Presentation on theme: "LEFT HOLDING THE BAG? : CRC FOLLOW-UP CARE FOR FAMILY PHYSICIANS"— Presentation transcript:
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 jokeDr. Gary Harding, MD, FRCPCMedical Oncologist, BioethicistAssistant 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 survivalDiscuss the challenges FPs/NPs and patients face in adhering to follow-up protocolsIdentify clinic strategies to organize this care better
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 CanadaSo colorectal cancer gets…….
6 OUT OF A POSSIBLELike in elementary school: I think cancer should get starts…maybe not gold stars…but starsColon 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 bladePathology helps us stage, prognosticate and plan further treatmentGreg Vascular:
9 Colorectal Cancer Staging Tis: Involves only the mucosaT1: Cancer has grown into the submucosaT2: Cancer has grown into the muscularis propria (outer muscle layer)T3: Cancer has grown through muscularis propria and in pericolorectal tissuesT4a: Cancer has grown through the wall of the colon or rectum and penetrates to the surface of the visceral peritoneumT4b: Cancer has grown through the wall of the colon or rectum and directly invades or is adherent to other organs or structuresNx: No description of lymph node involvement is possible because of incomplete informationNX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastasis in 1-3 regional lymph nodesN1a Metastasis in one regional lymph nodeN1b Metastasis in 2-3 regional lymph nodesN1c Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasisN2 Metastasis in four or more regional lymph nodesN2a Metastasis in 4-6 regional lymph nodesN2b Metastasis in seven or more regional lymph nodesM0 No distant metastasisM1 Distant metastasisM1a 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 extentNO, N1(1-3 nodes positive), N2 (4 or more)N1a,b,c and N2a,b (new 7th Ed. AJCC)“M”: Metastasis – distant extentM0 or M1absence or presence of metastasesM1a or b (new 7th Ed. AJCC)
11 Post-operative Adjuvant Therapy Adjuvant chemotherapy with FOLFOX (5-FU and Oxaliplatin) to eliminate micrometastatic diseaseAll stage III (node positive)High risk stage II (eg. T4)Manitoba Data from 20041/3 of Stage II patients received chemo3/4 of Stage III patients received chemoRadiation and chemotherapy for rectal cancerStage 1 disease has about a 95 % cure rate
12 So why are we not done here? ……because the cat comes backQUESTION: 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 JAnswer over time is: No. There is stage 4 good and stage 4 bad….or more aptly stage 4 HopefullyWhat’s in a name? That which we call a Stage Four CancerBy 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 diseaseAlmost one third of patients will have disease confined to the liver at autopsy10-20% of patients presenting with liver metastases are amenable to surgical resection with intent to CURE85% 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 resectableLiver, lungBowelTo treat side-effects of cancer treatmentTo prevent recurrence through facilitating a healthy lifestyleTo help patients and families adapt to life after cancer
15 Hepatic Resection for Stage 4 Colorectal Cancer Author and yearNumber of patients5 yr OS, percentMedian survival, monthsHughes, KS; 198660733NRScheele, J; 199543440Nordlinger, B; 1996156828Jamison, RL; 199728027Fong, Y; 199910013742Iwatsuki, S; 199930532Choti, M; 200213358Abdalla, E; 2004190Fernandez, FG; 2004100Wei, AC; 200642347Rees, M; 20089293642.5de Jong, M; 20091669
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 done1,2,333 % reduction in risk of death from all causesabsolute difference = 7%Wide variation of follow-up programsNo conclusions on exact surveillance protocolsJeffery GM, et al. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2002;(1):CDRenehan 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.
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 otherhas never been formally testedWhat 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 cancersNOT established for screening60-90% of relapsed disease has an elevated CEA30% of CRC may not produce CEANot done during treatment b/c 5-FU can increase CEAMust be checked serially at each surveillance visit
22 ImagingThree meta-analyses looking at this issue showed benefit from CT imagingRoughly 25% improvement in mortality associated with CT imaging of the liverLess data looking at Chest imagingEuropean data showed benefit to Chest imagingPulmonary metastasisLess likely to have elevated CEAJust as common as liver in rectal cancerConsensus: yearly CT Chest/Abdomen for first three years of follow-up or if other evidence of relapse
23 ColonoscopyPreoperative and postoperative documentation of a polyp and cancer free colon3% to 5% of patients can have synchronous tumors1.5% to 3% risk of a metachronous tumor within first five yearsRepeat at 3 yearsIf normal can be every 5 years
24 Take Home Message #1Close 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 testsCBCFOBTChest X-raysPet Scan
26 Take Home Message #2If 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 cancerradiation proctitis, anal stenosis, chronic diarrheavaginal stenosis, dyspareuniapelvic sarcomas (>10 yrs) are quite rare
28 What are some challenges? Lots of tests to organizeLots of doctors involved and lack of clarity who is in chargePatients not clear on what’s needed
29 Take Home Message #3Colorectal cancer survivors often don’t get the follow-up tests they needThink about how you can organize to do this better in your office
30 Future DirectionsRectal Survivorship Care Plan Proposal at CancerCare ManitobaCanadian Partnership Against CancerAround 820 colorectal cancer cases in Manitoba in 20091/3 will be rectalPiloting a developed comprehensive rectal surveillance program that takes multidisciplinary approach on CCMB patientsFamily Physicians will be a key part ultimately
31 What can we do to help patients and doctors keep on track? Provide with follow-up scheduleInvolve family membersClear assignment of responsibilityChart remindersReminders from CCMBOther ideas?
32 CCMB Follow-Up Recommendations Stage II & III Colon Cancer Year 1, 2, 3Year 4, 5Physician Visits*Complete History & Physical includingRectal ExamEvery 3 monthsEvery 6 monthsBloodwork*Carcinoembryonic antigen (CEA)*Not routineCT Imaging*Chest/AbdomenAnnuallyChest X-Ray*Colonoscopy*End of Year 1Then every 3 – 5 years (if no polyps)Monitoring*Long-term Toxicities of ChemotherapyNo specific monitoring required32
33 Don’t forget about the family… Screen family membersFirst degree relatives should get average-risk staging staring at age 40If familial genetic syndromes are suspected, more intensive screening needed
34 Take Home MessagesClose follow-up of Stage II and III colorectal cancer patients with colonoscopy, liver imaging and CEA tests saves livesIf 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