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Presentation on theme: "LEFT HOLDING THE BAG? : CRC FOLLOW-UP CARE FOR FAMILY PHYSICIANS"— Presentation transcript:

“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 “… 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…..


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