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LEFT HOLDING THE BAG? : CRC FOLLOW-UP CARE FOR FAMILY PHYSICIANS Dr. Gary Harding, MD, FRCPC Medical Oncologist, Bioethicist Assistant Professor, University.

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Presentation on theme: "LEFT HOLDING THE BAG? : CRC FOLLOW-UP CARE FOR FAMILY PHYSICIANS Dr. Gary Harding, MD, FRCPC Medical Oncologist, Bioethicist Assistant Professor, University."— Presentation transcript:

1 LEFT HOLDING THE BAG? : CRC FOLLOW-UP CARE FOR FAMILY PHYSICIANS Dr. Gary Harding, MD, FRCPC Medical Oncologist, Bioethicist Assistant Professor, University of Manitoba “Are these Oncologists as lazy as I think? Why don’t they just finish what they start……”

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 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

5 Canadian Incidence and Mortality So colorectal cancer gets…….

6 OUT OF A POSSIBLE

7 Screening “a good thing”

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

9 Colorectal Cancer Staging

10 The TNM Staging System “T” : Tumor – local extent –T 1-4 –T4a or b (new 7 th 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 7 th Ed. AJCC) “M”: Metastasis – distant extent –M0 or M1 –absence or presence of metastases –M1a or b (new 7 th Ed. AJCC) “T” : Tumor – local extent –T 1-4 –T4a or b (new 7 th 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 7 th Ed. AJCC) “M”: Metastasis – distant extent –M0 or M1 –absence or presence of metastases –M1a or b (new 7 th 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 /3 of Stage II patients received chemo 3/4 of Stage III patients received chemo Radiation and chemotherapy for rectal cancer 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 /3 of Stage II patients received chemo 3/4 of Stage III patients received chemo Radiation and chemotherapy for rectal cancer

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? 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 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 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 yearNumber of patients5 yr OS, percentMedian survival, months Hughes, KS; NR Scheele, J; Nordlinger, B; NR Jamison, RL; Fong, Y; Iwatsuki, S; NR Choti, M; NR Abdalla, E; NR Fernandez, FG; NR Wei, AC; NR Rees, M; de Jong, M;

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 done 1,2,3 –33 % reduction in risk of death from all causes –absolute difference = 7% Wide variation of follow-up programs No conclusions on exact surveillance protocols The randomized trials were fraught with inconsistencies Three meta-analyses were done 1,2,3 –33 % reduction in risk of death from all causes –absolute difference = 7% Wide variation of follow-up programs No conclusions on exact surveillance protocols 1.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): 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 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 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 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 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 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 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 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 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? Provide with follow-up schedule Involve family members Clear assignment of responsibility Chart reminders Reminders from CCMB Other ideas?

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

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 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 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…..


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