SPECC – Significant Polyp and Early Colorectal Cancer Sarah Crane Pelican Cancer Foundation On behalf of the SPECC Team

Pelican Cancer Foundation Bill Heald and Basingstoke 1993 Funding from donations, industry, fees and charitable grants Conferences and workshops Research

What is SPECC? “SPECC is a national development programme, focussed on the treatment of significant polyps and small (T1) tumours” Multidisciplinary – surgeons, gastroenterologists, radiologists, pathologists, nurse specialists 6 free places for every MDT

Steering group Brendan Moran - Lead Brian Saunders Rob Glynn-Jones Phil Quirke Gina Brown Chris Cunningham John Stebbing Wendy Atkin Matt Rutter Rupert Pullan Bob Steele Graham Williams Sunil Dolwani Michael Machesney Gerald Langman Neil Borley Nicky Richards Sarah Crane

SPECC workshops SPECC workshops London Cancer Yorkshire & Humberside Started November 2015 SPECC workshops London Cancer Yorkshire & Humberside London Alliance West Midland East Midland Wessex Greater Manchester South East Coast Wales Northern England East of England Cheshire & Mersey South West Coast 17.12.17 Eire Ulster Scotland

So far….. 6 SPECC workshops completed 424 clinicians attended from 73 trusts Feedback on changes to clinical practice: Take more time at endoscopy Develop patient information Offer alternatives e.g. brachytherapy

Aims Definition – are you confident what it is? Recognition – who and when Documentation – who needs what Treatment - alternatives Strategic planning – locally, regionally, nationally

Guidelines

This is what a SPECC looks like

Introduction Incidence of colorectal polyps increasing Wider public awareness Bowel Cancer Screening Programme Basil Morson Morson B. The Polyp-cancer sequence in the Large Bowel. Proceedings of the Royal Society of Medicine. 1974;67:451-7

Risk of LN involvement 2% 8% 23% Kikuchi classification – sm1 is fisrt 1/3 of submucosa, sm2 is second 1/3 of submucosa, and sm3 is last 1/3 Risk of LN involvement 2% 8% 23%

SPECC not suitable for routine colonoscopic excision may occur anywhere in the colon or rectum a large (>20mm) sessile lesion morphologically aberrant & difficult to access endoscopically Malignancy spectrum- shades of grey non-involvement of lymph nodes not common – up to 5% polyps only 10% malignant. Increasing with BCSP

Factors contributing to significance Size Morphology Site Access Patient factors – comorbidity

Questions to ask yourself: Have you fully assessed the lesion? Are there high malignancy risk features? How should this lesion be managed? Is MDT discussion required? How does patient fitness impact on options? Has the patient been fully consented? If endoscopic resection –How complex will it be? –En bloc or piecemeal? When should it be removed? SPECC not prescriptive about treatment Meticulous assessment of the lesion Good decision making

Recognition - MRI Setup and planning are critical to achieve optimal images Structured reporting to allow best MRI input to decision making

CT Colonography well-tolerated test that find early CRC & significant polyps CTC has been around a long time Diagnostic performance seems good 95%+ sensitivity for cancer 90% sensitivity for 10mm+ polyps 80% sensitvitiy for 6mm+ polyps For symptomatic patients, CTC is an excellent alternative to colonoscopy in UK real-world practice Early cancers and polyps may present a particular challenge Radiologist QA is developing With thanks to Andrew Plumb at UCLH

Triple assessment Flexible Endoscopy Rigid Endoscopy TRUS With thanks to Neil Borley

Documentation: MRI reporting

Documentation What have you recorded? Picture Video Tattoo Report Not just a polyp!

Treatment: EMR Hardly features in the workshops or early patient information leaflet Assumptions Risk / benefit Piecemeal Time / available equipment & expertise Have a go……!

ESD Endoscopic Submucosal Dissection Drive for single piece resection – especially in uncertain lesions

Potential advantages of ESD En bloc resection Better interpretation of pathology Potentially better decision making BUT Time & Effort intensive Training If more than sm1 – Is local resection alone…?

TEMS T1 disease Balancing risk Potential to extend with adjuvant therapy Thanks to Chris Cunningham

Contact Brachytherapy ‘Papillon’ NICE guidelines Patient selection Older patients Patients with high surgical risk

Key messages Think twice and cut once Maximise local expertise in diagnostic assessment Developing local service / up skilling Work with virtual polyp / SPECC MDTs Regional and supra-regional referral networks Thanks to James East

Next Pelican project is SMART SPECC Coming to South West in December 2017 Next Pelican project is SMART Synchronous Metastases, Advanced and Recurrent colorectal Tumours

4th International Workshop on Complete Response to Neoadjuvant Therapy for Rectal Cancer Discussing the challenges in recognition and treatment of a clinical Complete Response to neoadjuvant therapy for rectal cancer. This meeting will seek consensus on the terminology of a complete response. With an international faculty from across Europe, the USA and Brazil 22nd March 2016 | Basingstoke, UK Convenors: Professor Bill Heald & Mr Brendan Moran To find out more or book a place: www.pelicancancer.org/our-courses | courses@pelicancancer.org