Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support Panelists: Michael Loreto MD FRCP(C) Kathleen Callaghan BSC RN ET Julie Whitten BSc RD Traci Franklin MSW RSW
Jan 21, 2015
Panel 2:Optimizing Integrated
Colorectal Cancer Treatment Planning and Patient Support
Panelists:
Michael Loreto MD FRCP(C)
Kathleen Callaghan BSC RN ET
Julie Whitten BSc RD
Traci Franklin MSW RSW
Mr. TW: Case History 2
• Colonoscopy reveals a rectal cancer• A rectal MRI for pre-operative staging
reveals Stage III rectal cancer• Pre-operative chemo-radiotherapy, then a
total mesorectal excision followed by post-operative chemotherapy
• Mr. TW has a temporary colostomy, has bowel habit changes and feels depressed
Role of MRI in Staging and Treatment Decisions for Patients
with Rectal Cancer
Dr. Michael Loreto
Associate Radiologist, Health Sciences North
Which patients benefit from a pre-operative MRI?
ALL patients with rectal cancer should have a pre-operative MRI as hi-resolution MRI has become the diagnostic standard for the accurate LOCAL STAGING of rectal cancer.
What information does a pre-operative MRI provide?
• Local staging– primary tumour (T-stage)– regional lymph nodes (N)
Assessment of the Primary Tumour – T-stage
Modified TNM Staging (AJCC)
StageT2
Hi-res T2-weighted axial (short-axis) image Kaur H et al. RadioGraphics (2012)
“early stage” T3 “advanced stage” T3
Kaur H et al. RadioGraphics (2012)
How does rectal MRI influence treatment decisions?
• Identification of patients who may benefit from pre-operative chemoradiation
• Surgical planning
Neo-adjuvant Treatment
• Current Cancer Care Ontario (CCO) guidelines:– Pre-operative chemoradiation for stage II (T3-T4N0) and stage
III (T1-4N1-2) primary rectal cancer
• Recommendations based on multiple RCTs showing that pre-op RT and pre-op CRT significantly reduce the risk of local recurrence
Low Rectal Cancers
• Lower extent between 0 – 5 cm from the anal verge
• Lower extent above the top border of the puborectalis may be amenable to sphincter-sparing surgery
• Lower extent at or below the top border of the puborectalis will require abdominal perineal resection (T1 and early T2), extralevator APR (advanced T2 and T3) or pelvic exenteration (T4)
CCO Synoptic Report for Rectal Cancer
• In an attempt to standardize reporting, CCO has developed an evidence-based synoptic report template that radiologists have been encouraged to utilize
• Report template includes important rectal tumour characteristics that influence neo-adjuvant and surgical treatment decisions
How are rectal cancer treatment decisions made at HSN?
• Rectal cancer cases are discussed at multidisciplinary case conferences (MCC) on a weekly basis
• Imaging is reviewed by the radiologist, and treatment decisions are discussed amongst the attending medical oncologists, radiation oncologists and surgeons
Summary
• Rectal MRI is the diagnostic standard for local staging of primary rectal cancer
• CCO has created an evidence-based synoptic report emphasizing key findings to help identify patients requiring neo-adjuvant treatment and to assist surgeons in determining the type/extent of surgery required
• Multidisciplinary case conferences at HSN ensure that proper discussion occurs between radiologists, oncologists and surgeons prior to a treatment plan being implemented
References
1. Taylor FGM et al. A Systematic Approach to the Interpretation of Preoperative Staging MRI for Rectal Cancer. AJR: 191; pp.1827-1835 (2008).
2. Kaur H et al. MRI Imaging for Preoperative Evaluation of Primary Rectal Cancer: Practical Considerations. RadioGraphics: 32; pp.389-409 (2012).
3. Cancer Care Ontario User’s Guide for the Synoptic MRI Report for Rectal Cancer
(https://www.cancercare.on.ca).
Role of the Enterostomal Therapist
Kathleen Callaghan BScN RN ET
Enterostomal Therapist
Nurse Continence Advisor, HSN
Nutrition Intervention During Rectal Cancer Treatment
Julie Whitten, B.Sc., RD
Supportive Care Program
Northeast Cancer Centre, HSN
Nutrition Intervention During Rectal Cancer Treatment
• Automatic nutrition referral
• Monitor bowel function and nutritional status throughout treatment
Symptom Management Guidelines Nutrition Interventions
Nutrition Interventions
• Low Roughage, Low Fibre Diet – Avoid insoluble fibre – Focus on soluble fibre
• Fluid intake – Increased fluid needs– Avoid hyper-osmotic fluids (fruit drinks, sodas) – Oral rehydration solutions– Parenteral hydration
• Limit caffeine, alcohol, fried/greasy foods, carbonated beverages
• Small, frequent meals at regular times
Symptom Management Guidelines Pharmacological Interventions
Psychosocial Care for Colorectal Cancer
Traci Franklin MSW RSW
Supportive Care Program
Northeast Cancer Centre, HSN
ESAS Guidelines: Depression
Depression in Cancer
• Mood• Affect• Thoughts: hopeless, helpless• Fears:
–Disability, loss of roles, disfigurement, loss of control, loss of support, dying, pain
–Feeling they are being punished
Depression in Cancer
• The prevalence of significant emotional distress, defined as anxiety, depression, and adjustment disorders, ranges from 35% to 45% across studies in North America (Carlson & Bultz, 2003; Zabora, Brintzenhofeszoc, Curbow, Hooker & Piantadosi, 2001)
Psychosocial Factors
Sexual Dysfunction pelvic surgery, radiotherapy
Body Image colostomy
Relational Adjustment Anxiety about bowel incontinence
Financial Concerns Cost of supplies
Coping with Side effects of Treatment
ESAS GUIDELINESDepression: 4-6