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