1. Upper Gastrointestinal Cancers Top ⑩ Tips
Gloucestershire Cancer summit Wednesday 30th September 2015
Mr simon m higgs consultant upper gi surgeon
Three counties oesophagogastric cancer unit, Gloucester royal hospital

2. The Bottom Line!
Oesophagus 8300
Stomach 7100
Pancreas 8800

3. Are they preventable? = ~16000 cancers
89% of Oesophageal, 75% of Stomach and 37% of Pancreatic Cancers are linked to preventable/treatable lifestyle and other risk factors
= ~16000 cancers

4. Back in the real world! Prevention is the goal
How can we improve outcomes
Improve patient awareness
Optimise 2 week wait referral pathways
Reduce emergency presentations
Increase capacity in secondary care
Better access to diagnostic tests

5. TOP ⑩ TIPS OESOPHAGO-GASTRIC PANCREATIC GENERAL
①&② ANAEMIA ③ DYSPHAGIA ④ ENDOSCOPY ⑤ EARLY CANCERS ⑥ FAMILY HISTORY ⑦ BARRETT’S OESOPHAGUS
⑧ ULTRASOUND ⑨ CA 19.9
GENERAL
⑩ DYSPEPSIA AND WEIGHT LOSS, RECURRENT DYSPEPSIA/REFLUX, PROLONGED PPI TREATMENT

6. ①② Anaemia
Non-Iron deficient anaemia (Low Hb, Normal MCV/Ferritin) alone is associated with a very low pick up rate of oesophageal or gastric malignancy
Iron deficiency anaemia (IDA ie. Low Hb, Low MCV+/-Ferritin ) without specific upper GI symptoms should be investigated via an IDA 2WW Pathway
Causes of IDA
Aspirin/NSAID use 10-15%
Colonic Carcinoma 5-10%
Gastric Carcinoma 5%
Oesophageal carcinoma 1-2%

7. ③ Dysphagia
Food getting stuck on swallowing has the highest positive predictive value for the identification of OG cancers
BUT:
Only present in 40% of patients with oesophago-gastric cancers
Is often a sign of more advanced disease
AND:
Should always be referred urgently for endoscopy

8. ④ Endoscopy v Barium swallow
OGD is the investigation of choice for upper GI symptoms
More information
Instant
Safe
Biopsy options
Barium swallow is not an easy option even in the very frail and any abnormality will need an endoscopy to confirm

9. ⑤ The earlier the better
Oesophageal Cancer
Gastric Cancer
Pancreatic Cancer

10. ⑥ Family History
Stomach cancer risk is 2-10 times higher in people with a family history of the disease
1-3% of stomach cancers are linked to inherited stomach cancer predisposition syndromes (eg hereditary non-polyposis colon cancer (HNPCC))
Stomach cancer risk is higher in people with BRCA2 mutation in their family

11. ⑦ Barrett’s Oesophagus
Barrett’s oesophagus significantly increases the risk of oesophageal cancer
Barrett’s with no dysplasia = 0.25% risk per year
Barrett’s with high grade dysplasia = 6%
Increased risk with
Untreated GORD, smoking, male sex, advancing age and obesity
Key Interventions:
Treat GORD – PPI or Anti-reflux surgery
2 Yearly surveillance with biopsy
Early referral for change in symptoms

12. ⑧ Jaundice and Ultrasound
Patients with jaundice should have an abdominal ultrasound and LFTs before referral to 2WW pathway
Differentiate other causes of jaundice (ie non-obstructive)
Next management clearer with US result
Earlier specialist referral
Gallbladder stones and dilated duct – MRCP and/or ERCP
No Stones and dilated duct – CT and ERCP/PTC

13. ⑨ CA 19-9
The tumour marker CA 19-9 is not recommended as a screening test
Seen in benign conditions, such as the following:
Biliary tract obstruction
Cholangitis
Inflammatory bowel disease
Acute or chronic pancreatitis
Liver cirrhosis
Cystic fibrosis
Thyroid disease
5% of the population do not produce CA 19-9
Test in the presence of a proven pancreatic or biliary lesion or metastatic disease of unknown primary

14. ⑩ Dyspepsia and other red flags
Urgent 2WW referral should be considered for patients with:
Persistent abdominal pain with weight loss
Reflux symptoms requiring PPI for more than 5 years
New onset of dyspepsia/reflux which recurs after stopping PPI (>55yrs)

15. Any Questions?