Serena
Welcome to this evening's webinar: Latest Advances in Reflux Disease Management and Colorectal Cancer Screening. My name is Serena, your RACGP representative for this evening. We are joined by our presenters, Dr Lisa Shim, Dr Mifanwy Reece and GP facilitator, Dr Natasha Feingold. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders past, present and emerging. I myself am joined from Gadigal Land located in Sydney CBD. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening. Our presenters for this evening, Lisa is a gastroenterologist and a fellow of the Royal Australasian College of Physicians. Her expertise is in the management of functional gut disorders, including irritable bowel syndrome and refractory reflux disease. She has had multiple publications in GI motility and has interest in the brain-gut interactions. She pioneered the oesophageal functional study at Macquarie University Hospital, which is the first private hospital in New South Wales to provide these tests. Mifanwy is a colorectal surgeon working at Concord Hospital, Macquarie University Hospital and Gosford Private Hospital. Her main interest is in performing minimally invasive colorectal surgery, and she is one of the only handful of colorectal surgeons in Australia to have undertaken a formal robotic surgical fellowship. She is passionate about bowel cancer screening and won the CSSANZ Philip Douglas ±«ÓãÊÓƵ Prize in 2020 for her presentation on the topic. Also joining is Natasha, a GP from Sydney who has moved to the Gold Coast and works for a specialised women's health clinic where she has speciality interests in chronic disease management. She is committed to the quality of medical education of junior doctors, and worked for many years as a lecturer at University of Notre Dame School of Medicine. Welcome to our presenters. I will now pass it over to Natasha who will go over the learning objectives.
Dr Natasha Feingold
Thank you so much, Serena, for that warm welcome. We have a lot to get through today, but they are very important topics for us as GPs, and we hope that you find this evening very informative and that we will pass on all these pearls of knowledge we learn from our amazing presenters and pass that on to our patients and improve their outcomes. Our learning objectives today: #1 Discuss the management of reflux disease and primary care. #2 Recognise alternative diagnoses when PPIs do not work. #2 Identify who should have a screening colonoscopy based on family history. #4 Discuss how GPs can make the biggest impact in preventing bowel cancer. Our first presenter, Dr Lisa Shim, I will pass on the microphone over to you. Get right to it.
Dr Lisa Shim
Thanks, Natasha. Thanks, everyone. It is great to be here this evening. I will just share my slides. I will be talking about advances in reflux disease management. Basically what is reflux? We know that reflux is one of the most common presentations seen in primary care as well as in specialist centres. Up to 30% of the adult population has some form of reflux symptom. It is associated with an increased healthcare burden and also significantly impact on quality of life. The definition of reflux is movement of gastric contents into the oesophagus, resulting in symptoms and/or mucosal damage. It is really important to assess reflux as untreated acid reflux can lead to complications such as stricture, Barrett's oesophagus and ultimately oesophageal cancer. I think it is useful to understand a little bit about the pathophysiology of reflux because it can help us educate our patients regarding reflux management. Just to orientate you to the anatomy of the oesophagus and the stomach. The lower esophageal sphincter and the crural diaphragm both form the anti-reflux barrier between the oesophagus and the stomach. Any factors that would disrupt the integrity of this musculature would result in reflux of gastric content into the oesophagus. If you have a poorly functioning gastroesophageal junction such as a hiatal hernia, as you can see here, the top part of the stomach is being pushed up and hence the lower oesophageal sphincter has been displaced. This would result in a decrease in lower oesophageal sphincter resting tone, and hence more likely for the patient to experience reflux. Increased intra-abdominal pressure such as obesity can also reduce the lower oesophageal sphincter resting tone and again increases risk of reflux. Certain diets such as chocolate, high fat intake or even caffeine has also been shown to reduce lower oesophageal sphincter pressure. Not only that you need the anti-reflux barrier to control reflux into the oesophagus, having an intact oesophageal motility of the oesophagus also helps to prevent reflux getting into the oesophagus. In conditions that have an impaired oesophageal clearance, such as someone with oesophageal dysmotility, that can also result in poor acid clearance. Finally, delayed gastric emptying, such as in patients with gastroparesis, will also present with symptoms of reflux.
The typical symptoms of reflux are heartburn, regurgitation and retrosternal chest pain, but there are some patients who present with atypical symptoms such as sore throat, cough, voice hoarseness, globus and even asthma. There are a number of studies that have shown that symptoms are not well correlated with pathological diagnosis of reflux disease, and even using validated questionnaires may not be helpful in those who have non-erosive reflux disease. Why is that? That is because gastroesophageal reflux disease is no longer regarded as a single disease entity. It is now regarded as a spectrum of disease. As you can see here, you can have on one spectrum erosive oesophagitis, which is associated with pathological acid exposure. On the other end of the spectrum, you have functional heartburn where majority of these patients do not actually have pathological acid reflux but similarly present with very troublesome symptoms. How do we actually define these phenotypic subgroups? Let us talk about diagnosis of GORD. All of us provide PPIs to patients who present with symptoms of reflux, but how effective is this in actually diagnosing reflux disease. Let us bring you to this table here which shows you the responses of symptoms to acid suppression therapy. In PPIs, in patients with uninvestigated heartburn, you can see that the response rate to PPI is not too bad. It is about 70%, but it also has quite a substantial placebo response, and the number needed to treat is about two. If the patient has regurgitation, the response rate is a little bit lower with a much higher placebo response rate, and the number needed to treat goes up to around six. If patients actually have atypical symptoms, the response to treatment becomes even poorer with a significantly elevated number needed to treat. In fact, the PPI trial has very variable sensitivity and specificity in diagnosing GORD. Salivary pepsin, you may have heard of, has been proposed as a surrogate test for looking at laryngopharyngeal reflux. It is available in certain commercial centres but is currently not routinely recommended. It is not associated with accurate diagnosis of GORD. What about barium radiography? Sometimes you get a report back saying that there is significant reflux on the barium swallow, but there are studies to show that only around 50% of abnormal reflux found on barium swallow is associated with pathological acid reflux. You may have heard of reflux scintigraphy or you may have referred patients for reflux scintigraphy. It is a test that is done majority in nuclear medicine department. It measures the radioactivity rate in the oesophagus after ingesting radioisotope, and there have been some studies to show that it can detect aspiration and also laryngopharyngeal reflux. Again, there are studies to show that this test actually has very poor sensitivity and specificity in diagnosing GORD. However, it is not uncommonly used in the paediatric population given that it is minimally invasive. It has minimal radiation and is quite tolerable by younger children, but it is not recommended routinely in adults. Gastroscopy is a very useful test for diagnostic workup in patients with GORD because it helps to look for mucosal damage of the oesophagus such as ulcerations in the oesophagus and also Barrett's disease. However, it is normal in up to 70% of patients with reflux symptoms. What do you do then with these patients? You need to think about oesophageal function tests. These include an oesophageal manometry. This is a test that measures the motor function of the entire oesophagus. It can also measure the integrity of the lower oesophageal sphincter, whether it is opening and closing properly or not, or whether there is a hiatus hernia causing a weakness in the LES pressure. On the right here, you can see that that is the esophageal manometry probe. It is inserted transnasally with the use of topical xylocaine. The patient is awake during the test because the patient does need to follow certain instructions during the entire study. This is a very useful test as it may uncover some oesophageal motor disorder which can present with reflux such as achalasia. Achalasia is a condition where the LES pressure actually tightens up. These patients will not benefit from just acid suppression therapy. In fact, they need treatment to loosen the LES pressure. This is just a topography representation of what a single swallow looks like on the oesophageal manometry. If the oesophageal manometry is normal or inconclusive, patients should then be followed on to have a 24-hour pH monitoring test, which is currently considered as a gold standard for measuring acid reflux. There are two types of tests available, either the wireless or the catheter based study. The catheter based study measures the amount of acid that flows through the oesophagus during a 24-hour period. It is an ambulatory outpatient setting. The insertion of the probe is similar to a manometry except that the outer part of the tube is connected to a portable recorder. It looks like this here on the picture. There are buttons on the recorder for the patient to press in relation to their meal times, bedtime and also their symptoms. The addition of impedance channels also helps to detect not just acid reflux but also non-acid reflux. Of course, this test has its limitations because it does require the patient to be able to press the buttons accurately, and because it is only a snapshot of a 24-hour period, it loses its day-to-day variability data. Nevertheless, this is the best test we have for assessing acid reflux. Just a quick snapshot of what a 32nd tracing looks like for you. Based on the direction of the graphs, one can read whether this patient has a liquid swallow. In here, the patient is having a reflux episode followed by clearance. This is associated with a pH drop of less than four, and hence this is an acid reflux event whereas on this one here, the reflux episode is associated with a pH of more than 5. Hence, this is a weak acid reflux event. In here you can see that the patient actually pressed a symptom here indicating that they have got some sort of symptom related to their reflux. This is associated with a pH drop of less than 4, and hence this is a positive reflux symptom association. The pH test does provide a lot of information regarding the patient's reflux symptom. Why do we measure weak acid reflux? Weak acid reflux is actually not uncommonly found in healthy individuals. However, it is important to know that when you put your patient on PPI, you are actually not reducing the number of acid reflux events. You are merely changing the pH from acid to non-acidic. As you can see this study here, 95% of the reflux becomes weak acid reflux. Why is that important? It has been shown that in patients who have persistent symptoms on acid suppression therapy, they present with a variety of symptoms as seen here. More importantly, when these patients go on to have a pH study, it is found that over a quarter of these patients actually have symptoms correlated to non-acid reflux. It is important not to ignore non-acid reflux.
Let us look at some treatment algorithm. If you have a patient who presents with typical symptoms of heartburn and regurgitation who has no alarm symptoms, it is really important to assess that. If you have a patient who has dysphagia or weight loss or the patients are elderly or have some symptoms of haematemesis, you really need to have a low threshold for referring the patient on for objective testing. Let us say if you have a patient who has no alarm symptoms with just typical reflux symptoms, it is certainly not unreasonable to give them a trial of empiric PPI therapy, even though I have shown you that the sensitivity and specificity is quite variable. In real life situations, this is definitely a very reasonable approach and you would want to give them a once daily dose and important to tell them to dose it at least half an hour before a meal, as studies have shown that this is the best time to provide maximum acid suppression. I would also hope that at the same time, you would have counselled your patient regarding lifestyle modifications such as not eating too close to bedtime, elevating the head of their bed, avoiding food triggers and also losing weight if the patient is obese. If, let us say the patient has complete relief, great. You would want to try and bring the PPI to the lowest dose possible, and hopefully you will be able to stop the treatment and then have the patient go on demand therapy when needed. However, if your patient has incomplete or no relief, you need to pause and think about why is the patient not having any symptoms at all. Let us look at refractory GORD. It occurs in up to 45% in patients taking once daily standard dose of PPI. It is important to think about the potential causes. Always make sure that your patient is actually taking the medication and also taking the medication correctly. Whether it is definitely before a meal. A lot of patients actually do not know that, and they actually take it after a meal or take it in the middle of the day. It is really important to counsel them about the time of dosing. Do they have weak acid reflux as I have alluded to before? Do they have nocturnal acid breakthrough, which I will talk about later? Also, it is important to think about the genetic variability of PPI metabolism in patients who have CYP2C19 polymorphism, for example, they are considered the rapid metaboliser and is commonly seen in the Asian population. In this group of patients, perhaps they do need a higher dose of PPI or maybe they carry the CYP3A4 polymorphism where they do better with omeprazole or rabeprazole. Do they have delayed gastric emptying? Does your patient have gastroparesis? Do they have functional oesophageal disorders which I will touch on later, and also do they have disorders of gut-brain interaction, which is formerly known as the functional GI disorder such as rumination syndrome or your chronic belches. These are the things that you need to think about when patients tell you "I am still not better. The PPI has not made a difference to my symptoms." As I have said, once you have assessed that they are being compliant with the medication, it is not unreasonable to increase the dose to twice daily dosing, particularly in the Asian population, or switch them to a different class. Very important, once you do that, never just leave them on the medication for 12 months or so. It is important to reassess after four to eight weeks. If there is no improvement, it is time then to refer them for objective testing for a gastroscopy and it is often done asking them to stop their PPI for about two weeks. Similarly, in your patients who have had recurrence of symptoms after successfully weaning off the medication, they should also similarly undergo endoscopic examination. If it shows moderate-to-severe reflux oesophagitis or Barrett's, then you know that the patient definitely has GORD. If, however, it is a normal endoscopy meaning they have non-erosive reflux disease, then they should proceed to an oesophageal function test with 24-hour pH monitoring. If it is an abnormal test, again it confirms GORD. If it is a normal test, then we need to start considering other causes. What about if you have patients who present with extra oesophageal symptoms? Now I want to bring your attention that patients with extra oesophageal symptoms often do not have reflux disease. It is actually really important that other causes have been carefully identified and/or excluded and I always get help from my other colleagues. If patients present with throat discomfort like voice hoarseness or globus, they should really see an ENT surgeon to rule out any local disease. If the patients have cough or asthma, it is important to have a lung function test or get respiratory involvement. If the patient has all those conditions excluded and also has typical reflux symptoms in addition to their atypical symptoms, these patients often it is very reasonable to give them a trial of PPI. Some studies have also shown that in this group of patients, they do need to go up to a twice daily dosing and perhaps for even a longer period of up to 12 weeks. Again, I stress that these are patients who have both typical and atypical reflux symptoms. Again, assessing them after 12 weeks is really important. The pathway for assessment will be very similar to what I have shown you before.
I will just move this along quickly. Now I do want to spend the last few minutes talking about functional oesophageal disorders. Before I do that, let us look at this group of patients here. Again just to recap, this is a typical patient who comes in with heartburn or regurgitation, has a normal endoscopy, proceeded to have a 24-hour pH study and is found to have an abnormal pH test. This patient definitely has gastroesophageal reflux disease, but they still have persistent symptoms. What do you do with these patients? As I have said before already, check compliance, check adherence, switch class of PPI or double the dose of PPI. You can also consider H2 receptor antagonists, particularly in patients who have nocturnal acid breakthrough, and some studies have shown that adding an additional H2 receptor antagonist before bedtime does help to improve nocturnal acid breakthrough. Alginates such as Gaviscon and Sucralfate acts as a raft between the junction of the stomach and oesophagus, and is actually pretty good in reducing symptoms of regurgitation, in particular. Baclofen is a good medication that actually reduces transient lower oesophageal sphincter relaxation and has been found to actually improve regurgitation as well as non-acid reflux. However, its use is mainly limited by its side effects. I must say I have used a handful of baclofen in some patients who have quite difficult to treat reflux and I have had some success, but it is really, really dependent on the patient. Of course, if your patient has not recovered based on the above strategies that you have adopted, then you really need to consider anti-reflux surgery. What about this functional oesophageal disorder group where a patient has reflux hypersensitivity, meaning that they have got a normal pH test, so they do not have acid reflux, but they have positive symptom association to physiological reflux. You can see that this is an important group because overall 14% of patients with typical symptoms will have reflux hypersensitivity. What do you do with these patients? Clearly they do not have pathological acid reflux. You should really try to educate the patient and consider stopping PPI because obviously adding acid suppression therapy is not really going to improve their symptoms. There are studies to show that in this group of patients, neuromodulators using tricyclic antidepressants or SSRIs such as a low-dose citalopram can help improve reflux hypersensitivity. There has been a recent randomised controlled study to say that perhaps these patients might actually do well on anti-reflux surgery, but of course this needs to be taken into serious consideration. What about this group here, which is your group with functional heartburn? In my opinion, these are the hardest group to treat. They are the ones that have normal endoscopy, normal 24-hour pH test, and they might be pressing the symptom buttons throughout the night, but none of those symptoms correlated with any acid or any physiological acid at all. They really are the hardest group to treat because they often have underlying psychological illness or some sort of anxiety or depression and very, very important that you must stop and pause and not give them acid suppression therapy because it will do more harm than good. It is very important to stop PPI if this is what has been found and very important to then counsel them about getting psychological assessment. There have been a lot of studies which have looked at this area that cognitive behavioural therapy and hypnotherapy do work for these patients.
In summary, my take home message is that gastroesophageal reflux disease is a heterogeneous disease. Symptoms correlate poorly with endoscopic and physiological findings. It is very reasonable to provide empirical treatment with PPI in patients with GORD provided there are no alarm features. Consider factors for your patients who do not respond to PPI and also consider objective testing. Upper endoscopy is essential to exclude structural diseases and oesophageal manometry is useful to exclude major motor disorder. Finally, ambulatory pH impedance study is currently the gold standard for diagnosing both acid and non-acid reflux. Thank you.
Dr Natasha Feingold
Thank you so much, Lisa. There are a couple of questions. We just have a few more minutes before we talk that in the chat box, can you give some details about switching the class when PPIs are not effective?
Dr Lisa Shim
In some patients whom, for example, you have put on pantoprazole and after four or eight weeks, they come back and they tell you that all my symptoms are no better and they are taking it at the appropriate time and if you are thinking that they could be the CYP3A4 polymorphism carrier, perhaps they do better with omeprazole or rabeprazole. Not uncommonly, I do switch PPI. I will switch them from pantoprazole and I will put them onto esomeprazole at 20 mg or rabeprazole at 20 mg to see how they go. I do not normally double the dose straight up front. I would give them a trial of switching the class. You might have also some patients who do not tolerate one particular PPI because of certain unfounded side effects. Also, in those circumstances, it is very reasonable to switch class. I am not saying switch and try all four different types of PPIs. I think just switching one to the other, and if they have not improved, that is when you would either double the dose or refer them on for further testing, as I have discussed before.
Dr Natasha Feingold
Do you ever use the pharmacogenomics tests that are out there?
Dr Lisa Shim
They are available. They are not cheap as well. I do not find them that particularly helpful. I do not think that it will necessarily change your management. In some patients who are absolutely, absolutely refractory to certain PPIs and in those patients who have Barrett's oesophagus, who have erosive oesophagitis that you know, that they definitely need to go on PPI, but somehow they are just not responding, perhaps in those patients there is a role in it, but it is definitely not routinely used at this stage in clinical practice.
Dr Natasha Feingold
Okay, great. There are a few more questions in the chat box, but I think some of them we might be able to maybe you can have a look and see if you can answer some of them or if not we can leave them till the end with our group Q&A, but up next we have Dr Mifanwy Reece, who will go ahead and give us a talk on the very important topic of bowel cancer screening. I will hand that over to you Mifanwy.
Dr Mifanwy Reece
Thank you very much, Natasha, and thank you for the invitation to speak to you today about updates in bowel cancer screening. I am Dr Mifanwy Reece, a colorectal surgeon, and I work at Concorde Macquarie and also up on the Central Coast. So I would like to acknowledge the traditional owners of the land on which I sit today, which are the Darkinjung people. I have got no disclosures. Just to go over the learning objectives for today, I hope by the end you will understand who should have a screening colonoscopy based on family history, which has changed in the recent guidelines, and also understand how you can make the biggest impact in preventing bowel cancer. Why is this important? Well, unlike breast cancer, there is no brown ribbons for bowel cancer. It is not talked about as much in the media, but bowel cancer screening is actually better than breast cancer screening because it reduces the incidence and mortality from colorectal cancer, and similar to cervical cancer screening, it has the opportunity to identify pre-malignant disease, and that is what I think makes it a very effective screening program. Bowel cancer was the fourth most common cancer diagnosed in Australia last year, but the second leading cause of cancer death, and it is actually increasing in young people. 2% of colorectal cancers were diagnosed in those under 40 in the year 2000, and last year it accounted for 6% of colorectal cancers. The current screening in Australia, as I am sure you all know, is the National Bowel Cancer Screening programme, which involves doing FOBT testing for average risk people and then colonoscopy for higher risk individuals. The aims of the screening programme are to improve survival by diagnosing early stage colorectal cancer and reducing the number of patients diagnosed with metastatic disease at first diagnosis. The other aim is to reduce the incidence of colorectal cancer by enabling the resection of premalignant polyps. Now the evidence in support of FOBT testing is excellent. There are multiple large scale randomised controlled trials from the Guaiac FOBT test, less specific tests than the currently used foecal immunochemical test. Hundreds of thousands of patients from all over the world in multiple studies that have demonstrated a reduction in mortality and incidence of colorectal cancer with FOBT screening. Our screening program involves people being sent a home test kit. The screening program was established in 2006 and started with a couple of age groups being sent this test kit, and then there has been a gradual decrease in the screening interval so that as of 2020, people between the ages of 50 and 74 are sent a kit every two years. They put the liner in the toilet. They do scrape it with a stick and then store the first of the two samples in the fridge because the sample is affected by heat. Then they do the second test the next day and then they pop their test into the post. It gets sent to a centralised laboratory and then the patient gets sent a result. How good is the test? It has got a pretty good sensitivity and specificity. The positive predictive value is 3.6%. If you have a positive test, it is 3.6% chance that you have actually got a bowel cancer and the negative predictive value is 99.9%, so that is excellent. It detects twice as many advanced adenomas as the Guaiac FOBT test, and very importantly, the number of needed to treat for doing colonoscopy screening is about 200, but one in 28 positive test result in a cancer, so you only have to do 28 colonoscopies to pick up a cancer based on this screening program, so it is very cost effective. The stats from 2018 and 2019 demonstrate that there are millions of participants, and 2500 colorectal cancer deaths per year are prevented with a small number but not insignificant number of adverse events related to colonoscopy, and it costs about $40 million per year. The gradual rollout of the screening program enabled the analysis of bowel cancer outcomes between those who were invited and those who were not invited yet to screen, and there was a significantly higher number of patients developing bowel cancers in the not invited test group. The number of people with a positive FOBT has dropped over time, but it was 12% when they did this review, which was based on numbers from the early part of the screening programme, and you can see that the great majority of people will have a normal colonoscopy and no cancer or adenoma identified, but a number will have cancers and advanced adenomas. The risk of developing a cancer within two years of having a negative FOBT was very low. If we compare the outcomes of people who were screened versus those who were not screened, there was a statistically significantly lower number of people who had cancer diagnosed at an early stage. In those who were screened, they had a lower risk of death from bowel cancer and a lower risk of death from any cause. This graph here shows the improved survival between the patients who had a screen detected cancer versus those who were never invited or did not respond to the invitation to screen, and this graph here shows that for the people who had a screen detected bowel cancer in dark blue, they were much more likely to have an earlier stage or localised bowel cancer compared to non-responders and non-responders were more likely to have nodal disease or distant disease at diagnosis. Now, it takes a long time for a screening program to reduce the incidence of colorectal cancer, and when a screening program is introduced, the incidence of cancer actually goes up, as you can expect because there are more diagnoses. In 2006 the screening program was introduced, the incidence went up, and then about ten years after the screening program was introduced, the incidence has started to fall. The bowel cancer screening program is achieving its goals. I hope that that will motivate you to help your patients to participate. Now I would like to talk about to help you to understand who should have a screening colonoscopy based on their family history. The Cancer Counsel have published these clinical guidelines that talk about lots of different aspects of care related to colorectal cancer management. I think the guidelines were first published in 1999. The guidelines I am going to be comparing the most recent changes to other 2017 ones and they were updated last year. There are two chapters in this guideline that have been updated since that 2017 publication, and here you can see these are the two chapters, Population screening and risk and screening based on family history. This is an important slide I will spend some time talking about this. This splits up people in the general population into their risk category, and when you are calculating someone's risk to determine what sort of screening they should have, you need to take into account their family history on both sides of the family. A person with an average population risk will either have no family history or a first degree relative over the age of 60. This is the first change to the guidelines. It used to be over the age of 55, but it is now increased to over the age of 60. Their lifetime risk of developing colorectal cancer is 5-7%, and the recommendation is that they participate in the FOBT component of the bowel cancer screening program, but the age has now changed. Instead of being from 50 to 74, it is now recommended from age 45 to 70. People who have a slightly increased risk of developing bowel cancer will either have a first degree relative under the age of 60 who has been diagnosed in the past, two first degree relatives with bowel cancer at any age, or one first and one second degree relative at any age, and their risk of developing bowel cancer is two to four times increased over the average population risk. That risk is deemed high enough to justify the use of screening colonoscopy. These people should have a colonoscopy every five years, either from the age of 50 to 74 or 10 years before the youngest person in their family with colorectal cancer, whichever is the younger of those two ages. Family gene testing is not usually recommended in this risk category group. Those who are at substantially increased risk have either two first degree relatives and one second degree relative, one of whom is under the age of 50, or two first degree relatives and at least two second degree relatives at any age or three first degree relatives at any age. These people have up to 20 times the risk of developing bowel cancer compared to the average population risk. They are also recommended for colonoscopy screening, which should happen from the age of 40 or 10 years before the youngest bowel cancer patient in their family, whichever is earliest and referral to a culturally safe family cancer clinic for gene testing is recommended and should be prioritised for people whose family history is all on one side of the family. People who have a known or suspected mutation that puts them at great risk of having a bowel cancer, which actually counts for less than 5% of all colorectal cancers, have a variable lifetime risk of up to 100% of developing a bowel cancer, and the guidelines vary about when and how often they should have a colonoscopy, but usually it is one to two yearly and sometimes from the age of 16 or 18, depending on the condition. They also did some modelling tests to look at cost effectiveness of increasing the screening age. Looking at the age group of 40 to 44, it is cost effective, but it is a less favourable benefits to burden ratio. The recommendations in the new guidelines is that if a patient requests screening that you consider offering them a FOBT test. Similarly, cost effectiveness exists for patients aged 75 to 85. In fact, the risk of colorectal cancer goes up with age, so patients in that age group are more likely to develop colorectal cancer than those in younger age groups, but the benefits do not outweigh the burden and that is why those patients are not part of the National Bowel Cancer Screening Programme catchment age group, but you should consider offering these patients an FOBT test, especially if they remain fit and well even after the age of 74 when the screening program stops. At this stage, flexible sigmoidoscopy is not recommended as a screening test and biomarker testing is not currently recommended, but watch this space, I am sure it will be in the future, but it is just very expensive at the moment, and CT colonography can be used as an alternative to colonoscopy. Another important change in the guidelines is that we consider giving low dose aspirin to all risk categories from the age of 45 to 70. This is not new, but I just wanted to highlight that after someone has a good quality colonoscopy, good bowel prep and the whole colon has been viewed, so the intubation rate of the coecum and terminal ileum is good. Then I would usually recommend that they skip the next FOBT and then resume FOBT screening after that. It is a bit challenging when someone does a FOBT is positive 6 or 12 months after having had a colonoscopy, and of course, because we are all worried about potentially missing a cancer, then we will often feel obliged to repeat a colonoscopy. If they have had a good quality colonoscopy, I usually recommend that they skip that, and that is also part of the guidelines. I hope you will understand who should have a screening colonoscopy based on family history, and now we can move on to talking about how you can make the biggest impact in preventing bowel cancer. 75% of colorectal cancer patients will still present with symptoms like PR bleeding or altered bowel habit, and one of the questions that got raised to me when I was making the slides for this presentation is what should we do about young people who present with PR bleeding? Now this is very difficult. The incidence of colorectal cancer is increasing in young people, and young people tend to be diagnosed with colorectal cancer at a later stage because their symptoms are often ignored and thought not to be related to colorectal cancer. My suggestion would be take a history, look for any red flag symptoms, do an examination, perform a PR examination. What I would normally do with these patients is, reassure them that I think that their bleeding is unlikely to be related to a cancer. I think it sounds like it is haemorrhoidal bleeding, but I cannot be absolutely sure unless I have a look with a scope, and for people who are under the age of 30, I would often speak to them about the risks and benefits of flexible sigmoidoscopy versus colonoscopy. To be honest, most people would choose to have a colonoscopy, but I always talk to them about the two options and often can offer them some haemorrhoid treatment at the same time if their bleeding is problematic. You will see patients who have symptoms, but you have a very important role in encouraging screening. We know that patients are much more likely to participate in a screening test if it is endorsed by their healthcare professional, and you have a critical role in the patients aged between 45 and 49 because even though the screening age of the National Bowel Cancer Screening Programme has been lowered, those patients do not get sent a kit. It needs to be given to them or they need to request it. How can your patients access a kit? Between the ages of 45 and 49 all ex-patients who are sent a kit but they are not doing it for some reason, you can order bulk screening kits to give to eligible patients. The patients still need to be registered online, and there is a form that you need to print out and give to the patient. They need to check that the details are correct so that when they send in their sample with the form, they know where to send the result, and you can also request a kit via the healthcare professionals portal, or the patient can request one online or by phoning this 1800 number. This is the link here to the alternative access to bowel screening kits for healthcare providers, and you can register there to get a kits sent to your practice, but unfortunately patients have a perception about bowel cancer screening that they are going to have to put their arms into mounds of dinosaur like faeces in order to get a result, and so the participation rate is not amazing. It is about 40%. It is fluctuated a little lower, a little higher. This graph here, the darker the colour, the higher the participation rate by area in Australia. It is probably no surprise that women are more likely to participate than men and older patients more likely than younger patients and people who have already participated once are much more likely to do it again. If you can get your patients to do it, once they find out it is not so bad, then hopefully they will participate again. There have been some strategies to try to improve participation, like Merv Hughes's Talking Shit Show and very importantly, the National Indigenous Bowel Screening Pilot Study, on which the changes to the age range now are based. It will be no surprise that there are some inequities in colorectal cancer screening. So indigenous populations in Australia are tend to be diagnosed with colorectal cancer at an earlier age. They have a lower survival and also have a lower participation rate. The recommendation from the guidelines is that these patients should be screened from the age of 40, and recently, a National Indigenous Bowel Screening Pilot study was performed where healthcare providers were given cultural training, the kits were provided with different packaging, and the participation rate was able to be increased from 23% to 40%. This is the kind of impact that that targeted giving people kits and doing it in a culturally sensitive way. This is the kind of impact that you can have as a GP, and so obviously you need to provide culturally safe and sensitive information when you are encouraging participation, and keep in mind other populations who might have difficulty with the screening program, such as patients with disability, culturally and linguistically diverse populations and those who are geographically isolated, but the improvement in participation rate that happened with this indigenous bowel screening pilot study then formed the basis for being able to order kits and give them to people who were aged 45 to 49. Just lastly, I am going to address, is there a better test? Like why do not we just do screening colonoscopy for everyone? It is a better test for picking up colorectal cancer. Well, why do not we do any of these newer tests? There are a number of circulating tumour DNA blood tests. There are foecal DNA tests, you can blow into these machines that will detect volatile organic compounds, or there are sniffer dogs that can detect colorectal cancer. I am just going to compare FIT testing and colonoscopy. Just to give you an idea of why we might not use some of these tests, even though they might be more sensitive or specific. If we just compare FIT testing with colonoscopy, FIT testing is as a screening test, safer than a colonoscopy, which has obviously a risk of perforation. One in 1000 risk of perforation is higher than what we would expect for screening colonoscopy. That is colonoscopy for all comers there. The reduction in incidence and mortality of FIT testing has been well documented, and for colonoscopy screening there is not great studies out there, but it is probably better for the people who actually have the test. The sensitivity is higher for colonoscopy, but the specificity is similar between the two different modalities, but really importantly, the participation rate is much higher for FIT testing patients. People are more likely to do their FIT testing than they are to show up for a colonoscopy, and very importantly, the number needed to screen in Australia is 380 with a FIT test to detect one cancer, and so the number needed to colonoscopy is only 28. With colonoscopy you have to do 200 colonoscopies in order to detect a colorectal cancer, and the cost is very high. It would be extremely expensive and would completely overwhelm our endoscopy services in Australia, and the overall efficacy of a less sensitive can be compensated for by increased uptake. If we could increase the uptake of FIT testing by 10%, it would prevent an additional 16,800 deaths in addition to the 60,000 lives already saved. This, I think, is where you can have the biggest impact on reducing colorectal cancer by encouraging your patients to participate. We already know that the increased age range is going to increase the demand for colonoscopy by 3% to 14%, and we really need to try to keep colonoscopy available for the patients that really need it. Ultimately, the best screening test is the one that gets done. It is all very well to say colonoscopy is a better test, but if people are not going to do it, then it is not going to be as effective. I hope now that you will understand how important your role is in having a big impact on preventing bowel cancer. Thank you.
Dr Natasha Feingold
SPEAKER S2: Thank you so much Mifanwy, that was so helpful. So many gems in there that I know we will take on to our daily practice. We have a few more questions in the chat box that I thought maybe that you can answer. We have got a bit of time left. Any updates on risk factors that are causing an increased incidence of bowel cancer in young people?
Dr Mifanwy Reece
I do not think we really completely understand why this is happening. I see young people who are fit and healthy and not overweight who really have no risk factors. We know about risk factors like smoking, alcohol, eating red and processed meat, having a low fibre diet, but I do not think there has been any identifiable factor in young people that will give us a clue yet. Lisa, I do not know whether you have got anything to add to that.
Dr Lisa Shim
No, I agree with what you are saying Mif.
Dr Natasha Feingold
I also might ask a question for both of you. How do you decide between referring to a gastroenterologist or a colorectal surgeon for a colonoscopy for a positive FOBT?
Dr Mifanwy Reece
That is a good question. I think that the quality of colonoscopy amongst colorectal surgeons is improving, and I am really happy that there are now that we all need to do our reaccreditation with the Gastroenterological Society to make sure that our colonoscopy standard is excellent. I am happy to say that my adenoma detection rate is very high, higher than average, but I think, you could refer to either. As long as they can get in reasonably quickly and have their colonoscopy within the recommended 120 days, but I think you would like to know that the person who was doing the scope had a good polyp detection rate. I think that is really important. Lisa might disagree with me.
Dr Lisa Shim
No, I totally agree. I think there is really no real difference between gastroenterologists and colorectal surgeon, but like what you have said, I think the quality of the colonoscopy is much more important than the type of surgeon that is performing the procedure, and having a good adenoma detection rate is really important.
Dr Mifanwy Reece
I think if a patient has some other problem, like they have haemorrhoids that need to be treated at the same time, then that makes sense. Whereas maybe if someone has got reflux or needs a gastroscopy, I mean, most colorectal surgeons will do gastroscopies, but you know, if you think that someone has got really bad reflux, I think it would be more appropriate to send to a gastroenterologist in that situation.
Dr Natasha Feingold
Is there a clinical role for a PillCam or a Camera capsule in bowel cancer screening?
Dr Mifanwy Reece
There is a colonic version of the PillCam. It is slightly different because compared to the small bowel one because the camera has to last a bit longer, because it has to get through all of the small bowel before the battery runs out and before it stops taking photos. There have been some studies that have looked into the colonic version of the PillCam for screening, and I think there might be a study running in Scotland at the moment where they are using the pill test. At the moment, it is not an established thing in Australia, but it is a reasonable thing, and the I guess the problems are that the patients still need to take bowel prep. They still need a clean bowel to be able to do it, and if something is identified, they still need a colonoscopy to take it off and to deal with it, but it could be a really helpful test for patients who are in remote areas. I could see that being really useful in Australia.
Dr Natasha Feingold
Maybe on that same note, could you expand more on the CT colonography and when you think about doing that and for which patients?
Dr Mifanwy Reece
A CT colonography is basically that the patient still needs to have a bowel prep, although it is a slightly modified bowel prep and there is a minimal prep CT colonography you can get for people who you do not think will tolerate bowel prep. The patient needs to have a catheter put in their bottom, their colon gets filled with gas and then they have a CT scan and the images get reconstructed. It is pretty good for detecting polyps that are of a decent size, 6 mm and greater. I usually reserve it for people who have an incomplete colonoscopy, cannot get around for some reason they have got bad diverticular disease or I also use it for people whom I am worried about giving sedation for a colonoscopy. I use it sort of more as an alternative rather than a as a general screening test usually, but I talk to patients about it. Some people say, oh, is there anything else rather than a colonoscopy? and then I will talk about CT colonography as an option. I do not know about you, Lisa. Do you recommend it for people?
Dr Lisa Shim
I do not do it routinely, definitely not for screening, but I agree that certainly in some patients, particularly the elderly patients, who are on anticoagulants, who are quite frail and cannot really tolerate anaesthetics, in those circumstances, I do offer them the option of CT colonography, but I definitely do not routinely recommend it as an upfront sort of screening strategy.
Dr Mifanwy Reece
I do not think the patients love it, like it is pretty uncomfortable. They are awake. I think once they have had it done, they are probably almost prefer a colonoscopy with an anaesthetist.
Dr Natasha Feingold
That is the number one question is am I going to be knocked out for colonoscopies? I think some patients do not realise that. What about polyps that require more frequent colonoscopies? Are there certain polyps in that regard or that you need to think about that?
Dr Mifanwy Reece
We have similar guidelines that tell us how frequently patients should have colonoscopy based on both the number and the type of polyp. The patients who have sessile serrated adenomas, for example, they are often a bit more subtle and occur in the right colon, and we usually have a lower threshold for doing more frequent colonoscopies in that situation, but it is also based on the number of polyps and the size and whether there are any adverse features of the polyps. If the patients need to have another colonoscopy in one or three years as opposed to five, they probably do not need an FOBT test in between, and you base the next colonoscopy based on the one before, so the screening interval might change with time or surveillance interval.
Dr Natasha Feingold
So a lot of factors that you have to think about that. Another question came up is about referring to private pathology companies for FOBT. Is that the same as the government programmes?
Dr Mifanwy Reece
If you guys request an FOBT test or if foecal immunochemical test, that is only what is used now. I have never heard of anyone having a Guaiac test anymore, and then usually there are three samples I think in those tests, as opposed to the two samples in the bowel cancer screening program. Each lab may have a slightly different threshold for what they consider to be positive and not like I know in New Zealand, for example, they have a higher threshold so that they do not have the same burden on their colonoscopy system. So you need to have more blood in your poo to get a positive test than you do in Australia, and that is just based on resources and things. I think that is the main difference is that it is three rather than two.
Dr Natasha Feingold
Is there is there a tablet based prep for colonoscopies?
Dr Mifanwy Reece
There is a tablet based prep that I think has been trialled in America. It will probably come at some point. It is not going to stop the horrible diarrhoea that people need to have, but yeah, I think it will be an improvement for some people that have a lot of trouble getting there.
Dr Lisa Shim
There was a tablet prep before. I cannot remember the name now, but it is taken off the market, but patients actually have had to take like 42 tablets, something ridiculous like that. I think I only had two patients who chose that, but it was horrible to take it anyway, but it is now off the market. I do not really know the reason.
Dr Natasha Feingold
I think along with getting my practice manager to buy some more brown ribbons or invest in some purchasing some brown ribbons, I think we need to advocate for, people have horror stories around there or they hear about horror stories around prep, and it can be really difficult to try and actually convince some patients to go for their scope. They are so petrified of the prep. Now I think we are going to have to wrap up. We have got one last question. In terms of the aspirin, the recommendation of aspirin for higher risk patients is that lifelong?
Dr Mifanwy Reece
I think the guideline it was from the age of 45 to 70. I think 100 mg a day, and it was actually for anyone, not just for the higher risk people, but even in the low or the average risk people, that is written as one of the recommendations, so it is interesting. Obviously it needs to be prescribed making sure that there is no other contraindication to having it.
Dr Natasha Feingold
Lisa did you have something?
Dr Lisa Shim
Yeah. I just wanted to quickly touch on there were a number of attendees who were asking similar questions regarding Helicobacter pylori infection and reflux, and in fact, there is no real good evidence to suggest that having Helicobacter pylori infection is actually associated with reflux symptoms. Patients who have H. Pylori typically present with epigastric discomfort. It might be a coincidence that patients are also experiencing reflux. Just because they have H. Pylori infection and you have treated that successfully does not mean that they do not get reflux symptoms. I just wanted to make that clear that there is really no real evidence to suggest that they are associated with each other.
Dr Natasha Feingold
Thank you so much for that. Serena, I think that might be it for us time wise, and I just want to thank you so much to both of our speakers. That was a fabulous, informative evening, and we are really, really very thankful for you both to be here tonight to share so much important knowledge with us, and I know that our patients will be better for it. Thank you so much. Lots of thumbs up and hearts coming your way.
Serena
I would like to extend my thanks to Lisa, Mifanwy and Natasha for presenting this evening and also everyone who joined us online. We do hope you enjoyed the session and you also enjoy the rest of your evening.