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ACS issues new care guidelines for survivors of colorectal cancer
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The American Cancer Society has issued cancer survivorship care guidelines for providing comprehensive care to survivors of colorectal cancer.
These guidelines — published in CA: A Cancer Journal for Clinicians — include recommendations for surveillance to detect recurrence, screening for second primary cancers, the management of treatment-related adverse events and promoting healthy lifestyle choices following treatment.
Colorectal cancer is the third most common malignant disease and the second leading cause of cancer deaths in the U.S., according to study background. However, there has been a recent decline in incidence and mortality, with almost two-thirds of survivors of colorectal cancer now living at least 5 years after diagnosis.
Khaled El-Shami, MD, PhD, assistant professor of medicine at The George Washington University School of Medicine and Health Sciences, and a multidisciplinary team of researchers conducted a literature review, as well as a review of publically available U.S. and global clinical practice guidelines, to determine their recommendations.
“The goal of these guidelines is to optimize the care delivered for cancer survivors and to help improve the overall health and quality of life of colorectal cancer survivors,” El-Shami and colleagues wrote. “These guidelines provide guidance on methods to identify and manage the potential physical and psychosocial long-term and late effects of colorectal cancer and its treatment, surveillance for recurrence and screening for second primary cancers, health promotion and how to enhance communication between the oncology team and primary care physicians.”
Recommendations
The researchers issued five recommendations related to surveillance for colorectal cancer recurrence. Further, they endorsed an ASCO recommendation that stated that surveillance should only be performed in patients for whom the results of testing will change treatment decisions.
The surveillance recommendations included:
- That clinical follow-up care provided to survivors of colorectal cancer should be individualized based on the specific diagnosis and treatment protocol;
- Survivors should receive surveillance colonoscopy according to a schedule based on recurrence risk;
- Survivors should receive a history and physical every 3 to 6 months in the first 2 years, then every 6 months in years 3 to 5;
- Carcinoembryonic antigen testing should be conducted every 3 to 6 months for the first 2 years if a patient is a potential candidate for further intervention, then every 6 months for years 3 to 5 if a patient is a potential candidate for further intervention; carcinoembryonic antigen testing is not recommended after 5 years; and
- Chest, abdominal and pelvic CT should be performed annually for up to 5 years in patients with stage I or stage II disease at high risk for recurrence, as well as patients with stage III disease; routine PET/CT is not recommended at any stage and routine CT is not recommended after 5 years.
Regarding screening for secondary primary cancers, the researchers recommended that survivors at an average risk for recurrence should receive age- and sex-appropriate screening. However, women with Lynch syndrome should receive annual endometrial sampling, as well as transvaginal ultrasound, due to their increased lifetime risk for endometrial cancer.
The researchers issued several recommendations regarding the assessment and management of physical and psychosocial long-term effects of treatment. They wrote that primary care physicians should regularly ask survivors whether they are experiencing diarrhea, rectal bleeding, rectal incontinence or other bowel dysfunction. Patients experiencing bowel dysfunction should be treated similarly to members of the general population experiencing those symptoms.
Further, although they acknowledged that cardiovascular morbidity did not appear to be increased among survivors of colorectal cancer, they recommended that survivors who are obese or who had prior coronary artery disease should be surveilled.
Survivors of colorectal cancer should be screened regularly for psychosocial distress, depression and anxiety, with special attention paid to patients with a stoma and those experiencing sexual dysfunction. When appropriate, patients should be referred to appropriate mental health professionals or other appropriate community resources.
Survivors who received pelvic irradiation should be monitored for chronic proctitis, according to the researchers. Further, survivors should be screened regularly for urinary incontinence and retention; those experiencing urinary incontinence should be managed in the same way as patients with an average risk for urinary incontinence.
Regarding health promotion in survivors of colorectal cancer, the researchers recommended that physicians should continue to treat chronic conditions while providing routine general medical care and health promotion recommendations regarding obesity, physical activity, nutrition and smoking cessation, when appropriate.
Primary care physicians should initiate and maintain direct communications with all specialists involved in a patient’s oncology care and symptom management, in addition to requesting treatment summary and follow-up care plans to guide coordination of follow-up care post-treatment.
Looking forward
The researchers acknowledged limitations of their review, including the limited evidence base to provide clear and specific recommendations for the prevention and management of long-term and late effects. Other limitations included the lack of patient/consumer participation in the guideline determination process, the lack of a radiation oncologist in the study workgroup and the reliance on previous surveillance guidelines.
These guidelines will be updated every 5 years as new research becomes available.
“Considering the potential significant impacts of cancer and its treatment on colorectal cancer survivor health and quality of life, it is imperative that clinicians have credible guidance to help ensure that cancer survivors receive high-quality, comprehensive, coordinated clinical follow-up care,” Catherine Alfano, PhD, project director for the National Cancer Survivorship Resource Center and vice president of survivorship in the Office of Cancer Control at the ACS, said in a press release. “While there are still important gaps in research, enough evidence exists to provide these consensus-based guidelines to improve post-treatment care, which we expect to help cancer survivors mitigate the known impacts of colorectal cancer and its treatment.” – by Cameron Kelsall
Disclosure: El-Shami and Alfano report no relevant financial disclosures. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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