Colorectal Cancer: Guidelines to Management

Colon cancer is the third leading cause of cancer deaths in Jamaica. Unique features may exist in this predominantly black population that impact management. Additionally, there is rationalization of some resources that may impose restrictions on the widespread applicability of some international guidelines. We have developed here guidelines that are consistent with the best available evidence and which are appropriate to use in our local context. Screening: We recommend that screening should start at age 45 for the average risk patient and may take the form of yearly stool testing (three serial samples) followed by colonoscopy where positive. Endoscopic evaluation with flexible sigmoidoscopy every five years in combination with stool testing, or colonoscopy every 10 years are all acceptable options. Computed tomography (CT) colonography every five years is especially useful in some patients. Staging: Staging patients by CT scan of the chest, abdomen and pelvis is desirable. Other options may be used but are of inferior accuracy. Magnetic resonance imaging (MRI) for staging is acceptable where CT contrast reactions exist. Rectal cancer requires additional local staging by MRI or the less desirable transrectal ultrasound. Positron emission tomography/computed tomography (PET/CT) has limited role in confirming or localizing metastatic disease. Surgery: Oncologic outcomes are the same with open and laparoscopic approaches, however, patient postoperative mobilization and cosmetic outcomes are better with the laparoscopic approach. The required advanced minimally invasive surgical skills are not universally available. Extent of resection is determined based on curative versus palliative intent and tumour location in relation to vascular supply. Total mesorectal or mesocolon resections are desirable. Stapled anastomoses may be advantageous over hand sewn but suffer from reduced availability and increased cost of stapling devices. Metastases: Patients with metastatic disease are best managed by multidisciplinary teams with a view to neoadjuvant chemotherapy, multi-visceral resection and intraperitoneal chemotherapy. Pathological Assessment: Apart from tumour confirmation the pathologist assists with quality control (eg regional lymph node harvest) and suggestions on genetic and histochemical testing. Better clinical information and specimen orientation would assist the pathologist in providing clearer guidance. Ideally, fresh specimens should be received/retrieved but this may be impossible in most institutions. A pathology reporting checklist is strongly advised in order to achieve standardization. Adjuvant Therapy: Stage 1 and low risk Stage 2 disease patients are generally not offered adjuvant chemotherapy. Patients with Stage 4 disease should be tested for mutations in the KRAS and NRAS gene and offered EGFR agents like cetuximab and pantuximab. Surveillance for survivors: No internationally agreed guidelines exist. We suggest the following for average risk patients managed with curative intent: Every six months for five years, patients should have clinical evaluation, carcinoembryonic antigen (CEA) [if indicated] and CT scans of the chest, abdomen and pelvis. Other modalities like abdominal ultrasound and chest X-ray may substitute if CT is unavailable. A colonoscopy should be done one year after surgery and then every five years. Surveillance for high-risk patients would be different. The Management Flowchart in Appendix 1 captures this summary.