PowerPoint Presentation

							SCOPE OF GUIDELINE



              • Management of invasive
                adenocarcinoma of the colon or rectum

              • Preoperative assessments through to
                treatment and follow-up




                Download guideline and resources at
                        www.nzgg.org.nz
GUIDELINE IN CONTEXT

 Groups at high risk for                 Population Screening            Patients presenting with
   colorectal cancer                                                            symptoms
    New Zealand Guidelines Group             Ministry of Health             New Zealand Guidelines Group
    Surveillance and Management          bowel cancer screening pilot       Suspected Cancer in Primary
    of Groups at Increased Risk of               2011-2015                  Care 2009
    colorectal cancer 2004




                                                                                                           Supportive Care
                               Management of early colorectal cancer
                                                                                                             Ministry of Health
                                                                                                           Guidance for improving
                                   New Zealand Guidelines Group                                              supportive care for
                                  Clinical Practice Guidelines for the                                      adults with cancer in
                                                                                                             New Zealand 2010
                                Management of Colorectal Cancer 2011




                            Management of advanced colorectal cancer
PREOP ASSESSMENTS: COLON CANCER


   Clinical examination
   Complete blood count
   Liver function tests
   Renal function tests
   CEA
   Microsatellite instability/immunohistochemistry
    (selected cases only)
PREOP IMAGING: COLON CANCER


 Chest x-ray
 Contrast-enhanced CT of abdomen/pelvis/liver
 Colonoscopy of the entire large bowel
  If complete colonoscopy examination not possible then
  CT colonography
  If CT colonography not available, then barium enema

PET-scanning not recommended as routine assessment for
non-metastatic colon cancer.
PREOP ASSESSMENTS: RECTAL CANCER


   Clinical examination
   Complete blood count
   Liver function tests
   Renal function tests
   CEA
PREOP IMAGING: RECTAL CANCER


 Chest x-ray
 Contrast-enhanced CT of abdomen/pelvis/liver
 MRI of pelvis – to identify if circumferential resection margin
  (CRM) involvement and for local staging
RECTAL CANCER


Use of endorectal ultrasound
• For T1 rectal cancers, endorectal ultrasound may be used for
  local staging as an alternative to MRI of pelvis


• Endorectal ultrasound should not be used as sole assessment
  to predict CRM involvement in people with rectal cancer
ADJUVANT THERAPY: COLON CANCER

All people with resected colon cancer should be considered
for adjuvant therapy

People with resected note positive colon cancer (Stage III)
• Should be offered postoperative chemotherapy unless there is
  a particular contraindication, such as significant comorbidity or
  poor performance status
• Combination chemotherapy with oxaliplatin and a
  fluoropyrimidine is recommended
ADJUVANT THERAPY: COLON CANCER cont.

People with resected node negative colon cancer (Stage II)
• May be offered postoperative chemotherapy
 Discussion of risk and benefits of treatment should include the
 potential but uncertain benefits of treatment and the potential
 side effects

Single agent postoperative chemotherapy
• Either capecitabine or bolus fluorouracil plus leucovorin are
  appropriate regimens

Irinotecan should not be given as postoperative adjuvant
chemotherapy for people with Stages I, II or III colon cancer.
TRIALS IN PROGRESS: CHEMOTHERAPY REGIMENS

 Trial            Investigating                     Patient Group
 PETACC-8         FOLFOX-4 +/- cetuximab            Stage III colon cancer

 NSABP C-08       Adding bevacizumab to             Stage II & stage III
                  oxaliplatin-based chemotherapy    colon cancer
 Intergroup/      FOLFOX-6 regimen +/-              Stage III colon cancer
 NCCTG N0147      cetuximab
 Haller et al     Capecitabine + oxaliplatin        Stage III colon cancer
 N016968          (XELOX) vs 5FU-leucovorin
 (ASCO, 2010)
 AVANT            Efficacy & safety of bevacizumab Stage III or high-risk
                  in combination with XELOX or     stage II colon cancer
                  FOLFOX-4

 French           5FU-leucovorin +/- ininotecan     Resected Stage II &
 Intergroup R98                                     stage III rectal cancer
ADJUVANT THERAPY: RECTAL CANCER

Preoperative or postoperative adjuvant therapy should be
considered by a multidisciplinary team for all people with rectal
cancer.

Preoperative radiotherapy may lower the incidence of late
morbidity compared to postoperative radiotherapy.

Where people are receiving long-course radiotherapy
(preoperative or postoperative), concurrent chemotherapy
should be considered.
ADJUVANT THERAPY: RECTAL CANCER cont.

People with rectal cancer at risk of local recurrence
• Either preoperative short-course radiotherapy (25 Gy in
  5 fractions)
• Or preoperative long-course chemoradiation (45-50.4 Gy in
  25-28 fractions)

People with a low rectal cancer or threatened
circumferential resection margin
• Preoperative long-course chemoradiation (45-50.4 Gy in
  25-28 fractions)
   MULTIDISCIPLINARY CARE

Multidisciplinary Team              Tumour Board
 Comprehensive                      Treatment planning following
  multidimensional assessment         review and discussion of
  and planning considering            medical condition and
  physical, mental, emotional,        treatment options
  functional and social needs of
  patient                            May include a medical
                                      oncologist, surgical oncologist,
 In addition to medical              radiation oncologist,
  specialists, may include allied     radiologist
  health (eg. occupational
  therapist, clinical
  psychologist), nurses, GP and
  palliative care practitioners,
  and others
MULTIDISCIPLINARY CARE cont.


• Every health practitioner involved in colorectal cancer care
  should actively participate in a multidisciplinary team

• All people with colon cancer and all people with rectal cancer
  should be discussed at a Tumour Board meeting

• The Tumour Board and multidisciplinary team involved in
  cancer care should provide culturally appropriate and
  coordinated care, advice and support

• Outcomes of Tumour Board and multidisciplinary team
  meetings should be communicated to the individual
  and their GP
COMMUNICATION & INFORMATION PROVISION

 People with colorectal cancer should be acknowledged as key
 partners in the decision-making about their cancer management.
 • Encourage note taking and recording of consultations
 • Have a support person present in consultations
 • Maintain a patient hand-held record where available

 Practitioners should provide information about:
 •   diagnosis
 •   treatment options (including risks and benefits)
 •   support services
 •   managing bowel function, particularly diet, after surgery
FOLLOW-UP: OVERVIEW


• Follow-up should be under the direction of the multidisciplinary
  team and may involve follow-up in primary care

• People with colorectal cancer should be given written
  information outlining planned follow-up (eg. discharge report) at
  discharge from treatment including what they should expect
  regarding the components and timing of follow-up assessments

• Use of faecal occult blood testing as part of colorectal cancer
  follow-up is not recommended
FOLLOW-UP: WHEN TO REVIEW

All people who have undergone colorectal cancer resection
• Should undergo clinical assessment if they develop relevant
  symptoms
• Should receive intensive follow-up
FOLLOW-UP: WHEN TO REVIEW cont.

People with colon cancer
• High risk of recurrence (Stages IIb and III): clinical assessment
  at least every 6 months for first 3 years after initial surgery,
  then annually for 2 further years
• Lower risk of recurrence (Stages I and IIa) or comorbidities
  restricting future surgery: annual review for 5 years after initial
  surgery

People with rectal cancer
• Review at 3 months, 6 months, 1 year and 2 years after initial
  surgery, then annually for a further 3 years
   FOLLOW-UP: SPECIFIC COMPONENTS

Colon Cancer Stages I to III         Rectal Cancer Stages I to III
Colonoscopy before surgery or        Colonoscopy before surgery or
within 12 months following initial   within 12 months following initial
surgery                              surgery

Follow-up should include:            Follow-up should include:
 physical examination and CEA        physical examination and CEA
 liver imaging at least once         liver imaging at least once
  between years 1 and 3                between years 1 and 3
 colonoscopy every 3 to 5            digital rectal examination and
  years                                either proctoscopy or
                                       sigmoidoscopy at 3 months,
                                       6 months, 1 year and 2 years
                                       after initial surgery
                                      colonoscopy thereafter at
                                       3 to 5-yearly intervals