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

LEFT HOLDING THE BAG? : CRC FOLLOW-UP CARE FOR

FAMILY PHYSICIANS

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……”

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

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

Canadian Incidence and Mortality

So colorectal cancer gets…….

OUT OF A POSSIBLE

Screening

“a good thing”

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

Colorectal Cancer Staging

The TNM Staging System• “T” : Tumor – local extent

– T 1-4– 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)

• “T” : Tumor – local extent– T 1-4– 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)

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

• 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

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?

What’s in a name? That which we call a Stage Four CancerBy any other name would smell just as NOT-sweet

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

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

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 33 40

Nordlinger, B; 1996 1568 28 NR

Jamison, RL; 1997 280 27 33

Fong, Y; 1999 1001 37 42

Iwatsuki, S; 1999 305 32 NR

Choti, M; 2002 133 58 NR

Abdalla, E; 2004 190 58 NR

Fernandez, FG; 2004

100 58 NR

Wei, AC; 2006 423 47 NR

Rees, M; 2008 929 36 42.5

de Jong, M; 2009 1669 47 36

An asymptomatic patient is a happy patient….

…Better rates of cure with liver resection

Overall, does early detection of recurrent disease improve

survival?

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

• 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 protocols1. Jeffery GM, et al. Follow-up strategies for patients treated for non-metastatic colorectal cancer.

Cochrane Database Syst Rev 2002;(1):CD002200.2. 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.

3. Figueredo A, et al. Follow-up of patients with curatively resected colorectal cancer: a practice guideline. BMC Cancer 2003 Oct 6;3(1):26.

So what actually do you do?

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

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

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

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

Take Home Message #1

• Close follow-up of Stage II and III colorectal cancer patients with colonoscopy, liver imaging and CEA tests saves lives

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


• If your patient is not well enough for a liver or lung resection….

• ……they should not be followed closely for recurrence!

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

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


• 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

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

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?

Follow Up 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)*

Every 3 months Not routine

CT Imaging* Chest/Abdomen

Annually Not routine

Chest X-Ray* Not routine Not routine

Colonoscopy* End of Year 1Then every 3 – 5 years (if no polyps)

Monitoring* Long-term Toxicities of Chemotherapy

No specific monitoring required

CCMB Follow-Up RecommendationsStage II & III Colon Cancer

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

Take Home Messages


• 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


• 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

THANK YOU! Any questions…..

Documents

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