ROLE OF SURGEON IN

EARLY DETECTION
AND DIAGNOSIS OF
COLORECTAL CANCER
Ignatius Riwanto
Dept. of Surgery, Digestive Division
Faculty of Medicine Diponegoro University
Semarang

PABI meeting, Palembang April 2018

 Colorectal cancer 2011-2016 RSDK Semarang

Stadium UICC < 40 Y 40 Y > TOTAL (%)

Stadium 1 0 0 0

Stadium 2 29 99 128 (46.9%)

UNDERSTAGE DUE TO
Stadium 3 15 37 52 (19%) INCOMPLETE L.N. EXAMINATION
53.1%
Stadium 4 17 76 93 (34.1%)

273
 Number of cases (1996-2006) and five-year relative survival of colorectal cancer
patients (diagnosed 1996-2002) by stage at diagnosis, England.

Percentage of
5-year Confidence
Stage at Number of Percentage of cases
relative interval
diagnosis cases cases (%) excl.Unknow
survival (%) (95%)
n (%)
Dukes A 26,727 8.7 13.2 93.2 92.5 - 93.9
Dukes B 74,784 24.2 36.9 77.0 76.4 - 77.5
Dukes C 72,806 23.6 35.9 47.7 47.1 - 48.3
Dukes D 28,377 9.2 14.0 6.6 6.1 - 7.0
Unknown 106,040 34.3 35.4 35.0 - 35.8
Total 308,734 100.0 100.0 50.7 50.4 - 51.0

http://www.ncin.org.uk/publications/data_briefings/colorect
ANGKA BERTAHAN HIDUP 5 TAHUN al_cancer_survival_by_stage
BERDASARKAN STADIUM KANKER KOLO-
REKTAL (Modifikasi Duke ) Riwanto & Riyanto.
Ropanasuri 1996;XXIV:28-35
COLORECTAL CANCER DEVELOPMENT
CAN BE DETECTED EARLIER?
 NATURAL HISTORY OF COLORECTAL CANCER DEVELOPMENT

Phase A & B: Need community

screening program

exposure Phase C: Need awareness of

biological
first time medical/ surgical staff
change
symptom
A: Pre-cancer phase time to
Sub detect
B: Subclinical phase outcome
clinical Clinical
C: Clinical phase
period period
D: Treatment phase
A B C D

Risk factors screening early early

detecti diagnosis
& prevention
on
Management study

Causal study Diagnostic study Prognostic study

 COMMUNITY SCREENING

COLORECTAL CANCER SCREENING IN U.S.

High cost.
Still impossible to be done in
Indonesia within short period

IMPROVING THE NUMBER OF

GENERAL SURGEON WHO
COMPETENT IN DOING
COLONOSCOPY
Colorectal examination is protective
factor for developing CRC
 IMPROVING THE
INTERVENTIONAL
COLONOSCOPY AMONG
GENERAL SURGEON
Factors associated with colon cancer screening: the
role of patient factors and physician counseling
• Hispanics were less likely to undergo FOBT [OR 0.7 (95% CI 0.6–0.9)] and
sigmoidoscopy or colonoscopy [OR 0.8 (95% CI 0.7–0.9)] compared to
Whites.
• Respondents with lower education levels were also less likely to undergo
screening.
• Among respondents who did not undergo FOBT, 64% were unaware they
needed the test; only 2% cited pain and discomfort as a deterrent, but 94%
were not counseled by their physician about the test.
• Among those who did not undergo sigmoidoscopy or colonoscopy, 72%
were unaware that they needed the test and only 1% was deterred by pain
and discomfort; 92% were not counseled by their physician.

Preventive Medicine, Volume 41, Issue 1, July 2005, Pages 23-29

Colonoscopy screening for high risk group
• Familial adenomatous Polyposis
syndrome
• Juvenile polyposis
• Peutz-Jegher Syndrome
• Familial cancer syndrome (Heriditary
Non Polyposis Colorectal Cancer)
• Ulcerative colitis (>10 years)
• Crohn colitis
• Ureterosigmoidostomy
• Previous colonic cancer
• Previous colonic adenoma
FAMILIAL COLORECTAL CANCER (CRC)
• 15-20 % of CRC. follow a familial pattern.
• Familial adenomatous polyposis coli syndrome (FAP) and its subtypes are
responsible for only about 1 % of all CRCs,
• Hereditary nonpolyposis colon cancer (HNPCC) accounts for approximately
3-8 % of cases
• The characteristic presentation of HNPCC is:
 frequently right-sided localization,
 the presence of synchronous and metachronous CRCs, and
 its association with other HNPCC-related extra colonic tumors, including gastric,
endometrial, and urinary and biliary tract cancers in afflicted families
• Compared to sporadic colorectal carcinomas, HNPCC has an earlier age of
onset,

World J Gastroenterol 2006 February 28; 12(8):1192-1197

 YOUNG CRC PATIENTS (LESS THAN 50 Y)
SHOULD BE EXPLORE THE POSSIBILITY OF
HAVING AMSTERDAM OR BETHESDA
CRITERIA TO CONFIRM THE DIAGNOSIS
OF HNPCC

FAMILY TRACING
 HERIDITARY CANCER
PEDIGREE MAY BE BETTER
USED ROUTINELY IN CASE
OF YOUNG COLORECTAL
CANCER
 Colorectal Cancer Signs and
Symptoms
• A change in bowel habits, such as diarrhea, constipation, or narrowing of
the stool, that lasts for more than a few days
• A feeling that you need to have a bowel movement that is not relieved by
having one
• Rectal bleeding with bright red blood
• Blood in the stool, which may make the stool look dark
• Cramping or abdominal (belly) pain
• Weakness and fatigue For early detection or diagnosis,
• Unintended weight loss patients with one sign or symptom
mention above need prompt further
https://www.cancer.org/content/dam/CRC/PDF/Public/8606.00.pdf,
Last Medical Review: October 15, 2016 Last Revised: March 2, 2017
colon examination
DELAY DIAGNOSIS OF COLORECTAL CANCER
(Personal case experience)

- PATIENTS DELAY
- GENERAL PRACTIONERS DELAY
- INTERNAL MEDICINE DELAY
- SURGEON DELAY
DELAY DIAGNOSIS IN A CASE WITH LOW RECTAL CANCER

• 11/02/2018, Tn S 54 tahun, datang ke poli gawat darurat RSDK PATIENT DELAY

• Keluhan Utama : BAB tidak lancar
• + 3 bulan SMRS pasien mengeluh sulit BAB, BAB 3 hari sekali
terkadang keras, terkadang bercampur lendir dan darah, kemudian
pasien berobat ke puskesmas diberi obat untuk memperlancar buang
air besar, setelah minum obat pelancar BAB lancar tetapi keluhan • GP DELAY
timbul lagi setelah obat habis. • NO D.RE
• + 1 bulan SMRS pasien kembali mengeluhkan BAB sedikit – sedikit, • NO
bercampur lendir dan darah, pasien juga mengeluh terasa mules pada THINKING
pagi hari dan kembung hilang timbul, setiap BAB berbentuk cair dan CRC
bercampur darah, mual (-), muntah (-). demam (-), kencing merah (-),
kencing nyeri (-), sering kencing (-). Pasien kemudian kembali berobat
ke Puskesmas, karena kembung tidak ada perbaikan kemudian pasien
dirujuk ke poliklinik Penyakit Dalam RSUD Salatiga.
• Di RSUD Salatiga pasien dilakukan pemeriksaan laboratorium darah,
CT Scan perut, teropong usus besar dan biopsi 30/01/2018 . SPECIALIS
Dikatakan pasien menderita tumor kemungkinan ganas pada rectum DELAY
dan harus dilakukan operasi. Karena kurangnya fasilitas, pasien
disarankan dirujuk ke RSDK.
Tumor rectum 1/3
distal curiga ganas
T4bN1M1
PA: waktu
dikirim belum jadi
OFFICE MANAGEMENT OF HEMORRHOID DONE BY G.P.

WRONG
DIAGNOSIS
WOMAN 34 Y, MALIGNAN MELANOMA
TREATED AS HEMORRHOID WITH &
SCLEROTHERAPHY
WRONG
DELAY DIAGNOSIS
MANAGEMEN
DONE BY
GENERAL
PRACTITIONER

MAN 56 Y, LOW RECTAL CANCER,

TREATED AS HEMORRHOID WITH
SCLEROTERAPHY
HOW TO PREVENT WRONG DIAGNOSIS AND
WRONG MANAGEMENT DONE BY G.P.
• GOOD & INTENSIVE EDUCATION TO MEDICAL STUDENT REGARDING
ANO-COLORECTAL DISEASE AND TRAINING IN DIGITAL RECTAL
EXAMINATION.
• CONTINUING EDUCATION FOR G.P REGARDING ANO-COLORECTAL
DISEASE
• CERTIFICATION AND SUPERVISION FOR G.P. WHO DO OFFICE
MANAGEMENT OF HEMORRHOID
• “ NO D.R.E. FOR ANORECTAL COMPLAINTS COSIDERED CRIMINAL”?
• SURGEON HAS CENTRAL ROLE FOR ABOVE PROGRAM
 4 HEMORRHOIDECTOMY CASES DONE BY GENERAL SURGEON WITH
UNDETECTED RECTAL CANCER

MD, MAN 52 Y, ANAL STRICTURE

MAN 56 Y, ANAL STRICTURE 2 MONTHS AFTER AFTER WHITEHEAD
WHITEHEAD HEMOORHOIDECTOMY,
SURGEON MAL-
HEMORRHOIDECTOMY, LOW & LONG
COLONOSCOPY RECTAL CANCER 8 CM FROM RECTOSIGMOID CANCER PRACTICE.  UNDER
ANAL VERGE PROCEDURE (NO RECTAL
EXAMINATION ) 
DIAGNOSIS DELAY

S 34 Y, PAIN & RECTAL BLEEDING

AFTER WHITEHEAD
MAN 42 Y, ANAL STRICTURE 1 MOTH AFTER HEMORRHOIDECTOMY
WHITEHEAD HEMORRHOIDECTOMY, DRE RECTALCANCER 3 CM ABOVE ANAL
RECTAL CANCER 1 CM ABOVE ANAL VERGE VERGE & SIGMOID FLEXURE
HOW TO PREVENT MISS DIAGNOSIS OF CRC
DURING HEMORRHOID/ ANO-PERINEAL DISEASE
MANAGEMENT
• Complete history taking for the symptoms of CRC
• Complete abdominal examination
• Digital rectal examination routinely
• Routine rigid sigmoidoscopy for case above 50 Y
• Complete colon examination in case with CRC sign and symptom
• Complete colon examination if has family history of CRC
SUMMARY
• COMMUNITY SCREENING FOR EARLY DETECTION OR EARLY DIAGNOSIS OF
C.R.C IS EXPENSIVE AND NOT PRIORITY PROGRAM YET IN INDONESIA
• SURGEON HAS STRATEGIC POSITION IN EARLY DIAGNOSIS OF C.R.C BY:
Complete history taking, complete abdominal examination, digital rectal
examination routinely for patients with complain of change of bowel habit
and prompt complete colon examination in case with CRC signs and
symptoms
Family tracing for young C.R.C. and complete colon examination to family
with family history of CRC
Complete recto sigmoid or complete colon examination (if indicated)
before ano-perineal procedure.
Colonoscopy diagnostic and intervention training for general surgeon
Educate to medical student and continuing education to G.P. regarding
anorectal disease and D.R.E training
 Role Of Surgeon In Early Detection And Diagnosis Of Colorectal Cancer
Ignatius Riwanto
Dept. of Surgery, Diponegoro Medical Faculty

Abstract
Up till now colorectal cancer come in the late stage, makes the curative resection only can
be done in a small proportion of cases. Community screening for early detection or early
diagnosis of C.R.C is expensive and not priority program yet in Indonesia, therefore
awareness of the surgeon to the possibility of having CRC among the patients they manage
will be the only way to early detection or diagnosis of CRC. Surgeon has strategic position
in early detection or diagnosis of c.R.C by doing complete history taking, complete
abdominal examination, digital rectal examination routinely for patients with complain of
change of bowel habit and prompt complete colon examination in case with CRC sign and
symptom. Family tracing for young C.R.C. and complete colon examination to family with
family history of CRC may detect CRC in the early stage. Educate to medical student and
continuing education to G.P. regarding anorectal disease and D.R.E training, can be done
by surgeon in the hope that GP should aware for the possibility of CRC in case with change
of bowel habit. Surgeon should do complete recto sigmoid or complete colon examination
(if indicated) before anoperineal procedure.

Key word: Colorectal cancer, family tracing for young CRC, digital rectal examination