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116 The prevention, early detection
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What is the role of the stomal ther
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What happens if a blood transfusion
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References 1. Bass EM, Del Pino A,
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32. The National Working Party on t
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CHAPTER 11 ELECTIVE SURGERY FOR COL
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Total or subtotal colectomy may be
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11.12 Self-expanding metal stents f
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18. Gall FP, Tonak J, Altendorf A.
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etween 1993 and 1999. The local rec
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When should local excision of recta
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What factors influence sphincter pr
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It has been demonstrated that there
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References 1. Smith TJ, Hillner BE,
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36. Vernava AM, III, Moran M, Rothe
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69. Pimentel JM, Duarte A, Gregorio
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A clinical diagnosis of large bowel
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When should primary anastomosis be
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17. Deans GT, Krukowski ZH, Irwin S
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Table 14.1 Clinicopathological stag
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The ACPS system embodies the simpli
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14.4 Translation between staging sy
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16. Shepherd NA, Baxter KJ, Love SB
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CHAPTER 15 ADJUVANT CHEMOTHERAPY FO
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isk of death-favouring treatment (H
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improvement in survival at five yea
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There has been one trial 55 of intr
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References 1. National Institute of
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30. Zaniboni A, Labianca R, Marsoni
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57. Gastrointestinal Tumour Study G
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CHAPTER 16 ADJUVANT THERAPY FOR REC
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preoperative RT 45Gy over 5 weeks s
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This suggests that a policy of preo
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Mortality from non-cancer causes wa
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References 1. Fu KK. Interactions o
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29. Swedish Rectal Cancer Trial. Im
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Rates of intraluminal recurrence an
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Ultrasonographic screening Ultrason
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References 1. Nava HR, Pagana TJ. P
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• those with a history of psychia
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References 1. Maisey NR, Norman A,
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CHAPTER 19 RECURRENT AND ADVANCED C
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What are the recommendations for in
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References 1. National Health and M
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31. Phillips RK, Hittinger R, Bleso
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Recurrent and advanced colorectal c
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(23% compared to 12%, p
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more patients having disease down-s
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References 1. Best L, Simmonds P, B
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30. Fuchs CS, Moore MR, Harker G, V
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CHAPTER 21 MANAGEMENT OF LIVER AND
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21.1.3 Imaging controlled destructi
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Does combination systemic chemother
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References 1. Woodington FF, Waugh
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34. Wood BJ, Ramkaransingh JR, Fojo
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66. Headrick JR, Miller DL, Nagorne
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Management of liver and other dista
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years gained can be assessed, which
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‘If neither of the above cases ap
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Study Country Study questions Concl
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Study Country Comparator/ screening
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Three United States studies investi
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Table 22.6 Results of studies inves
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22.9 Treatments 22.9.1 Surgery Seve
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Table 22.10 Results of studies inve
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Table 22.11 Summary of findings fro
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References 1. Australian Institute
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32. Nakama, H., B. Zhang, and A.S.
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65. Sieg, A., et al., Screening for
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97. Durand-Zaleski, I., et al., Eco
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Cost effectiveness 289
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References 1. National Health and M
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Appendices
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“Zorbas et al 2 Multidisciplinary
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a pathologist-molecular biologist o
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References 1. Australian Cancer Net
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Chapter 2 — Primary prevention an
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Three Cochrane systematic reviews w
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Dates 1 January 1998 to June 2004 S
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Dates Update of 1999 document from
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Search terms MeSH terms were ‘col
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Chapter 20 — The role of systemic
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Search terms Colorectal Cancer, soc
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However, in some cases it was also
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Professor James St John Gastro ente
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Working party on emergency surgery
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Dr Russel Stitz Surgeon, Royal Bris
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14. Dr Michael Izard Radiation Onco
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Mrs Avis Mcphee Consumer (June 9 an
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DVT deep venous thrombosis ECOG Eur
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TNM tumour, node, metastasis stagin
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Chemotherapy The use of drugs (whic
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Malignant Cancerous Malignant cells
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with a specific disease might survi
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