1. LEFT HOLDING THE BAG? : CRC FOLLOW-UP CARE FOR FAMILY PHYSICIANS
“Are these Oncologists as lazy as I think? Why don’t they just finish what they start……”
Dr. Sisler’s topic…..i am a funny guy, but it is not a colostomy joke
Dr. Gary Harding, MD, FRCPC
Medical Oncologist, Bioethicist
Assistant Professor, University of Manitoba

2. Objectives Brief Overview of Colorectal Cancer
Describe the recommended follow-up testing after treatment for colorectal cancer and its impact on survival
Discuss the challenges FPs/NPs and patients face in adhering to follow-up protocols
Identify clinic strategies to organize this care better

3. Colorectal Cancer: “I am kind of a big deal”

4. 1968 Advertising Archive “The Question was very simple. One that you…
1968 Advertising Archive “The Question was very simple. One that you….any smoker….might ask a doctor: “What cigarette do you moske, Doctor?
1942: Camels began touting their smoothness and taste by inventing the "T Zone" -  T for Taste, T for Throat.  "Test them in your 'T Zone'."

5. Canadian Incidence and Mortality
2nd leading cause of death in Canada
So colorectal cancer gets…….

6. OUT OF A POSSIBLE
Like in elementary school: I think cancer should get starts…maybe not gold stars…but stars
Colon Ca gets Two death stars out of a possible three death stars

7. Screening “a good thing”
LESS than 20% of doctors screen their patients: FOBT x 3 yearly post 50 years or colonoscopy q 10 years if normal

8. Primary Treatment Goal: CURE “…..to cut is to cure….” - surgeon
Cells can escape the blade
Pathology helps us stage, prognosticate and plan further treatment
Greg Vascular:

9. Colorectal Cancer Staging
Tis: Involves only the mucosa
T1: Cancer has grown into the submucosa
T2: Cancer has grown into the muscularis propria (outer muscle layer)
T3: Cancer has grown through muscularis propria and in pericolorectal tissues
T4a: Cancer has grown through the wall of the colon or rectum and penetrates to the surface of the visceral peritoneum
T4b: Cancer has grown through the wall of the colon or rectum and directly invades or is adherent to other organs or structures
Nx: No description of lymph node involvement is possible because of incomplete information
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1-3 regional lymph nodes
N1a Metastasis in one regional lymph node
N1b Metastasis in 2-3 regional lymph nodes
N1c Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis
N2 Metastasis in four or more regional lymph nodes
N2a Metastasis in 4-6 regional lymph nodes
N2b Metastasis in seven or more regional lymph nodes
M0 No distant metastasis
M1 Distant metastasis
M1a Metastasis confined to one organ or site (eg, liver, lung, ovary, nonregional node)
M1b Metastases in more than one organ/site or the peritoneum

10. The TNM Staging System “T” : Tumor – local extent
T4a or b (new 7th Ed. AJCC)
Colorectal: depth of invasion of tumor
“N” : Lymph Nodes – regional extent
NO, N1(1-3 nodes positive), N2 (4 or more)
N1a,b,c and N2a,b (new 7th Ed. AJCC)
“M”: Metastasis – distant extent
M0 or M1
absence or presence of metastases
M1a or b (new 7th Ed. AJCC)

11. Post-operative Adjuvant Therapy
Adjuvant chemotherapy with FOLFOX (5-FU and Oxaliplatin) to eliminate micrometastatic disease
All stage III (node positive)
High risk stage II (eg. T4)
Manitoba Data from 2004
1/3 of Stage II patients received chemo
3/4 of Stage III patients received chemo
Radiation and chemotherapy for rectal cancer
Stage 1 disease has about a 95 % cure rate

12. So why are we not done here?
……because the cat comes back
QUESTION: So why do we care if a cat comes back if we find it on surveillance camera video footage in our backyard or if it jumps out behind a bush and lands on your shoulder? If it is going to claw your eyes out anyway….does it really matter how you found it….? Isn’t stage 4 stage 4?
So why do it at? It will be stage 4 anyways and fatal?
Shakespeare: R and J
Answer over time is: No. There is stage 4 good and stage 4 bad….or more aptly stage 4 Hopefully
What’s in a name? That which we call a Stage Four Cancer
By any other name would smell just as NOT-sweet

13. Stage 4 and “Stage 4-H” Stage Four-Hopeful
Approximately one half of patients will relapse in the liver at some point in the course of their disease
Almost one third of patients will have disease confined to the liver at autopsy
10-20% of patients presenting with liver metastases are amenable to surgical resection with intent to CURE
85% of colon cancer recurrences are diagnosed within the first three years after surgical resection of the primary tumor

14. Goals of Follow-up Care
To identify recurrences and new cancers early, while they are surgically resectable
Liver, lung
Bowel
To treat side-effects of cancer treatment
To prevent recurrence through facilitating a healthy lifestyle
To help patients and families adapt to life after cancer

15. Hepatic Resection for Stage 4 Colorectal Cancer
Author and year
Number of patients
5 yr OS, percent
Median survival, months
Hughes, KS; 1986
607 33 NR
Scheele, J; 1995
434 40
Nordlinger, B; 1996
1568 28
Jamison, RL; 1997
280 27
Fong, Y; 1999
1001 37 42
Iwatsuki, S; 1999
305 32
Choti, M; 2002
133 58
Abdalla, E; 2004
190
Fernandez, FG; 2004
100
Wei, AC; 2006
423 47
Rees, M; 2008
929 36
42.5
de Jong, M; 2009
1669

16. An asymptomatic patient is a happy patient….
…Better rates of cure with liver resection

17. Overall, does early detection of recurrent disease improve survival?

18. The Evidence The randomized trials were fraught with inconsistencies
Three meta-analyses were done1,2,3
33 % reduction in risk of death from all causes
absolute difference = 7%
Wide variation of follow-up programs
No conclusions on exact surveillance protocols
Jeffery GM, et al. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2002;(1):CD
Renehan AG, et al. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002 Apr 6;324(7341):813.
Figueredo A, et al. Follow-up of patients with curatively resected colorectal cancer: a practice guideline. BMC Cancer 2003 Oct 6;3(1):26.

19. So what actually do you do?

20. In the office… Cup of coffee together with patient or a H&P?
What does the evidence suggest?
No evidence that supports one over the other
has never been formally tested
What is it good for then?
allows physician opportunity to determine symptoms, coordinate follow-up and offer counseling

21. Blood TEST (singular) CEA: Carcinoembryonic antigen
Oncofetal protein elevated in many cancers
NOT established for screening
60-90% of relapsed disease has an elevated CEA
30% of CRC may not produce CEA
Not done during treatment b/c 5-FU can increase CEA
Must be checked serially at each surveillance visit

22. Imaging
Three meta-analyses looking at this issue showed benefit from CT imaging
Roughly 25% improvement in mortality associated with CT imaging of the liver
Less data looking at Chest imaging
European data showed benefit to Chest imaging
Pulmonary metastasis
Less likely to have elevated CEA
Just as common as liver in rectal cancer
Consensus: yearly CT Chest/Abdomen for first three years of follow-up or if other evidence of relapse

23. Colonoscopy
Preoperative and postoperative documentation of a polyp and cancer free colon
3% to 5% of patients can have synchronous tumors
1.5% to 3% risk of a metachronous tumor within first five years
Repeat at 3 years
If normal can be every 5 years

24. Take Home Message #1
Close follow-up of Stage II and III colorectal cancer patients with colonoscopy, liver imaging and CEA tests saves lives

25. What NOT to order? No evidence…
Liver function tests
CBC
FOBT
Chest X-rays
Pet Scan

26. Take Home Message #2
If your patient is not well enough for a liver or lung resection….
……they should not be followed closely for recurrence!

27. Long-Term Complications
2% risk of a new primary colorectal cancer
radiation proctitis, anal stenosis, chronic diarrhea
vaginal stenosis, dyspareunia
pelvic sarcomas (>10 yrs) are quite rare

28. What are some challenges?
Lots of tests to organize
Lots of doctors involved and lack of clarity who is in charge
Patients not clear on what’s needed

29. Take Home Message #3
Colorectal cancer survivors often don’t get the follow-up tests they need
Think about how you can organize to do this better in your office

30. Future Directions
Rectal Survivorship Care Plan Proposal at CancerCare Manitoba
Canadian Partnership Against Cancer
Around 820 colorectal cancer cases in Manitoba in 2009
1/3 will be rectal
Piloting a developed comprehensive rectal surveillance program that takes multidisciplinary approach on CCMB patients
Family Physicians will be a key part ultimately

31. What can we do to help patients and doctors keep on track?
Provide with follow-up schedule
Involve family members
Clear assignment of responsibility
Chart reminders
Reminders from CCMB
Other ideas?

32. CCMB Follow-Up Recommendations Stage II & III Colon Cancer
Year 1, 2, 3
Year 4, 5
Physician Visits*
Complete History & Physical including
Rectal Exam
Every 3 months
Every 6 months
Bloodwork*
Carcinoembryonic antigen (CEA)*
Not routine
CT Imaging*
Chest/Abdomen
Annually
Chest X-Ray*
Colonoscopy*
End of Year 1
Then every 3 – 5 years (if no polyps)
Monitoring*
Long-term Toxicities of Chemotherapy
No specific monitoring required 32

33. Don’t forget about the family…
Screen family members
First degree relatives should get average-risk staging staring at age 40
If familial genetic syndromes are suspected, more intensive screening needed

34. Take Home Messages
Close follow-up of Stage II and III colorectal cancer patients with colonoscopy, liver imaging and CEA tests saves lives
If your patient is not well enough for a liver or lung resection… they should not be followed closely for recurrence!
CRC survivors often don’t get the follow-up tests they need. Think about how you can organize to do this better in your office

35. THANK YOU! Any questions…..