The UK significant polyp and early colorectal cancer (SPECC) program

Introduction

There is an increased detection of polyps of the colon and rectum due to more public awareness of bowel problems (particularly bowel cancer), and more widespread adoption of colon cancer screening. The fundamental basis of screening is that most colon and rectal cancers originate from a polyp by a process called the polyp – cancer sequence (also known as the adenoma – carcinoma sequence) described by Basil Morson in 1974, a world renowned pathologist in St Mark’s Hospital London [1].

Most polyps are small and can be safely, and fully, removed endoscopically by polypectomy alone and the majority are noninvasive and benign. However, larger polyps are more likely to be malignant and are technically more difficult to remove. Reports suggest that about 5% of colon and rectal polyps are greater than 20 mm in size and are complex polyps requiring advanced endoscopic skills such as EMR (endoscopic mucosal resection) or ESD (endoscopic submucosal dissection) to achieve safe and adequate removal [2–4]. It has been established that approximately 10–15% of polyps >20 mm in size have a focus or have invasive malignancy. However, generally the malignancy is at the base and superficial biopsies may be misleading with noninvasive low grade or high grade dysplasia in the biopsy fragments. However despite the size and complexity of a polyp, the majority of such polyps are still benign and an alternative treatment to polypectomy, such as bowel resection, may be over-treatment for most patients. Bowel resection has considerable morbidity, and occasional mortality. Rectal resection in particular may result in life-long bowel dysfunction and many patients finish up with a permanent stoma if a lesion is low in the rectum, or if a complication such as anastomotic leakage occurs after a restorative procedure.

For this reason careful assessment of the polyp, the patient and the treatment options are crucial. As outlined above, a further key distinction is whether the lesion is in the rectum (and indeed the precise location in the rectum) as both treatment options and functional outcomes vary considerably between treatment for a cancer or significant polyp of the colon or rectum.

One major issue has been the difficulty in precisely predicting which lesions are more likely to be malignant based on endoscopic appearance and size alone and the limitations of superficial biopsies.

The concept of SPECC

Due to the limitations in accurately categorizing large and complex colorectal polyps, we have developed the concept of SPECC as a nomenclature for significant polyps and early colorectal cancer. We have popularized the concept that a ‘SPECC’ is helpful terminology incorporating complex polyps and early colon and rectal cancers [5]. The thinking behind the term has emerged from Neil Borley and James Wheeler’s publication in 2011 where they described the clinical diagnosis and management of ‘a significant rectal neoplasm’ in that it is commonly not possible to categorize a lesion by appearance and/or superficial biopsies [6]. The term ‘neoplasm’ incorporates benign and malignant lesions and is all encompassing. They suggested that mucosectomy (as a big and adequate biopsy) rather than an initial full-thickness excision was an accurate mechanism for rectal neoplasms where uncertainty existed and a full-thickness excision might well compromise definitive treatment, should the lesion be malignant. We have extended this concept to what we now call SPECC to include lesions of the colon in addition to the rectum, incorporating the uncertainty associated with determining if a complex colorectal polyp is benign or malignant at endoscopic assessment. The concept of SPECC also incorporates early colon and rectal cancers and in particular ‘polyp cancers’ where there is an unexpected finding of a cancer in a polypectomy specimen.

SPECC workshop program

The overlap with colorectal cancer has meant that complex polyps, and early cancers, usually come under the umbrella of the colorectal cancer multidisciplinary team (MDT) and for this reason we designed and delivered MDT workshops aiming to raise awareness and optimal outcome for patients with a SPECC [7]. A SPECC workshop program, funded by the Pelican Cancer Foundation, was developed and delivered by an MDT comprising surgeons, and gastroenterologists in particular, but also clinical nurse specialists, pathologists, radiologists and oncologists (5.7). The multidisciplinary SPECC workshops were delivered to all colorectal cancer MDTs in a series of regional workshop across the UK and Ireland. One of the overarching themes was that ‘decisions are more important than incisions’ when it comes to optimal treatment of a SPECC, a concept we had published previously on the overview of our experience with the English National Low Rectal Cancer Development Program [8]. In conjunction with the SPECC Program we have recently reported the variations in the management of significant polyps and early colorectal cancers on a multicentre observational study of 383 patients [9]. All 383 patients had polypoid lesions greater than 20 mm in size and were detected either at bowel cancer screening (108/383 = 28%) or at endoscopy for either symptomatic patients or colonic surveillance in 275 (62%). Overall 12.8% had surgical resection with 87.2% being treated by endoscopic resection. The unexpected cancer detection rate in these SPECC lesions was 10%, similar to previous publications. A significant original observation was that SPECC lesions detected in the Bowel Cancer Screening Program were significantly more likely to have successful endoscopic resection suggesting that endoscopic skill and adequate time and resources were associated with more effective and safer treatments [9].

Conclusion

The concept of SPECC is a useful advance focusing on recognition of a complex polyp, optimal photo-documentation and ideally video recording and careful consideration of treatment options. There have been a number of key messages developed during the delivery of this program, including awareness of the need to pause and think that a patient with a SPECC might be best treated another day, by another endoscopist and maybe in another hospital if needed. The limitations of superficial biopsies should be appreciated and consideration given to what Neil Borley describes as ‘high value lesions’, of high value to the patient, family, endoscopist and health-care system. SPECC helps to convey the spectrum between benign and malignant, the balance between over and under-treatment and the need for careful planning and often novel specialized approaches to optimize cost-effective outcome and minimize risk for current and future patients.

Disclosure statement

No potential conflict of interest was reported by the author.