Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
Background information
Information resources for patients and carers
Updates to this care map
Note: this care map is currently under local review within Derbyshire
Multidisciplinary team (MDT) discussion
Preoperative assessment and staging
Operable disease
Complete the venous thromboembolism (VTE) risk assessment
Inoperable disease
Go to colorectal cancer advanced disease
Go to VTE risk assessment
Preparation for surgery
Colonic tumour
Rectal tumour
Operable metastatic disease
Surgery Preoperative therapy
Surgery
Surgery
Histopathology
Consider preoperative chemotherapy
Histopathology
Surgery Consider adjuvant chemotherapy
Histopathology
Consider ablation therapy
Postoperative radiotherapy
Consider radiotherapy
Consider adjuvant chemotherapy Consider adjuvant chemotherapy
Psychosocial support
Follow-up
Follow-up schedule
Tumour recurrence
Consider palliative care
Ongoing follow-up
Management
Go to end of life assessment and planning
Published: 17-Jun-2011
Valid until: 17-Jun-2012
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
1 Background information Quick info: Scope: • presentation, investigation, staging, and management (including surgical and adjuvant chemo- and radiotherapy) of colorectal cancer, in adults and the elderly • primary and secondary care settings Out of scope: • screening and detection • end of life care (see 'End of life care in adults' care map) • management of Familial Adenomatous Polyposis (FAP), Hereditary Nonpolyposis Colon Cancer (HNPCC) • previous cancer • anal cancer Definition: • most cases of colorectal cancer evolve from polyps (outgrowths of the bowel wall) • a malignant polyp is defined as cancer if it invades the muscularis mucosae and penetrates the submucosa Incidence and prevalence: • in the UK: • colorectal cancer is the third most common cause of cancer related deaths [1] • approximately 100 new cases of colorectal cancer are diagnosed each day [1] • 5 year survival rates are approximately 45% [2] • 50-60% of patients diagnosed with colorectal cancer will develop metastases [3] Preventative factors: • pharmacological interventions: • studies have indicated a protective role of the following drugs in the development of colorectal cancer: • non-steroidal anti-inflammatory drugs (NSAIDs), eg aspirin • cyclo-oxygenase-2 inhibitors • NSAIDs and cyclo-oxygenase-2 inhibitors are associated with cardiovascular events and gastrointestinal (GI) harm • long-term follow-up studies are required to establish the effects of less frequent doses and lower doses of such interventions • hormone replacement therapy (HRT) − benefits should be balanced against the possible risk of breast cancer, stroke, and pulmonary embolism (PE) Risk factors: • increasing age • hereditary disease • high intake of processed meat and red meat • low intake of vegetables • smoking • obesity (especially men) • low levels of physical activity • alcohol consumption • male population • history of inflammatory bowel disease (IBD) References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancers. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009.
Published: 17-Jun-2011
Valid until: 17-Jun-2012
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [5] Dai Z, Xu YC, Nui L. Obesity and colorectal cancer: a meta-analysis of cohort studies. World J Gastroenterol 2007; 21: 4199-206. [6] Flossmann E, Rothwell PM. Effects of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies. Lancet 2007; 369: 1603-13. [7] Larsson SC, Wolk A. Meat consumption and risk of colorectal cancer: a meta-analysis of prospective studies. AM J Clin Nutr 2007; 86: 556-65. [8] Nguyen SP, Bent S, Chen YH et al. Gender as a risk factor for advanced neoplasia and colorectal cancer: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2009; 7: 676-81. [9] Rostom A, Dube C, Lewin G et al. Nonsteroidal anti-inflammatory drugs and cylo-oxygenase-2 inhibitors for primary prevention of colorectal cancer: a systematic review prepared for the US prevention services task force. Ann Intern Med 2007; 146: 376-89. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
2 Information resources for patients and carers Quick info: The following resources have been produced by organisations certified by The Information Standard: • 'Bowel cancer' (URL) from Bupa at http://www.bupa.co.uk • 'Bowel cancer (colorectal cancer)' (URL) from Cancer Research UK at http://www.cancerresearchuk.org/ • 'Colon cancer' (URL) from Macmillan Cancer Support at http://www.macmillan.org.uk • 'Colorectal cancer' (URL) from Datapharm at http://www.medguides.medicines.org.uk • 'Colon cancer' (URL) from Datapharm at http://www.medguides.medicines.org.uk • 'Rectal cancer' (URL) from Datapharm at http://www.medguides.medicines.org.uk • 'Hereditary non-polyposis colorectal cancer (HNPCC)' (URL) from Macmillan Cancer Support at http://www.macmillan.org.uk • 'Treating rectal cancer' (URL) from Macmillan Cancer Support at http://www.macmillan.org.uk • 'Colorectal (bowel) cancer' (PDF) from Patient UK at http://www.patient.co.uk • 'Healthcare services for bowel (colorectal) cancer: Understanding NICE guidelines − information for the public' (PDF) from National Institute for Health and Clinical Excellence (NICE) at http://www.nice.org.uk Information for carers and people with disabilities is available at: • 'Caring for someone' (URL) from Directgov at http://www.direct.gov.uk • 'Disabled people' (URL) from Directgov at http://www.direct.gov.uk Explanations of clinical laboratory tests used in diagnosis and treatment are available at ‘Understanding Your Tests’ (URL) from Lab Tests Online-UK at http://www.labtestsonline.org.uk NB: This information appears on each page of this care map.
3 Updates to this care map Quick info: Date of publication: 17-June-2011 This care map was created in line with the following references: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [5] Dai Z, Xu YC, Niu L. Obesity and colorectal cancer risk: a meta-analysis of cohort studies. World J Gastroenterol 2007; 13: 4199-206.
Published: 17-Jun-2011
Valid until: 17-Jun-2012
Printed on: 18-Jul-2012
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[6] Flossmann E, Rothwell PM. Effect of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies. Lancet 2007; 369: 1603-13. [7] Larsson SC, Wolk A. Meat consumption and risk of colorectal cancer: a meta-analysis of prospective studies. Int J Cancer 2006; 119: 2657-64. [8] Nguyen SP, Bent S, Chen YH et al. Gender as a risk factor for advanced neoplasia and colorectal cancer: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2009; 7: 676-81. [9] Rostom A, Dube C, Lewin G et al. Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force. Ann Intern Med 2007; 146: 376-89. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [11] Ballinger A, Clark S, Wexner S. Colorectal cancer. BMJ Best Practice; 2009. [12] Map of Medicine (MoM). London: MoM; 2009. [13] Contributors to the international care map, invited by Map of Medicine (MoM). 2010. [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009. [15] Abraham NS, Byrne CM, Young JM et al et al. Meta-analysis of non-randomized comparative studies of the short-term outcomes of laparoscopic resection for colorectal cancer. ANZ J Surg 2007; 77: 508-16. [16] Zhang C, Chen Y, Xue H. Diagnostic value of FDG-PET in recurrent colorectal carcinoma: a meta-analysis. Int J Cancer 2009; 124: 167-73. [17] Cao Y, Tan A, Gao F et al. A meta-analysis of randomized controlled trials comparing chemotherapy plus bevacizumab with chemotherapy alone in metastatic colorectal cancer. Int J Colorectal Dis 2009; 24: 677-85. [18] Wagner AD, Arnold D, Grothey AA. Anti-angiogenic therapies for metastatic colorectal cancer. Cochrane Database Syst Rev 2009; 3: CD005392. [19] Tilney HS, Lovegrove R, Purkayastha S et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 2007; 21: 225-33 [20] The Royal College of Physicians (RCP), the Academy of Medical Royal Colleges (AMRC). A clinician’s guide to record standards – Part 1: Why standardise the structure and content of medical records? London: Digital and Health Information Policy Directorate; 2008. [21] The Royal College of Physicians (RCP), the Academy of Medical Royal Colleges (AMRC). A clinician’s guide to record standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital. London: Digital and Health Information Policy Directorate; 2008. [22] Bridgelal Ram M, Carpenter I, Williams J. Reducing risk and improving quality of patient care in hospital: the contribution of standardized medical records. Clin Risk 2009; 15: 183-7. [23] Derbyshire colorectal pathway group; 2011. NB: This information appears on each page of this care map.
4 Note: this care map is currently under local review within Derbyshire Quick info: For further information, please contact Anne Hayes, NHS Derbyshire County Public Health Specialist
5 Multidisciplinary team (MDT) discussion Quick info: Management should be discussed by a multidisciplinary team (MDT); the core MDT should include [1]: • at least two surgeons specialising in colorectal cancer (each surgeon should carry out at least 20 colorectal resections per year) • an oncologist • a diagnostic radiologist • a histopathologist • a skilled colonoscopist • clinical nurse specialists (provides support, assistant, and information) • a palliative care specialist (doctor or nurse) • a meeting coordinator
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• a team secretary Extended MDT members should include [1]: • a gastroenterologist • a liver surgeon • a thoracic surgeon with expertise in lung resection • an interventional radiologist • GPs • a dietician • a social worker • a geneticist or genetic counsellor • a clinical trial co-ordinator Treatment should be given within 31 days of decision to treat being made [1]. Reference: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007.
6 Preoperative assessment and staging Quick info: Preoperative assessment should include: • CT scan of the thorax, abdomen, and pelvis [1,3,4,14] • endorectal or pelvic MRI for rectal cancer [4,14] • fluorodeoxyglucose-positron emission tomography (FDG-PET) [2,4]; however, this has not been established across clinical practice [13] Further investigations include: • cytoscopy − indicated if bladder involvement is suspected [3,4] • complete blood count [3] • platelet count [3] • chemistry profile [3] • carcinoembryonic antigen (CEA) determination [3,4] • anorectal physiological testing (consider in elderly patients) [4] Preoperative staging is important to assess the location and extent of the disease (ie lymph node involvement), benefits of adjuvant therapy, and the surgical technique required; patients with rectal cancer should have [1,2]: • high resolution magnetic resonance imaging (MRI) to assess the rectum and peri-rectal lymph node • endorectal ultrasound [14], if local excision is being considered Colorectal cancer can be staged according to the Dukes classification system [2]: • Dukes A − tumour limited to the bowel wall and lymph node negative [1] • Dukes B − tumour spread beyond the muscularis propria and lymph node negative [1] • Dukes C1 − lymph node positive and apical node spared [1] • Dukes C2 − apical lymph node involvement [1] • Dukes D − distant metastases [2] Dukes classification should be used in tandem with tumour, node, metastasis (TNM) classification [13]. References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009.
Published: 17-Jun-2011
Valid until: 17-Jun-2012
Printed on: 18-Jul-2012
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [13] Contributors to the international care map, invited by Map of Medicine; 2010. [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009.
7 Operable disease Quick info: Consider surgery depending on multidisciplinary team (MDT) discussion based around: • tumour staging [12] • general physical fitness for surgery [12] • scoring systems, such as [1]: • the physiological and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) scoring system • Cleveland Clinic scoring system References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007 [12] Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2010.
8 Inoperable disease Quick info: Consider surgery depending on multidisciplinary team (MDT) discussion based around: • tumour staging [12] • general physical fitness for surgery [12] • scoring systems, such as [1]: • the physiological and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) scoring system • Cleveland Clinic scoring system References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [12] Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2010.
9 Complete the venous thromboembolism (VTE) risk assessment Quick info: All patients should undergo venous thromboembolism (VTE) risk assessment as per National Institute for Health and Clinical Excellence (NICE) guidance: • upon admission • for a second time, within 24 hours of initial assessment • regularly thereafter for the duration of the inpatient stay, and, in some cases, following discharge • whenever the clinical situation changes Reference: National Institute for Health and Clinical Excellence (NICE). Venous thromboembolism: reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Clinical guideline 92. London: NICE; 2010.
10 Preparation for surgery
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
Quick info: Surgery is the first-line treatment for approximately 80% of patients [2]. Preparation for surgery should include: • informed consent − discuss the following with the patient: • benefits and risks of surgery [1] • what the treatment involves [1] • likely outcome of the procedure [4] • implication of not receiving treatment [1,4] • alternative treatments [1,4] • prognosis [4] • preparation of stoma formation: • patient should be seen by a stoma nurse before surgery [1,4,10] • patients should receive counselling by a colorectal cancer clinical nurse specialist or a stoma specialist [2,4,10] • preoperative visit by a stoma nurse should involve [4]: • assessment of physical, social, psychological, and cultural factors • initiation of patient education • selection of stomal site • patient reassurance • blood crossmatching [1,4] • thromboembolism prophylaxis [2,4,10] using compression stockings and heparin [1] • antibiotic prophylaxis [1,2,4,10], providing aerobic and anaerobic cover [2] • maintanence of normal body temperature [4] • bowel preparation prior to surgery; advice regarding bowel preparation differs between guidelines: • The Association of Coloproctology of Great Britain and Ireland (ACPGBI) recommend that bowel preparation should not be routinely used prior to colorectal cancer resection [1] • The National Institute for Health and Clinical Excellence (NICE) recommends that bowel preparation should be agreed by each Cancer Network [2] • Australian Government National Health and Medical Research Council (NHMRC) do not recommend bowel preparation unless there is a problem with faecal loading that may lead to technical difficulties [4] • in general, the issue of bowel preparation prior to surgery is contentious; clinical opinion is divided and guidance may have to be informed by local policy [13] Consider sexual counselling [4]: • by stomal therapy nurse; and/or • sexual and relationship counsellors Consider referral to an appropriate specialist with regards to [4]: • ovarian and fertility preservation References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [13] Contributors invited by the Map of Medicine; 2010
12 Rectal tumour Quick info:
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
Any tumour with a distal margin at 15cm or less from the anal verge is classified as rectal [1]. Reference: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007.
13 Operable metastatic disease Quick info: Liver metastases is detected at the time of diagnosis in 20-25% of patients − 8% of these patients are suitable for liver resection [2]: • resection should not be attempted unless complete removal of all known tumours is possible [3] • consider for resection patients with liver or lung metastases [10] References: [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
14 Surgery Quick info: Surgical techniques for colorectal cancer include: • extended right hemicolectomy [1,4] • segmented resection [1,4] • serosubmucosal anastomosis [1,4] • open resection [1,3] • laparoscopic surgery: • should be performed by a trained surgeon [1,3,4] • should involve abdominal exploration [3] • should not be performed on patients at high-risk for prohibitive abdominal adhesions [3] • has better short-term outcomes than open surgery [2] • may limit tumour staging [2] • compared to open surgery can reduce: • postoperative pain and the use of analgesia [10] • the length of hospital stay [10] • blood loss [10] • the length of time taken until first flatus, passage of bowel motion, tolerance of oral fluids and solid diet [15] • morbidity rate [15] • en bloc resection of primary tumour and attached organ, if the tumour has adhered to a nearby structure [4] If the patient has received a stoma [2]: • a cancer clinical nurse specialist or a stoma specialist should be available to: • assist patients in managing the stoma • advise on problems associated areas of concern, including: • physical problems • social problems • sexual problems • emotional problems • give contact details for support groups
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• they should have access to specialist dietary support and advice NB: recording of tumour involvement of non-peritonealised resection margin when appropriate can help in the selection of patients for postoperative therapy [1]. References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington: NCCN; 2009. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [15] Abraham NS, Byrne C, Young JM et al. Meta-analysis of non-randomised comparative studies of the short-term outcomes of laparoscopic resection for colorectal cancer. ANZ J Surg 2007; 77: 508-16.
15 Preoperative therapy Quick info: Preoperative radiotherapy: • should be considered for patients with operable rectal cancer [10] • is preferable if there are predictive factors for local recurrence, such as evidence of [1]: • tumour at the circumferential resection margin • mesorectal lymph node involvement • extramural invasion • can be delivered via [1]: • conventional fractionation: • used to shrink the tumour before resection [14] • delivered in 25 daily fractions over 5 weeks followed by surgery 4-8 weeks after radiotherapy • short course pre-operative radiotherapy (SCPRY): • used to reduce the risk of local recurrence • delivered in 5 daily fractions over 1 week followed by surgery within 10 days • can avoid occurrence of radiation-induced injury to small bowel trapped in the pelvis by post-surgical adhesions [14] • increases the likelihood that an anastomosis with a healthy colon can be performed [14] • disadvantages include over-treating early stage tumours which do not require pre-operative therapy [14] • short-term complications include [4]: • lethargy • mild nausea • diarrhoea • tenesmus • urinary frequency • skin erythema or desquamation • long-term complication include [4]: • small bowel damage • rectal damage Consider chemotherapy in addition to radiotherapy: • 5-fluorouracil (5-FU) based regime [4,14] • benefits include [14]: • local radiotherapy sensitisation
Published: 17-Jun-2011
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• eradication of micrometastases • increased rates of complete response • sphincter preservation • complications include [4]: • mouth ulcers • diarrhoea • nausea • marrow suppression • palmar plantar erythema (uncommon) • skin photosensitivity (uncommon) References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009.
16 Surgery Quick info: Surgical options rectal cancer include: • complete excision of the mesorectum [1,2,4,10] − associated with low recurrence rates [1,10] • anterior resection [1,14] • abdominoperineal excision (APR) [1,4,14] • colo-anal anastomosis [13] with colonic reservoir [4] • local excision [1,4,10,14], eg polypectomy, transanal excision [4], transanal microsurgery [14]: • can be safely used to treat small pT1 rectal cancers which are: • less than 3cm in diameter [1,4,14] • well to moderately differentiated [1,4,14] • within 8cm of the anal verge [14] • limited to less than 30% of the rectal circumference [14] • should be followed-up with magnetic resonance (MR) scanning [1] If the surgeon is in doubt over choice of operation, a second opinion should be sought [1]. Care must be taken to [1]: • preserve the autonomic nerves and plexuses [2,10] • prevent perforation of the tumour during surgery It is recommended that lymph node clearance should extend 5cm beyond the distal margin of the rectal cancer where possible [1]. After mesorectal excision and anterior resection [1]: • a temporary defunctioning stoma is recommended • formation of a colonic pouch should be considered If the patient has received a stoma [2]: • a cancer clinical nurse specialist or a stoma specialist should be available to : • assist patients in management of stoma • advise on problems associated areas of concern, including: • physical problems Published: 17-Jun-2011
Valid until: 17-Jun-2012
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• social problems • sexual problems • emotional problems • give contact details for support groups • they should have access to specialist dietary support and advice References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009.
17 Consider preoperative chemotherapy Quick info: Chemotherapy: • it is unclear whether patients will benefit from preoperative chemotherapy [1] • should be given over a 2-3 month period [3] • participation in clinical trials evaluating the role of chemotherapy should be encouraged [2] • advantages of neoadjuvant chemotherapy include [3]: • treatment of micrometastases • determination of response to chemotherapy, if chemotherapy is to be considered postoperatively • avoidance of local therapy • disadvantages of neoadjuvant chemotherapy include [3]: • chemotherapy induced liver injury • missing the opportunity for resection due to disease progression Chemotherapy agents include: • oxaliplatin combined with 5-fluorouracil (5-FU) and folinic acid for metastases confined to the liver [2] • infusional 5-FU, leucovorin, and oxaliplatin [4] with or without bevacizumab or cetuximab [3] • bolus 5-FU, leucovorin, and oxaliplatin with or without bevacizumab or cetuximab [3] • capecitabine and oxaliplatin (CapeOx) with or without bevacizumab or cetuximab [3] • the addition of bevacizumab to chemotherapy: • improves progression-free survival and overall survival [17,18] in first and second-line therapies, depending on the type of chemotherapy it is associated with [18] • improves overall response rate, without compounding the severity of toxicities associated with chemotherapy [17] • side effects include increased frequencies of [18]: • high blood pressure (BP) • arterial thromboembolic events • bowel perforation Side-effects of chemotherapy include [3]: • wound healing complications − associated with bevacizumab • development of liver steatohepatitis − associated with irinotecan • development of sinusoidal liver − associated with oxaliplatin References:
Published: 17-Jun-2011
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [17] Cao Y, Tan A, Gao F et al. A meta-analysis of randomised controlled trials comparing chemotherapy plus bevacizumab with chemotherapy alone in metastatic colorectal cancer. Int J Colorectal Dis 2009; 24: 677-85. [18] Wagner A, Arnold D, Grothey A et al. Anti-angiogenic therapies for metastatic colorectal cancer (review). Cochrane Database Syst Rev 2009; CD005392.
18 Histopathology Quick info: Pathology of resection specimen is important [1]: • for determining prognosis [10] • for further treatment planning [10] • to confirm the diagnosis • to determine whether resection was curative The histopathologist: • should report on all resection specimens when surgery was carried out with a curative extend [2]; the report should include information on [10]: • tumour differentiation • staging (Dukes' and tumour, node, metastasis [TNM] systems) • margins • extramural vascular invasion • should search for lymph nodes in the excised specimen (12 or more lymph nodes should be examined) [2] Tumour restaging using the TNM system and Dukes' classification system is recommended [1,4,10]: • TNM staging: • T – primary tumour: • TX – primary tumour cannot be assessed • T0 – no evidence of primary tumour • Tis – carcinoma in situ • T1 – invasion of submucosa • T2 – invasion of muscularis propria • T3 – invasion into subserosa or into non-peritonealised pericolic tissue • T4 – perforation of visceral peritoneum or direct invasion into surrounding structures • N – regional lymph nodes: • NX – regional lymph nodes not assessed • N0 – no regional node spread • N1 – metastases to 1-3 pericolic or perirectal lymph nodes • N2 – metastases to 4 or more pericolic or perirectal lymph nodes • N3 – metastases in any node along course of a named vascular trunk • M – distant metastasis: • M0 – no distant metastases • M1 – distant metastases • pTNM – pathological classification • Dukes classification:
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• Dukes A − tumour limited to the bowel wall and lymph node negative • Dukes B − tumour spread beyond the muscularis propria and lymph node negative • Dukes C1 − lymph node positive and apical node spared • Dukes C2 − apical lymph node involvement References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
19 Surgery Quick info: Surgical options rectal cancer include: • complete excision of the mesorectum [1,2,4,10] − associated with low recurrence rates [1,10] • anterior resection [1,14] • abdominoperineal excision (APR) [1,4,14] • colo-anal anastomosis [13] with colonic reservoir [4] • local excision [1,4,10,14]; eg polypectomy, transanal excision [4], transanal microsurgery [14]: • can be safely used to treat small pT1 rectal cancers which are: • less than 3cm in diameter [1,4,14] • well to moderately differentiated [1,4,14] • within 8cm of the anal verge [14] • limited to less than 30% of the rectal circumference [14] • should be followed-up with magnetic resonance (MR) scanning [1] If the surgeon is in doubt over choice of operation, an second opinion should be sought [1]. Care must be taken to [1]: • preserve the autonomic nerves and plexuses [2,10] • prevent perforation of the tumour during surgery It is recommended that lymph node clearance should extend 5cm beyond the distal margin of the rectal cancer [1]. After mesorectal excision and anterior resection [1]: • temporary defunctioning stoma is recommended • formation of a colonic pouch should be considered If the patient has received a stoma [2]: • a cancer clinical nurse specialist or a stoma specialist should be available to : • assist patients in management of stoma • advise on problems associated areas of concern, including: • physical problems • social problems • sexual problems • emotional problems • give contact details for support groups • they should have access to specialist dietary support and advice References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. Published: 17-Jun-2011
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009.
20 Histopathology Quick info: Pathology of resection specimen is important [1]: • for determining prognosis [10] • for further treatment planning [10] • to confirm the diagnosis • to determine whether resection was curative The histopathologist: • should report on all resection specimens when surgery was carried out with a curative extend [2]; the report should include information on [10]: • tumour differentiation • staging (Dukes' and tumour, node, metastasis [TNM] systems) • margins • extramural vascular invasion • should search for lymph nodes in the excised specimen (12 or more lymph nodes should be examined) [2] Tumour restaging using the TNM system and Dukes' classification system is recommended [1,4,10]: • TNM staging: • T – primary tumour: • TX – primary tumour cannot be assessed • T0 – no evidence of primary tumour • Tis – carcinoma in situ • T1 – invasion of submucosa • T2 – invasion of muscularis propria • T3 – invasion into subserosa or into non-peritonealised pericolic tissue • T4 – perforation of visceral peritoneum or direct invasion into surrounding structures • N – regional lymph nodes: • NX – regional lymph nodes not assessed • N0 – no regional node spread • N1 – metastases to 1-3 pericolic or perirectal lymph nodes • N2 – metastases to 4 or more pericolic or perirectal lymph nodes • N3 – metastases in any node along course of a named vascular trunk • M – distant metastasis: • M0 – no distant metastases • M1 – distant metastases • pTNM – pathological classification • Dukes classification: • Dukes A − tumour limited to the bowel wall and lymph node negative • Dukes B − tumour spread beyond the muscularis propria and lymph node negative • Dukes C1 − lymph node positive and apical node spared
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• Dukes C2 − apical lymph node involvement References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
21 Surgery Quick info: Surgery should be performed as soon resection is possible [3]. Patients with resectable [1]: • liver metastases should be assessed by the multidisciplinary team (MDT) with a hepatobiliary surgeon • lung metastases should be assessed by the MDT with a thoracic surgeon Hepatectomy for metastatic colorectal cancer is associated with a 5 year survival rate in 33% of patients [1]. Surgical approaches used for liver metastases include: • simultaneous resection of colorectal cancer and liver metastases [3,4]; simultaneous resection requirements include [4]: • solitary liver metastases lesion that can be removed by a limited resection • limited blood loss or contamination • medical status that permits both procedures • availability of expertise • preoperative embolisation to increase function of the healthy liver that will remain following surgery [3] • hepatic resection [3] • placement of hepatic arterial port or implantable pump for subsequent administration of chemotherapy via the hepatic artery [3] Ovarian metastases [4]: • occur in 2-8% of colorectal cancer patients • consider bilateral oophorectomy if there are metastases in one or both ovaries References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005.
22 Consider ablation therapy Quick info: Consider radiofrequency ablative therapy (RFA) if surgery is not possible due to [3,14]: • co-morbidity • location of lesion • estimation of inadequate liver volume following resection RFA is inferior to resection in terms of 5-year recurrence rate [14] − do not consider RFA unless complete ablation is possible [3]. References: [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009.
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009.
23 Consider adjuvant chemotherapy Quick info: Postoperative adjuvant chemotherapy: • should be considered for patients with node-positive cancer [1] • should be considered for patients with high-risk node-positive colorectal cancer [1] • should be considered for patients with Dukes' C tumours [10] • improves survival of patients with Dukes' C tumour [10]: • chemotherapy should begin within 6 weeks of surgery [1,2] • consider if the patient is fit enough to tolerate it [1,2] • should be given under close supervision by oncologists or chemotherapy nurse specialists [2] • recommendations regarding the treatment of Dukes' B tumours differ between guidelines: • The Association of Coloproctology of Great Britain and Ireland (ACPGBI) recommend that some patients may benefit from adjuvant chemotherapy [1] • Scottish Intercollegiate Guidelines Network (SIGN) recommend that adjuvant chemotherapy should not be routinely considered for patients with Dukes' B tumours [10] Chemotherapy options include: • 5-fluorouracil (5-FU) and Folinic acid (FA) [4], given for 6 months [1,2,10] • oxaliplatin and 5-FU [1,3,4] • infusional 5-FU, leucovorin, and oxaliplatin for stage III (Dukes' C) colon cancer [3] • portal venous infusion 5-FU [4,10] • 5-FU therapies incorporating irinotecan [3] • 5-FU therapies incorporating capecitabine [3] All patients receiving chemotherapy should [2]: • have access to emergency care, information, and advice from oncology staff • receive written information on side-effects and how to cope with them References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington: NCCN; 2009. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
24 Histopathology Quick info: Pathology of resection specimen is important [1]: • for determining prognosis [10] • for further treatment planning [10] • to confirm the diagnosis • to determine whether resection was curative The histopathologist:
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• should report on all resection specimens when surgery was carried out with a curative extend [2]; the report should include information on [10]: • tumour differentiation • staging (Dukes' and tumour, node, metastasis [TNM] systems) • margins • extramural vascular invasion • should search for lymph nodes in the excised specimen (12 or more lymph nodes should be examined) [2] Tumour restaging using the TNM system and Dukes' classification system is recommended [1,4,10]: • TNM staging: • T – primary tumour: • TX – primary tumour cannot be assessed • T0 – no evidence of primary tumour • Tis – carcinoma in situ • T1 – invasion of submucosa • T2 – invasion of muscularis propria • T3 – invasion into subserosa or into non-peritonealised pericolic tissue • T4 – perforation of visceral peritoneum or direct invasion into surrounding structures • N – regional lymph nodes: • NX – regional lymph nodes not assessed • N0 – no regional node spread • N1 – metastases to 1-3 pericolic or perirectal lymph nodes • N2 – metastases to 4 or more pericolic or perirectal lymph nodes • N3 – metastases in any node along course of a named vascular trunk • M – distant metastasis: • M0 – no distant metastases • M1 – distant metastases • pTNM – pathological classification • Dukes classification: • Dukes A − tumour limited to the bowel wall and lymph node negative • Dukes B − tumour spread beyond the muscularis propria and lymph node negative • Dukes C1 − lymph node positive and apical node spared • Dukes C2 − apical lymph node involvement References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
25 Postoperative radiotherapy Quick info: Postoperative radiotherapy, for rectal cancer, should be consider for patients who did not receive pre-operative radiotherapy and if there is evidence of: • tumour at the circumferential resection margin [1] • mesorectal lymph node involvement [1] • extramural vascular invasion [1] Published: 17-Jun-2011
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
• high risk of local recurrence [10] Radiotherapy should be given in 25 fractions over 5 weeks [1,10] with a boost of 3-5 fractions [1]. References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
26 Consider radiotherapy Quick info: • radiotherapy can be delivered concurrently with 5-fluorouracil (5-FU) based chemotherapy for stage T4 tumours [3] • however, practice-based knowledge suggests that radiotherapy is not used in an adjuvant setting [13] References: [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington: NCCN; 2009. [13] Contributors to the international care map, invited by Map of Medicine; 2010.
27 Consider adjuvant chemotherapy Quick info: Consider perioperative chemotherapy, for 6 months, to eradicate microscopic disease [3]. All patients receiving chemotherapy should [2]: • have access to emergency care, information, and advice from oncology staff • receive written information on side-effects and how to cope with them References: [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version 3.2009. Fort Washington, PA: NCCN; 2009.
28 Consider adjuvant chemotherapy Quick info: Postoperative adjuvant chemotherapy: • should be considered for patients with node-positive cancer [1] • should be considered for patients with Dukes' C tumours [10] • should not be routinely considered for patients with Dukes' B tumours [10] • may benefit patients with Dukes' C cancer [2] • is recommended for all patients with stage II/III rectal cancer, regardless of pathology results, for 4 months [13] • should be given under close supervision by oncologists or chemotherapy nurse specialists [2] • should begin within 6 weeks of surgery [2] • should be considered if the patient is fit enough to tolerate it [2] Chemotherapy options include: • oxaliplatin in combination with 5-fluorouracil (5-FU) and folinic acid (FA) [1,14], given for 6 months [1] • 5-fluorouracil (5-FU) and folinic acid (FA), given for 6 months [2,10] • portal venous infusion 5-FU [10] All patients receiving chemotherapy should [2]: • have access to emergency care, information, and advice from oncology staff • receive written information on side-effects and how to cope with them Published: 17-Jun-2011
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009.
29 Psychosocial support Quick info: All patients diagnosed with colorectal cancer should have access to psychosocial support from a clinical nurse specialist; patients and carers should be provided with the contact number of the clinical nurse specialist so that problems and concerns can be addressed following discharge from hospital [2]. Elderly patients may need practical help from [2]: • a clinical nurse specialist • allied health professions • community care services Reference: [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004.
30 Follow-up Quick info: Short-term follow-up [2]: • should focus on postoperative problems, future planning, and stoma management • should involve a clinical nurse specialist • should include a complete colonoscopy within 6 months of discharge, if this was not performed before surgery • should include a CT scan of the liver, if this was not performed before surgery Follow-up: • should be carried out by the colorectal team in conjunction with the GP [23] • should include CT scan [10] of the abdomen and thorax during the first 2 years following resection [1] • should include colonscopy [4] at 5 yearly intervals [1,2], if the patient has a polyp-free colon (may not benefit patients with a polyp-free colon with a life-expectancy less than 15 years [2]) • may include sigmoidoscopy [4] • should include carcino-embryonic antigen (CEA) test [14]: • every 3-6 months for 2 years; then [4] • every 6 months for 5 years • if CEA levels are elevated after resection perform colonoscopy, chest, abdominal, and pelvic CT scans [14] • with positron emission tomography using fluor-18-deoxyglucose (FDG-PET) has been shown to have high diagnostic value in detecting recurrent colorectal carcinomas [16]; however, this is not a routine follow-up modality but should be considered in patients with a raised CEA and a normal CT scan [13]. References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004.[1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005.
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003. [13] Contributors to the international care map, invited by Map of Medicine; 2010. [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version 1.2010. Fort Washington, PA: NCCN; 2009. [16] Zhang C, Chen Y, Xue H et al. Diagnostic value of FDG-PET in recurrent colorectal carcinomas: A meta analysis. Inter J Cancer 2009; 124: 167-73. [23] Derbyshire colorectal pathway group; 2011.
31 Follow-up schedule Quick info: Follow-up to include [23]: • outpatient follow-up at 6 weeks, 1 year, 2 years, and 5 years • carcinoembryonic antigen (CEA) blood test every 3 months for the first 2 years • CT scan at 9 months and 24 months Reference: [23] Derbyshire colorectal pathway group; 2011.
32 Tumour recurrence Quick info: Management should be discussed by a multidisciplinary team (MDT) [2]. Reference: [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancer. London: NICE; 2004.
33 Ongoing follow-up Quick info: Long-term follow-up aims to [1]: • detect recurrent disease [4,10] • detect metachronous tumours (secondary primary cancer in the remaining large bowel) • provide psychological support [10] • improve survival rates • facilitate audits [10] References: [1] The Association of Coloproctology of Great Britain and Ireland (ACPGBI). Guidelines for the management of colorectal cancer. London: ACPGBI; 2007. [4] Australian Government National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Canberra: NHMRC; 2005. [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
34 Consider palliative care Quick info: Following cancer recurrence if resection is not possible, consider referral to palliative care [10,13]. References: [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; 2003.
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Colorectal cancer - specialist management Derbyshire local pathways > Oncology > Colorectal cancer
[13] Contributors invited by Map of Medicine; 2010.
35 Management Quick info: Careful consideration should be given to repeating surgical excision [10], if the tumour is resectable [13]. References: [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer − A national clinical guideline. Edinburgh: SIGN; 2003. [13] Contributors invited by the Map of Medicine; 2010.
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Colorectal cancer Oncology / Oncology
Provenance certificate Overview
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Editorial methodology
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Overview This document describes the provenance of the Derbyshire Health Community Colorectal cancer care map. This care map has been localised by Derbyshire Health Community, under the lead of Anne Hayes, NHS Derbyshire County Public Health Specialist. The care map has been reviewed by Derbyshire stakeholders and has been approved by relevant members of the Health Community-wide Clinical Effectiveness and Guideline Group (CEGG).
Published: Next scheduled update:
th 17 June 2011 31st December 2011
Editorial methodology The Map of Medicine Editorial Team have undertaken the localisation editing of the care map. The text is based on the Map of Medicine international care map, which was created in line with the Map of Medicine editorial methodology.
