Download P3143/Colorectal Report

Focus on Colorectal Cancer in Ontario
Driving quality, accountability and innovation
throughout Ontario’s cancer system
TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Anatomy of the Colon and Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Incidence of Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
Mortality from Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Colorectal Cancer Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Assessing Consistency of Practice Against Evidence-Based Recommendations . . . . . . . . . .
7
Practice Guidelines and the Treatment of Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . .
7
Surgical Treatment of Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Adjuvant Therapy of Early Stage Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
Management of Metastatic Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
Observations on the Treatment of Colorectal Cancers at the Regional Cancer Centres . . . .
10
Role of Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
Access to Cancer Treatment – Wait Times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26
Practice Guideline Publications of the Gastrointestinal Disease Site Group . . . . . . . . . . . . .
27
FOCUS ON COLORECTAL CANCER IN ONTARIO
Prepared by:
Dr. Jean Maroun
Chair, Gastrointestinal Disease Site Group
Dr. W.K. (Bill) Evans
Chief Medical Officer and Provincial
Vice-President
With the Assistance of:
Saira Bahl
Dr. Bernard Cummings
Mark Gregus
Dr. Eric Holowaty
Dr. Loraine D. Marrett
Dr. Tom McGowan
Diane Nishri
Sherman Quan
Dr. Linda Rabeneck
Dr. Marko Simunovic
Dr. Andy Smith
Dr. Hartley Stern
Dr. Terrence Sullivan
Beth Theis
Dr. Anthony Whitton
Dr. Brent Zanke
September 2004
FOCUS ON COLORECTAL CANCER
IN ONTARIO
Introduction
Colorectal cancer is the most
common form of gastrointestinal
cancer and includes cancers of
both the colon and the rectum.
Colorectal is the fourth most
common form of cancer in
Canada, after breast, lung and
prostate cancer. This monograph
on colorectal cancer has been
prepared to provide information
on patterns of practice to those
directly involved in the provision
of care to these patients
throughout Ontario, as well as
to those who are responsible
for managing components of
the health care system. The
practice patterns are shown
against the backdrop of the
evidence-based guidelines
developed by the Gastrointestinal
Disease Site Group of Cancer
Care Ontario’s Program in
Evidence-based Care. In addition
to information on patterns of
practice, this monograph provides
information on the timeliness of
access to care, the risk factors
associated with colorectal
cancer, and an overview of
the incidence and mortality of
colorectal cancer. In brief, it
provides a synoptic assessment
of the current quality of care for
colorectal cancer patients in the
province of Ontario. It is hoped
that this monograph will assist
those responsible for care
delivery to achieve the best
possible results for patients
with a diagnosis of colorectal
cancer.
The information in this
monograph has been collected
from a variety of Cancer Care
Ontario (CCO) sources. Data
on incidence, mortality, and
survival were extracted from
data held by the Ontario Cancer
Registry (OCR). The Oncology
Patient Information System
(OPIS) was the source of data
on wait times and treatment
practices. The information found
in the sections on incidence,
mortality, and survival was
largely extracted from
“Insight on Cancer. News and
Information on Colorectal
Cancer,” produced by Cancer
Care Ontario and the Canadian
Cancer Society, Ontario
Division.
1
Anatomy of the Colon
and Rectum
The colon and rectum make up
the large intestine, which removes
nutrients from food and stores
waste until it passes out of the
body as fecal material. As shown
in Figure 1, the colon starts
in the right lower quadrant of
the abdomen where the contents
of the small intestine enter the
cecum. The appendix is attached
to the lower part of the cecum.
The ascending colon is that part
of the colon that runs from the
cecum to the hepatic flexure
situated in the right upper
abdominal quadrant. The
transverse colon crosses the
abdomen to the splenic flexure
lying in the left upper abdominal
quadrant. The descending colon
extends from the splenic flexure
to the left lower abdominal
quadrant where it makes an
S-shaped loop, which is called
the sigmoid colon. The sigmoid
colon then connects to the rectum
and the junction between the
sigmoid colon and the rectum is
called the rectosigmoid junction.
The rectum extends from the
rectosigmoid junction to the
anal canal, which ends at the
anus.
Cancer located anywhere in the
colon, including the sigmoid
colon, is classified as colon
cancer. Cancer found within the
rectum, including the rectosigmoid junction, is classified as
rectal cancer. As cancers of the
colon and rectum have many
features in common, they
are commonly classified as
colorectal.
2
Figure 1
LEFT
RIGHT
transverse colon
splenic
flexure
hepatic
flexure
ascending
colon
descending
colon
small
intestine
cecum
sigmoid
colon
appendix
rectum
anus
rectosigmoid
junction
Risk Factors
Colorectal cancer is associated
with several risk factors. These
include age, diet, family history,
and social habits.
•
Age: As people become
older, the likelihood of
developing colorectal cancer
increases, which explains
why most of those diagnosed
with colorectal cancer are
50 years of age or older.
•
Diet: Obesity and centralbody fat result from a poor
diet. When coupled with low
physical activity, the risk of
developing colorectal cancer
increases.
•
Family History: A family
history of colorectal or some
other cancers is a marker
of increased risk, which may
be due to heritable factors,
similar unhealthy lifestyle,
or a combination of these
factors.
•
Personal Medical History:
A diagnosis of ulcerative
colitis or Crohn’s disease
increases the risk of developing colorectal cancer.
•
Social Habits: Long-term
heavy smoking, and excess
alcohol consumption, also
appear to increase the risk
of colorectal cancer. Studies
indicate that smokers are
30 to 40 percent more likely
than non-smokers to die of
colorectal cancer because of
a higher incidence of polyps
in smokers.
FOCUS ON COLORECTAL CANCER IN ONTARIO
Incidence of Colorectal
Cancer
Figure 2
In 2003, it is estimated that there
will be 18,000 new cases and
8,300 deaths from colorectal
cancer in Canada. In Ontario, it
is estimated that there will be
6,800 new cases and 3,000 deaths
from colorectal cancer in 2003.
Although the age-standardized
incidence rates are still lower than
those of 1985, the growth and
aging of the population has
caused the number of new cases
to rise steadily and significantly
in recent years among both men
and women. Figure 3 shows the
Key map of Ontario regions
E
Thunder Bay
Sudbury
70
Age-standardized rate per 100,000
(3-year moving averages)
60
50
40
30
20
10
0
1986
1981
1996
1991
2001
Year of diagnosis
Female incidence
Male incidence
Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
Figure 3
Colorectal Cancer Incidence Rates* by Region,
1997–2001
70
Age-standardized rate per 100,000
The incidence of colorectal
cancer has fluctuated over the
past 20 years but is now slightly
higher in males and lower in
females than in 1981 (Figure 2).
Since 1997, the incidence in men
has risen about 2% per year.
Female incidence rates have
also risen somewhat since 1997
after a steady fall from the early
1980s. The reasons for these
trends are not well understood,
although changes in diet and
social habits likely contributed
to the decline in the 1980s. There
is no obvious explanation for the
recent rise, although the greater
use of colonoscopy for screening
and /or diagnosis may be a
contributing factor.
Colorectal Cancer Incidence Rates by Sex in Ontario,
1981–2001
60
50
40
30
20
10
Ottawa
CE
0
Kingston
SE
Hamilton
NW
NE
S
SW
CW
CE
SE
Region
London
CW
Windsor
SW
S
An enlarged version of this map can be seen
in Appendix A
* points = incidence estimates; I = 95% confidence intervals
– the horizontal line represents the incidence rate for Ontario as a whole
Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
3
E
Figure 4 shows the agestandardized mortality rates
(death rate per 100,000
population) from colorectal
cancer for both men and women
over the past two decades.
Colorectal cancer mortality fell
for both sexes between 1981
and 2001, with a decline of 20%
for males and 27% for females.
These falls in mortality may
reflect the decline in incidence
in the 1980s and early 1990s and
possibly earlier diagnosis and
improvements in treatment.
Age-standardized mortality
rates by region are displayed
in Figure 5. Mortality rates do
not vary much by region, but
the Northeast and Southwest
regions are higher, whereas
the Central East region is lower.
The horizontal line represents
the average mortality rate for
all of Ontario.
Colorectal Cancer Survival
In general, there has been a
steady increase in survival for
both men and women over the
past several decades. This is
likely due to improvements in
treatment techniques, as well as
Colorectal Cancer Age-Standardized Mortality Rates
by Sex in Ontario, 1981-2001
40
35
Age-standardized rate per 100,000
(3-year moving averages)
Mortality from Colorectal
Cancer
Figure 4
30
25
20
15
10
5
0
1981
1986
1991
1996
Male mortality
Female mortality
Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
Figure 5
Colorectal Cancer Age-Standardized Mortality
Rates* by Region, 1997–2001
70
60
50
40
30
20
10
0
NW
NE
S
SW
CW
CE
SE
Region
* points = incidence estimates; I = 95% confidence intervals
– the horizontal line represents the average mortality rate for Ontario as a whole
4
2001
Year of death
Age-standardized rate per 100,000
geographic distribution of
incidence rates in the different
regions of Ontario. The Northeast
region appears to have the highest
incidence rate, whereas the
Central East region appears to
have the lowest. The Northeast,
Northwest, and Southwest
regions all have an incidence
rate above the provincial average
of 51.4 per 100,000. The horizontal
line represents the average
incidence rate for all of Ontario.
Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
E
FOCUS ON COLORECTAL CANCER IN ONTARIO
Figure 6
Colorectal Cancer Estimated* Five-year Relative
Survival † by Region, Age-adjusted, 1996-2000
100
90
80
Relative survival (%)
the diagnosis of colorectal cancer
at earlier stages, when treatment
is more effective. Figure 6 shows
the five-year relative survival for
Ontario by region, for cases under
follow-up during 1996 to 2000.
These survival estimates were
generated using the Brenner
period method of estimating
survival, which looks at cases
followed within a recent period,
1996 to 2000 in this case. There
are not significant differences
between regions, except for
the Northwest which has a
significantly lower relative
survival. The horizontal line
represents the average relative
survival for all of Ontario.
70
60
50
40
30
20
10
0
NW
NE
S
SW
Colorectal Cancer Screening
CW
CE
SE
E
Region
Definition of Effective Screening
The goals of screening are to
decrease the incidence of and
mortality from cancer. Effective
screening should detect: (1)
cancers at an earlier stage with
a better prognosis than those
detected because of symptoms;
and (2) premalignant lesions,
which when removed, lead to
a decrease in incidence of the
disease.
Why Colorectal Cancer Screening
Meets the Criteria for Effective
Screening
Colorectal cancer (CRC) may
bleed in amounts that are grossly
undetectable, but detectable by
a fecal occult blood test (FOBT),
which, if followed up by
colonoscopy, leads to the diagnosis of CRC. Survival with CRC
is markedly improved with
detection at an early stage. CRC
is preceded by the development
* Using Brenner’s period method, which estimates survival of all cases under follow-up
during 1996-2000, adjusted for age
† Bars = survival estimates, I = 95% confidence intervals
– the horizontal line represents the average five-year relative survival in the province.
Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
of adenomatous polyps, which
although rarely detectable by
FOBT are detectable and
resectable at colonoscopy.
Case-control studies of flexible
sigmoidoscopy (FS) have demonstrated a reduction in CRC
mortality. No previous studies
have evaluated the relationship
between screening colonoscopy
and CRC mortality. However,
the National Polyp Study,
a cohort study, evaluated CRC
incidence following screening
colonoscopy. The National
Polyp Study consisted of 1418
individuals who had a complete
colonoscopy during which one or
more adenomas were removed.
The subjects subsequently underwent periodic colonoscopy during
an average follow-up of 5.9 years,
and the incidence of CRC was
ascertained. The incidence was
compared with that in three
reference groups, including two
cohorts in which colonic polyps
were not removed and one
population-based cancer registry
(the Surveillance, Epidemiology
and End-Results [SEER] cancer
registry). A substantial reduction
(76-90%) in CRC incidence was
observed in the National Polyp
Study cohort compared to the
expected incidence estimated in
the three reference groups (1).
5
Review of Screening Methods
and Outcomes
FOBT: FOBT is the only modality
with randomized controlled trial
(RCT) evidence of mortality
reduction (2,3). RCTs of periodic
(annual or biennial) FOBT show
reduction in mortality from CRC
from 13%-33% with up to 50%
compliance with periodic FOBT.
FOBT has both false negative
rates and false positive rates
for detecting CRC. Individuals
with a positive FOBT must be
followed up by colonoscopy.
Flexible Sigmoidoscopy: FS
examines the distal colon and
rectum. Lesions observed in this
area can be removed or biopsied.
Retrospective case-control studies
have shown a reduction in
mortality from rectosigmoid
cancer of 60% to 80% with
screening FS, with a protective
effect lasting up to 10 years (2,3).
Colonoscopy: Colonoscopy
detects asymptomatic cancers
and precancerous lesions that can
be removed. There have been
no RCTs comparing screening
colonoscopy to other CRC
screening methods. In a crosssectional study of screening
colonoscopy, 3,121 asymptomatic
individuals aged 50 to 75 were
recruited from U.S. Veterans
Administration hospitals (4).
The subjects had no large bowel
evaluation within the previous
10 years, and no recent bowel
symptoms. Men comprised
96.8%, and 13.9% had a family
history of CRC (one or more
first-degree relatives). CRC
was detected in 1% and
non-invasive “neoplasms”
(adenomas ≥ 1 cm, villous
adenomas, and carcinoma
in situ) were detected in 10%.
6
Extrapolating from the National
Polyp Study, it is reasonable
to assume that screening
colonoscopy is a preventive, as
well as a screening, intervention.
There is no direct information
on the optimal frequency of
screening colonoscopy for
average-risk individuals. For
average-risk persons without
colonoscopic abnormality, the
polyp-cancer hypothesis suggests
an interval of 10 years before
the next screen.
Colorectal Cancer Guidelines and
Recommendations in Canada
Approximately 75% of CRCs
arise in average-risk individuals
(defined as 50 years or older
with no family history of CRC).
CRC screening is effective in
reducing both CRC incidence
and mortality, as summarized
above. After reviewing the
scientific evidence for CRC
screening, the Canadian Task
Force on Preventive Health Care
published its recommendations
in 2001 (5). For average-risk
individuals 50 years or older,
annual or biennial fecal occult
blood test (FOBT) or FS every
five years were recommended as
the initial CRC screening tests.
The Task Force determined that
the evidence was insufficient to
recommend for or advise against
colonoscopy as the initial CRC
screening test.
Despite strong evidence demonstrating the effectiveness of
CRC screening, there are no
population-based CRC screening
programs in Canada. In 1999,
Cancer Care Ontario (CCO)
convened an expert panel to
develop recommendations for
a CRC screening program in
Ontario. The panel recommended
the creation of an FOBT-based
CRC screening program for
average risk individuals between
the ages of 50 and 75 (Ontario
Expert Panel, 1999). This was
echoed in 2002 at the national
level by a committee convened
by Health Canada (National
Committee on Colorectal Cancer
Screening, 2002). CCO and its
partners are now evaluating
two implementation models
for FOBT aimed at Ontarians
aged 50-75 who are at average
risk of colorectal cancer. It is
anticipated that the information
from this evaluation will assist
in planning a population-based
CRC screening program in
Ontario.
Colorectal Cancer Screening
in Ontario
There is increasing demand for
colonoscopic screening from
asymptomatic average-risk
individuals and their physicians.
The volume of colonoscopies in
Ontario increased from 62,039
in 1992 to 172,204 in 2001 but it
is not known how much of this
increase is due to screening
versus diagnostic procedures (6).
Recently, an Ontario study of
nearly one million men and
women age 50-59 years with no
prior history of CRC or large
bowel evaluation revealed that
less than 21.5% had any type of
large bowel test. This is an upper
bound of the extent of screening,
since it includes all tests done,
whether for screening or for
diagnostic work-up (7). There
is a great need for educational
programs to raise awareness
among the public and physicians
about the importance of CRC
screening.
FOCUS ON COLORECTAL CANCER IN ONTARIO
Assessing Consistency of
Practice against Evidencebased Recommendations
The recent development of a
software for CCO called DS-Web
has made it possible to rapidly
interrogate a number of administrative databases, including
the Ontario Cancer Registry, the
Oncology Patient Information
System (OPIS) and the New
Drug Funding Program (NDFP)
database. Among other things, it
can rapidly determine the volume
of clinical activity in any cancer
centre across the province and
analyze radiotherapy and systemic therapy clinical practice
patterns. Where stage information
is available, it is now possible
to describe the stage-specific
treatment practices. In the future
it should be possible to assess
stage-specific survival. In the
paragraphs that follow, the
recommendations for treatment
by type and stage of colorectal
cancer are described and then
the actual clinical practices are
displayed for each of the regional
cancer centres.
For more information on
DS-Web, send inquiries to
<[email protected]>.
Practice Guidelines and the
Treatment of Colorectal
Cancer
The Gastrointestinal Disease
Site Group (DSG) is one of
14 DSGs that develop evidencebased practice guidelines and
evidence summaries as part
of Cancer Care Ontario’s
Program in Evidence-based
Care. The Gastrointestinal DSG
has 18 members from across
the province representing the
disciplines of surgical oncology,
radiation oncology, medical
oncology, anatomical pathology
and gastroenterology, in addition
to patient representatives and
oncology fellows in training.
The DSG has completed
14 guidelines and published
12 of them on various aspects
of the treatment for different
stages of colorectal cancer, as
well as other gastrointestinal
malignancies. These guidelines
can be found on Cancer
Care Ontario’s web site,
<http://www.cancercare.on.ca/
access_PEBC.htm>. The recommendations found in these
guidelines, as well as other
sources, are briefly summarized
below.
Surgical Treatment of
Colorectal Cancer
For patients presenting with
early stage colon and rectal
cancer (Stages 0-III), the usual
initial treatment is surgical
removal (resection) of the
tumour, assuming the patient
can tolerate the appropriate
operation. For those patients
who undergo a complete surgical
resection, roughly half survive
five years. The survival rate
depends on the stage of the
tumour at the time of surgery.
The tumour stage is determined
by factors such as the degree of
penetration of the tumour into
the bowel wall and the extent
of lymph node involvement by
cancer. The stage of the tumour
determines the risk of recurrence
and, in higher risk cases, signals
the need for further therapy
(adjuvant therapy) to reduce the
likelihood of recurrence and
death from cancer.
Colon Cancer
When the cancer is detected at
an early stage (Stage 0 and some
Stage I) and is limited to a polyp,
the standard practice is to
perform a polypectomy (removal
of the polyp). This procedure
avoids having to cut into the
abdomen by using a colonoscope
that is inserted through the
rectum. A local excision removes
superficial cancers and a small
amount of nearby tissue from
the inner layers of the colon.
If the tumour invades the bowel
wall or surrounding tissues, the
usual operation is a segmental
resection of the colon, where the
tumour and a length of normal
colon on either side of the tumour
is removed. Local lymph nodes
are also removed to appropriately stage the patient (10).
Accurately staging the patient is
important because this signifies
whether or not they are eligible
for adjuvant chemotherapy, a
well-established treatment
option for patients with Stage III
CRC. Unfortunately, provincewide research confirms that
Ontario surgeons and pathologists
currently fail to routinely stage
CRC and identify those who
would benefit from this treatment, even though this can be
achieved through a relatively
simple change in lymph node
retrieval and examination. An
initiative to improve colorectal
cancer staging in Ontario, led by
Dr. Andy Smith from the Toronto
Sunnybrook Regional Cancer
Centre, is currently underway.
Usually, about one-third of the
colon is removed, but more or
less tissue may be removed
depending on the exact size and
location of the tumour. After the
tumor is removed, the two ends
7
of the remaining colon are
reconnected, allowing normal
bowel function. In some situations, it may not be possible
to reconnect the colon, and a
colostomy (an opening in the
abdominal wall to allow passage
of stool) is needed (10).
Rectal Cancer
For early stage disease, a
polypectomy and local excision
can be used to remove superficial
cancers or polyps. Local transanal
resection involves cutting through
all layers of the rectum to remove
invasive cancers as well as some
surrounding normal rectal tissue.
This procedure can be used to
remove some Stage I rectal
cancers that are relatively small
and not too far from the anus.
Polypectomy, local excision,
and local transanal resection are
done with instruments inserted
through the anus, without making
a surgical opening in the skin of
the abdomen (10).
Some Stage I rectal cancers and
most Stage II or III rectal cancers
are removed by either low
anterior (LA) resection or
abdominoperineal (AP) resection.
LA resection is used for cancers
near the upper part of the rectum,
close to where it connects with
the colon. Low anterior resection
is like most abdominal operations
where an incision is made only
in the abdomen. The tumour,
along with a margin of normal
tissue on either side of it, is then
removed. In addition to removing
the tumour, lymph nodes and
a large amount of fatty tissue
around the rectum is removed.
The colon is then reattached to
the rectum that is remaining so
8
that a permanent colostomy is
not necessary. Sometimes, when
special techniques are necessary
to prevent a permanent colostomy, it is necessary to have a
temporary colostomy opening
for about eight weeks while the
surgical site heals. A second
operation is then performed to
close the temporary opening (10).
An abdominoperineal (AP)
resection is performed when the
cancer is in the farthest end of
the rectum near the anus and
involves the sphincter muscle
(the muscle that keeps the
anus closed and prevents stool
leakage). With this procedure,
an incision must be made in
the abdomen and the perineum,
which is the area around the
anus. The anus and tissues
surrounding it, including the
sphincter muscle, are then
removed. Having this procedure
means a permanent colostomy
is necessary to eliminate stool.
Recent Advances in Colorectal
Cancer Surgery
Laparoscopic surgery is a minimally invasive alternative to
open abdominal surgery that
involves one or more small
incisions in the abdomen. The
abdomen is insufflated with
carbon dioxide gas, which pushes
the abdominal wall away from
the intestine. Three to five
small incisions are made in the
abdomen to create ports for
inserting a laparoscope, a pencilthin instrument with its own
lighting system and miniature
video camera, and special surgical
instruments. The surgeon performs the entire operation by
observing the image projected
by the camera on a monitor.
The resected portion of the colon
or rectum is then removed by
enlarging one of the ports
and pulling it through (12).
Laparoscopic surgery provides
the benefits of less postoperative
pain, a shorter hospital stay
and a shorter recuperation
period (11).
Total mesorectal excision (TME)
has been shown to reduce the
local recurrence of rectal cancer
compared with non-TME
resection and is considered the
optimal surgical intervention (13).
The mesorectum is the fatty
tissue surrounding the rectum
under the peritoneum and
limited by the fascia recti. It
contains vessels and nodes and
is separated from the pelvic wall
by an avascular plane. A sharp
dissection allows the resection
of the mesorectum along this
avascular plane. The mesorectum is surrounded by a fascia
which should be kept intact and
removed with the specimen.
Nodules of cancer can be found
in the mesorectum as far as
5 cm below the lower tip of a
tumour. Therefore, if the tumour
is located in the upper part of
the rectum, the mesorectal
excision should be made up
to 5 cm below the lower edge of
the tumour. For mid or low rectal
cancers, a total mesorectal excision should be performed (14).
TME is a specialized resection
technique that requires some
training, so an extensive effort
to mentor surgeons in the
technique of TME is underway
provincially. This initiative is
being led by Dr. Marko Simunovic
from the Juravinski Cancer
Centre in Hamilton.
FOCUS ON COLORECTAL CANCER IN ONTARIO
Adjuvant Therapy of Early
Stage Colorectal Cancer
In Stage I colon and rectal
cancers where the tumour is
superficial and does not penetrate
deeply into the bowel wall, the
survival at five years following
surgical resection is > 90%. These
patients do not require any
adjuvant treatment. The treatment
of Stages II and III differs for
colon and rectal cancers. In
Stage II colon cancer, where the
tumour has a deeper penetration
into the bowel wall, or penetrates
through the wall, but without
involvement of the lymph nodes,
routine adjuvant chemotherapy
is not recommended, as no
effective adjuvant therapy for
this group has yet been identified.
In Stage III colon cancer where
the lymph nodes are involved
by cancer, the risk of recurrence
is high, ranging from 50 – 70%.
For these patients, six months
of adjuvant chemotherapy with
5-FU and leucovorin (LV) is
recommended with an estimated
absolute improvement in five-year
survival of 15%.
Rectal cancer differs from colon
cancer by the need to treat both
Stages II and III. In these patients,
postoperative radiotherapy is
added to chemotherapy in view
of the risk for local recurrence
of tumour in the pelvis. Treatment
consists of six months of 5-FU
based chemotherapy combined
usually in the third post-operative
month with five weeks of
radiation. The administration
of a continuous intravenous
infusion of 5-FU concurrent with
the radiation therapy appears to
achieve the best results.
Though postoperative
radiotherapy in combination
with chemotherapy is the
recommended standard of care
in North America, there are
emerging data from Europe
indicating that preoperative
radiotherapy is also effective.
Ongoing clinical trials to compare
these approaches to the timing
of radiation therapy relative
to surgery, as well as the role
of chemotherapy, are being
conducted.
Management of Metastatic
Colorectal Cancer (CRC)
The management of metastatic
colon and rectal cancers is the
same and guidelines developed
by the DSG are common to both
sites. In the last two decades,
there have been significant
advances in the treatment of
metastatic CRC. New drugs
have become available and
more effective chemotherapy
drug combinations have been
developed.
Three groups of drugs are
presently available for the
systemic treatment of metastatic
CRC: The fluoropyrimidines,
irinotecan and oxaliplatin.
5-Fluorouracil (5-FU) is a
fluoropyrimidine and for over
30 years it has been the principal
drug for treating colorectal
cancer. It is a thymidylate synthase (TS) inhibitor- an important
enzyme in DNA synthesis. Its
initial use as a single agent was
associated with minimal benefit.
The addition of leucovorin (LV),
also known as folinic acid (FA),
led to improved anticancer effects
and the combination of 5-FU/LV
(5-FUFA) became standard
therapy for several years.
Subsequently, other TS inhibitors
such as raltitrexed (tomudex)
and capecitabine (xeloda) were
developed and these had an
easier administration schedule
with a better toxicity profile.
The DSG guidelines recommend
their use as alternative options
for patients selected for
monotherapy when an easier
and better tolerated schedule
is desired. Capecitabine’s use
as first line monotherapy is
increasing in view of its ease of
oral administration, as well as
its better toxicity profile when
compared to 5-FU/LV. When compared to 5-FU/LV in randomized
studies, patients treated with
capecitabine have shown similar
survival outcomes but with higher
response rates.
The second compound that
has had a significant impact
on CRC outcomes is irinotecan,
a topo-isomerase I inhibitor that
interferes with DNA replication.
Irinotecan has demonstrated
significant survival benefit when
compared to best supportive
care in patients who have failed
first line therapy with 5-FU/LV.
Guidelines developed by the
DSG recommend the use of this
drug as a second line therapy.
Monotherapy is associated with
a median survival of about
12 months in patients with
metastatic colorectal cancer,
a modest improvement from
the six months median survival
observed in untreated patients.
The use of irinotecan in combination with 5-FU/LV as first line
therapy has demonstrated a
9
significant improvement in
response rate, time to progression, and overall survival when
compared to standard 5-FU/LV.
It has become the recommended
standard combination for the
first line therapy of metastatic
CRC in medically appropriate
patients.
Oxaliplatin, a third generation
platinum compound not yet
available on the Canadian market,
has demonstrated success in the
treatment of CRC. Randomized
trials have demonstrated its
efficacy in first and second line
therapy in metastatic CRC.
Oxaliplatin is synergistic with
5-FU and should be used in
combination with 5-FU/LV even
in patients who have had disease
progression on 5-FU/LV therapy.
Recent studies have confirmed
that the use of short infusion
schedules of 5-FU/LV in combination with either irinotecan
(FOLFIRI regimen) or oxaliplatin
(FOLFOX regimen) is associated
with higher efficacy and less
toxicity. Infusional therapy has
emerged as the new standard
of care in combination
chemotherapy for CRC.
Of interest is the fact that
capecitabine administered
orally for two weeks out of
every three weeks can emulate
the results of a 5-FU infusion
and ongoing combination trials
are evaluating its use as an
alternative to intravenous
5-FU infusions. Combination
chemotherapies in the first line
therapy of metastatic CRC have
led to an increase in the median
10
survival of patients to about
16 months and data on the use
of sequential combinations
are demonstrating a further
increase to a median survival
of 20-22 months.
The decision to use sequential
monotherapy or combination
chemotherapy depends on several
clinical factors that include
patient age, performance status,
comorbidities, and the willingness of the patient to accept
treatment with its trade-offs of
drug-induced toxicities against
the prospect of modest survival
and quality of life gains.
Observations on the
Treatment of Colorectal
Cancers at the Regional
Cancer Centres
The data displayed in figures 7-15
were extracted from two of
Cancer Care Ontario’s administrative databases, the Oncology
Patient Information System
(OPIS) and the New Drug
Funding Program’s database,
using DS-Web. In order to
evaluate practice relative to
evidence-based recommendations, it was necessary to select
only those cases for whom stage
information was recorded in the
chart electronically. The capture
of stage information has improved
at all cancer centres but is still
incomplete, which may account
for the modest number of cases
seen in some analyses. In 2002,
86% of patients diagnosed with
colorectal cancer at the regional
cancer centres were staged.
However, at the provincial level
in 2001, the last year for which
data from the Ontario Cancer
Registry are available, only
19.5% of patients diagnosed with
colorectal cancer had information
on stage assignment available.
Radiation Therapy
Radiation is used as part of
the treatment for patients
with Stage II and III rectal
cancer and for palliation of
symptoms in patients with
advanced unresectable or
recurrent rectal cancer.
When adjuvant treatment is
offered, it can be given pre- or
post-operatively (before or
after surgery). If delivered preoperatively for tumours that
appear resectable, it may be
administered in a few fractions,
usually as a total dose of 25Gy
in five fractions in one week, or as
multiple fractions (for example,
45 Gy in 20 to 25 fractions over
four to five weeks). The relative
merits of these two schedules
are being examined in ongoing
trials. The longer schedule is
generally preferred when the
primary tumour is of borderline
resectability, and surgery is
usually performed about four to
eight weeks after radiation, to
allow time for downsizing of the
cancer. If radiotherapy is administered post-operatively, a dose
of 45Gy in 25 fractions in five
weeks is considered standard,
and may be supplemented by
boost therapy to the tumour bed
of 5.4 to 9Gy in 3 to 5 fractions,
if it is judged that the boost can
be given safely.
FOCUS ON COLORECTAL CANCER IN ONTARIO
Figure 7 provides an analysis of
the treatment administered in the
regional cancer centres and it
shows that the majority of cases
are being treated with 25-30
fractions, which is considered
acceptable. Those patients being
Figure 7
treated for curative intent with
less than 25 fractions are likely
to be pre-operative radiotherapy
cases and the variability seen here
is likely due to local management
preferences. For the small
number of cases treated with > 30
fractions, there may be tumour
related factors that required
treatment with higher doses.
Higher doses are almost
invariably given to incompletely
resected cancers.
Percentage of Stage II and III Rectal Cases Treated with Curative Intent Grouped
by Number of Radiotherapy Fractions Given, Jan – Dec 2002
100%
Number of Treated Cases
80%
60%
A. >30
B. 25-30
C. <25
40%
20%
0%
No. of Cases:
HAM
78
KNG
21
LND
65
NEO
32
NWO
8
OTT
43
TSB
89
WND
20
ALL RCC
356
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
Legend:
HAM = Hamilton Regional Cancer Centre
OTT = Ottawa Regional Cancer Centre
KNG = Kingston Regional Cancer Centre
TSB = Toronto Sunnybrook Regional Cancer Centre
LND = London Regional Cancer Centre
WND = Windsor Regional Cancer Centre
NEO = Northeastern Ontario Regional Cancer Centre
RCC = Regional Cancer Centre
NWO = Northwestern Ontario Regional Cancer Centre
11
Advanced rectal cancer is
usually treated for palliation
by a few fractions (10 or less),
although in some cases a more
Figure 8
prolonged course can be
indicated. Figure 8 shows that
the majority of patients being
treated with palliative intent
in the regional cancer centres
are in fact given 10 or fewer
fractions.
Percentage of Rectal Cases (all stages) Treated with Palliative Radiotherapy,
Grouped by Number of Fractions Given, Jan – Dec 2002
100%
Number of Treated Cases
80%
60%
A. >10
B. 0-10
40%
20%
0%
No. of Cases:
HAM
11
KNG
14
LND
20
NEO
10
NWO
4
OTT
20
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
12
TSB
40
WND
1
ALL RCC
120
FOCUS ON COLORECTAL CANCER IN ONTARIO
Systemic Therapy of Rectal
Cancers
Stage II and III rectal cancers,
when offered adjuvant systemic
therapy are treated with 5-FU/FA,
5-FU with radiation therapy (RT),
5-FU for four or five days, or
5-FU by continuous intravenous
infusion (CIV) and concurrent
radiotherapy. All of these
regimens are considered
appropriate and as Figure 9
indicates, these are the regimens
predominantly used at the
regional cancer centres.
Figure 9
Capecitabine (CAPEC) and
Raltitrexed are not standard
therapies, although in some
cases, these TS inhibitors can
be substituted for 5-Fluorouracil
when ease of administration is
preferred or when severe toxicity
results from the administration
of 5-Fluorouracil. The presence
of 5-FU-mitomycin (5-FU-MITO)
is appropriate for treatment of
squamous cell cancer involving
the anal canal rather than the
treatment of adenocarcinomas of
the rectum. Etoposide-carboplatin
(ETOPCARBO) is also appropri-
ate for squamous cell cancer
but would not be used with
adenocarcinoma of the rectum.
Irinotecan in combination with
5-Fluorouracil and leucovorin
(IFL) is a regimen used in
metastatic or Stage IV colorectal
cancer and would not be
expected to be used in the
adjuvant setting. The inclusion
of a small number of these
cases in the data may either
represent inappropriate use
of the regimen, or an error in the
recording of stage information
in the health record.
Percentage of Stage II and III Carcinomas of the Rectum and Rectosigmoid Treated
with Adjuvant Chemotherapy Grouped by Regimen Given, Jan – Dec 2002
100%
RALTITREXED
80%
Number of treated Case
OTHER REG
5-FU-MITO
60%
IFL
5-FUFA
5-FU CIV + RT
40%
5-FU- 4 OR 5 DAYS
ETOPCARBO
20%
CAPEC
0%
No. of Cases:
HAM
96
KNG
60
LND
89
NEO
68
NWO
38
OTT
94
TSB
59
WND
72
ALL RCC
576
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
13
Figure 10 demonstrates that the
vast majority of patients seen
in regional cancer centres
with Stage II and III rectal or
rectosigmoid carcinoma are
treated appropriately with
adjuvant therapy. The presence
of IFL in the data set may
Figure 10
represent a data entry error at
the centre, while the presence
of etoposide-carboplatin may
be due to the inclusion of
patients with anal cancer.
In unusual circumstances where
5-Fluorouracil could not be
delivered or had previously
caused severe toxicity, the use
of Capecitabine or Raltitrexed
as a substitute would be
appropriate adjuvant therapy.
Percentage of Stage II and III Cancers of the Rectum and Rectosigmoid Treated
by Adjuvant Systemic Therapy Grouped as Consistent or Inconsistent with
Practice Guidelines, Jan – Dec 2002
100%
90%
Number of Treated Cases
80%
70%
OTHER REG
60%
IFL
ETOPCARBO
50%
5-FU-MITO
40%
CAPEC
30%
CONSISTENT
20%
Acceptable
Regimens:
10%
0%
No. of Cases:
HAM
65
KNG
29
LND
58
NEO
36
NWO
8
OTT
62
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
14
TSB
28
WND
41
ALL RCC
327
• 5-FUFA
• 5-FU CIV+RT
• 5-FU-4 or 5 Days
FOCUS ON COLORECTAL CANCER IN ONTARIO
Systemic Therapy of Colon
Cancers
The GI Disease Site Group does
not recommend the routine use
of adjuvant chemotherapy in
Stage II colon cancer. As can be
seen in Figure 11, the number of
Figure 11
patients who actually received
adjuvant 5-FUFA treatment is
relatively small. When it is used,
it is for those patients considered
to be at higher risk of recurrence
due to poor prognostic factors.
The fact that a small number of
colon cancer cases are coded as
having received anastrozole or
paclitaxel and carboplatin
suggests that these patients
have, in addition to Stage II
colon cancer, other malignancies,
possibly breast and/or lung
cancer.
Percentage of Stage II Colon Cancers Treated with Adjuvant Systemic Therapy
Grouped According to Treatment Regimen Used, Jan – Dec 2002
100%
ANASTRO
Number of Treated Cases
80%
PACLICARBO
IFL
60%
5-FU CIV + RT
5-FU- 4 OR 5 DAYS
5-FU (IV/CIV)+RT
40%
CAPEC
OTHER REG
20%
5-FUFA
0%
No. of Cases:
HAM
20
KNG
6
LND
9
NEO
6
NWO
4
OTT
20
TSB
4
WND
9
ALL RCC
78
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
15
The standard of care for
patients with Stage III colon
cancer is adjuvant 5-FU with
folinic acid (5-FUFA). As can
be seen in Figure 12, this is
the dominant treatment offered
in regional cancer centres.
Capecitabine (which is
metabolized to 5-Fluorouracil
within the body) is easier to
administer and would be an
appropriate alternative in
Figure 12
circumstances where intravenously administered
chemotherapy is difficult or
impossible. The inclusion of cases
in this data set of 5-FU in combination with radiation therapy
(5-FU + RT and 5-FU CIV + RT)
is inappropriate for the adjuvant
management of colon cancer
and these cases are likely rectal
cancers inappropriately coded
as colon cancer. Irinotecan-
5-FU-leucovorin (IFL) is
inappropriate for the adjuvant
therapy of colon cancer and may
represent a data entry error
as this treatment would only
be used for Stage IV cancer.
Anastrozole is used in the
management of breast cancer
and its inclusion in the data set
likely represents treatment for
a second cancer.
Percentage of Stage III Colon Cancer Treated with Adjuvant Systemic Therapy
According to Chemotherapy Regimen Used, Jan – Dec 2002
100%
ANASTRO
80%
Number of Treated Cases
IRINOTECAN
IFL
5-FU-LEV
60%
5-FU- 4 OR 5 DAYS
5-FU (IV/CIV)+RT
CYCLO-PO
40%
CAPEC
OTHER REG
20%
5-FUFA
0%
No. of Cases:
HAM
65
KNG
18
LND
45
NEO
33
NWO
15
OTT
57
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
16
TSB
22
WND
23
ALL RCC
278
FOCUS ON COLORECTAL CANCER IN ONTARIO
Figure 13 demonstrates that the
adjuvant systemic therapy used
in the treatment of patients with
Stage III colon cancer is very
consistent with the guideline
Figure 13
recommendations of the GI
Disease Site Group. Only a
relatively few cases would be
considered unacceptable and
these, in fact, may represent
coding errors, data entry errors
or patients who have other
malignant diseases in addition
to colon cancer.
Percentage of Stage III Colon Cancer Treated with Adjuvant Systemic Therapy
Grouped as Consistent or Inconsistent with Practice Guidelines Recommendations,
Jan– Dec 2002
100%
Number of Treated Cases
80%
ANASTRO
CYCLO-PO
60%
IRINOTECAN
CAPEC
OTHER REG
40%
CONSISTENT
20%
Acceptable
Regimens:
0%
No. of Cases:
HAM
65
KNG
18
LND
45
NEO
33
NWO
15
OTT
57
TSB
22
WND
23
ALL RCC
278
• 5-FUFA
• 5-FU CIV+RT
• 5-FU-4 or 5 Days
• 5-FU-LEV
• IFL
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
In the management of Stage IV
(metastatic) colon cancer, a
number of different chemotherapy regimens are acceptable
according to the Disease Site
Group guidelines. The approaches
include monochemotherapy
with Capecitabine and Raltitrexed
and combination chemotherapy
regimens based on 5-Fluorouracil,
usually in combination with
folinic acid and Irinotecan.
Figure 14 shows Capecitabine,
Irinotecan with 5-Fluorouracil
and Leucovorin (IFL), and
5-Fluorouracil with folinic acid
(FUFA) as the dominant regimens
used at the cancer centres.
17
Figure 14
Percentage of Stage IV Colon Cancer Treated with Systemic Chemotherapy
According to Chemotherapy Regimen First Used, Jan – Dec 2002
100%
RALTITREXED
MITOMYCIN
80%
Number of Treated Cases
IRINOTECAN
5-FU CIV + RT
60%
5-FU (IV/CIV)+RT
ETOP-PO
CISPETOP -3 DAYS
40%
CAPEC
IFL
OTHER REG
20%
5-FUFA
0%
No. of Cases:
HAM
22
KNG
6
LND
11
NEO
22
NWO
10
OTT
34
TSB
10
WND
16
ALL RCC
131
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
When these regimens are
grouped together as acceptable,
as seen in Figure 15, only a few
residual cases are identified as
receiving “inappropriate” therapy.
The use of cisplatin-etoposide
may indicate the co-existence
of another cancer or of a small
cell tumour rising in the
gastrointestinal tract. Overall,
these data show that the
practitioners in the regional
cancer centres treating
metastatic colon cancer use
treatment regimens that are
judged to be appropriate
according to the guidelines
of the provincial Disease
Site Group.
18
Role of Palliative Care
Palliative care plays a very
important role in the management
of colorectal cancer patients
because, as noted in the section
on colorectal cancer survival, the
five-year survival of colorectal
cancer patients remains less
than 60%. Many patients with
metastatic disease would benefit
from the expertise of a palliative
care team to assist in symptom
management, psychosocial
support, and attention to spiritual
needs. Unfortunately, there
is little information about the
proportion of colorectal cancer
patients who actually have access
to such important supportive care
and palliative care assistance.
In some cancer treatment
facilities, palliative care clinics
have been established to support
the needs of cancer patients
generally, and particularly those
with symptoms that are proving
difficult to manage with conventional medical interventions.
Future initiatives should optimize
the integration of supportive care
and palliative care services into
the management of the patient
with colorectal cancer particularly
if they have metastatic disease.
And there is a need for more data
on the proportion of patients who
are provided such care and the
degree to which their symptoms
are palliated.
FOCUS ON COLORECTAL CANCER IN ONTARIO
Figure 15
Percentage of Stage IV Colon Cancer Patients Treated with First-Line Systemic
Therapy Grouped as Consistent or Inconsistent with Practice Guidelines, Jan – Dec 2002
Number of Treated Cases
100%
80%
MITOMYCIN
60%
ETOP-PO
CISPETOP - 3 DAYS
OTHER REG
40%
CONSISTENT
Acceptable
Regimens:
20%
0%
No. of Cases:
HAM
22
KNG
6
LND
11
NEO
22
NWO
10
OTT
34
TSB
10
WND
16
ALL RCC
131
• RALTITREXED
• IRINOTECAN
• 5-FU CIV+RT
• 5-FU(IV/CIV)+RT
• CAPEC
• IFL
• 5-FUFA
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
Access to Cancer
Treatment – Wait Times
It is not known at what point
waiting for cancer treatment
can lead to physical harm.
Intuitively, it makes sense to
begin treatment as promptly as
possible after the diagnosis of
cancer. On the other hand, cancer takes many years to reach a
size that is clinically detectable,
so several weeks or months of
waiting may actually have little
or no impact on the ultimate
outcome. There are data to
show that anxiety levels are
high for people awaiting a diagnosis, and again from diagnosis
to the actual start of treatment.
In this context, the Canadian
Association of Radiation
Oncologists recommends that
the time interval from referral
to the start of treatment should
be no longer than four weeks.
There are, however, no standards
for wait times for surgery or the
administration of chemotherapy.
From a study of surgical wait
times at hospitals associated
with cancer centres in Ontario
and published in the CMAJ in
August of 2001, the average wait
time from referral to colorectal
surgery was 36 days (8). Wait
time data during 2003 from
the Princess Margaret Hospital,
University Health Network,
suggested an even more serious
waiting time problem, as the
time from the decision to
operate and the date of the
operation was 37 days for
gastrointestinal cancers. The
rate limiting steps appear to be
access to operating rooms and
the availability of specialized
personnel, including anaesthetists.
Surgical data in Ontario are
incomplete so wait times are
difficult to estimate. CCO has
taken action and is conducting a
Cancer Surgery Wait Times Pilot
Project at the request of the
Ministry of Health and Long-Term
Care. CCO is collecting cancer
surgery wait times data and
plans to merge this data with
19
from referral to consultation
and consultation to treatment.
When compared to Figures 18a
and 18b, which show the average
systemic therapy wait times for
colorectal cancer for the same
period, there is a noticeable
difference in how long patients
wait from consultation to
treatment. This difference can
be attributed to the fact that
chemotherapy treatment does
not have the same resource
constraints as radiation therapy,
that already collected by the
University Health Network. At
the same time, CCO is developing
plans for the implementation of
a province-wide database so that
data collection will eventually
be automated.
Radiation Therapy
Figures 16a and 16b show the
average radiation therapy wait
times (50th percentile and 90th
percentile) for colorectal cancer
or surgery for that matter.
Therefore, waiting times for
chemotherapy are generally
shorter. Where wait times
exceed two weeks from either
referral to consultation or
consultation to treatment,
the underlying cause is usually
either a shortage of medical
oncology consultants or poor
access to imaging studies (CT or
MRI scan), which are necessary
to assess the disease extent
prior to the start of treatment.
Figure 16a Radiation Therapy Wait Times for Colorectal Cancer (colon, rectum, rectosigmoid)
2000 Q1 to 2003 Q1
Weeks Wait
20
Referral to Consultation
15
10
5
8.4
8.3
6.7
6.6
3.0
2.7
3.0
3.3
7.0
6.2
6.0
3.2
3.1
5.6
2.8
2.5
6.7
6.4
6.0
4.8
2.9
2.6
1.7
1.1
4.3
1.4
0
Valid No.
of Cases
2000
Q1
2000
Q2
2000
Q3
2000
Q4
2001
Q1
2001
Q2
2001
Q3
2001
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
90
78
67
77
90
76
96
76
97
102
102
100
96
Figure 16b
20
Consultation to Treatment
Weeks Wait
15
10.0
10
5
7.7
3.6
8.1
7.0
7.0
2.9
9.6
3.1
3.7
3.5
7.9
3.1
9.0
9.9
9.1
10.3
11.0
7.6
2.8
3.1
3.1
3.3
3.1
4.0
3.1
0
Valid No.
of Cases
2000
Q1
2000
Q2
2000
Q3
2000
Q4
2001
Q1
2001
Q2
2001
Q3
2001
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
93
81
69
83
86
80
100
75
98
112
103
106
95
50th Percentile
Note: Excludes all patients whose wait times exceed 20 weeks.
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
20
90th Percentile
FOCUS ON COLORECTAL CANCER IN ONTARIO
Figures 17a and 17b would lead
one to believe that the average
wait times for colon cancer
radiation treatment are quite
good and conform to the
Canadian Association of
Radiation Oncologists’
recommendations for a time
interval of four weeks or less
from referral to treatment. This
may be misleading because most
of the treatment for colon cancer
is palliative, where patients only
receive one to two fractions of
radiation. This is in contrast to
the situation for patients who
receive treatment with curative
intent, which requires a much
larger number of fractions. From
a resource scheduling perspective, it is much easier to book
one to two palliative appointments, as opposed to 10-20
appointments for curative intent.
Figure 17a Radiation Therapy Wait Times for Colon Cancer 2000 Q1 to 2003 Q1
20
Referral to Consultation
Weeks Wait
16.4
15
12.4
9.9
10
9.6
3.2
2.7
1.9
2.6
5.0
2.3
2.4
7.9
7.0
5.0
5
8.9
8.1
7.4
4.4
2.7
1.9
4.7
3.6
3.0
1.9
1.4
1.4
0
Valid No.
of Cases
2000
Q1
2000
Q2
2000
Q3
2000
Q4
2001
Q1
2001
Q2
2001
Q3
2001
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
21
20
12
11
22
11
19
19
17
25
27
27
27
Figure 17b
20
Consultation to Treatment
Weeks Wait
15
13.3
10.9
10
8.9
7.7
6.0
5
1.8
3.9
1.1
1.1
8.6
7.0
5.9
3.4
1.8
9.4
8.0
7.0
2.0
1.4
2.7
3.3
0.9
1.9
1.7
2.0
1.0
0
Valid No.
of Cases
2000
Q1
2000
Q2
2000
Q3
2000
Q4
2001
Q1
2001
Q2
2001
Q3
2001
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
26
24
14
15
23
13
21
19
19
29
29
31
32
50th Percentile
90th Percentile
Note: Excludes all patients whose wait times exceed 20 weeks.
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
21
interval of two weeks, mainly
due to the lack of availability
of specialists to see the patients.
The wait times from consultation
to treatment are well below the
recommended two week time
interval. This results from the
Systemic Therapy
Figures 18a and 18b show the
average wait times for colorectal
cancer systemic therapy. The
wait from referral to consultation
exceeds the recommended time
fact that there are fewer inherent
resource constraints for the
treatment of patients with
systemic therapy.
Figure 18a Systemic Therapy Wait Times for Colorectal Cancer (colon, rectum, rectosigmoid)
2000 Q1 to 2003 Q1
20
Referral to Consultation
Weeks Wait
15
10
7.9
2.9
2.4
3.1
3.0
2.9
5.9
5.7
5.7
5.3
5.4
5
7.3
6.3
3.1
3.1
3.3
7.0
3.0
3.1
9.0
7.7
7.0
2.9
7.4
2.6
3.0
0
Valid No.
of Cases
2000
Q1
2000
Q2
2000
Q3
2000
Q4
2001
Q1
2001
Q2
2001
Q3
2001
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
243
205
212
244
247
219
198
207
202
207
188
181
172
5.7
5.6
Figure 18b
20
Consultation to Treatment
Weeks Wait
15
10
6.6
5.0
4.7
5
1.6
1.6
4.9
1.4
6.6
1.6
1.5
1.7
1.1
6.7
6.0
5.0
4.6
4.6
3.9
1.0
1.1
1.6
1.6
1.0
1.6
0
Valid No.
of Cases
2000
Q1
2000
Q2
2000
Q3
2000
Q4
2001
Q1
2001
Q2
2001
Q3
2001
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
229
198
205
232
238
217
198
199
192
197
180
177
169
50th Percentile
Note: Excludes all patients whose wait times exceed 20 weeks.
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
22
90th Percentile
FOCUS ON COLORECTAL CANCER IN ONTARIO
Cancer Care Ontario posts wait
time information on its web site
<http://www.cancercare.on.ca/
access_waitTimes.htm>. These
wait times represent the median
(average) wait times from referral
to treatment for the preceding
three months and are updated
monthly from the regional
cancer centres and Princess
Margaret Hospital. For the
three-month period June to
August 2003, the median wait
time from referral to start of
radiation treatment for colorectal
cancer by centre is shown
below. Although the data shows
gastro-intestinal cancer wait
times, colorectal makes up such
a large proportion of the cases
(approximately 90%) that the
numbers fairly represent the
wait times for colorectal cancer.
Gastro-Intestinal [GI] Radiation Therapy Wait Time Information for a Three-month Period,
June – August 2003
Centre
Weeks
Hamilton Regional Cancer Centre
4.5
Kingston Regional Cancer Centre
2.3
London Regional Cancer Centre
4.2
Northeastern Regional Cancer Centre
5.7
Northwestern Regional Cancer Centre
7.1
Ottawa Regional Cancer Centre
6.6
Princess Margaret Hospital
3.1
Toronto-Sunnybrook Regional Cancer Centre
5.6
Windsor Regional Cancer Centre
7.1
The benchmark time interval
from referral to treatment for
colorectal cancer is four weeks
and, as can be seen, not all
radiotherapy treatment centres
achieve this standard.
23
Conclusions
Colorectal cancer is one of the
most common malignancies in
Ontario and one of the leading
causes of cancer deaths. CRC
is commonly cured by surgery
alone when diagnosed early.
For colon cancer patients with
a high risk of recurrence (i.e.
Stage III and a subset of Stage
II), adjuvant chemotherapy is
recommended. Combination
chemotherapy with radiation
therapy is recommended for
patients with Stage II and III
rectal cancer. Cancer Care
Ontario guideline recommendations appear to have been
24
adopted in regional cancer
centres. The available data do
not allow us to determine if all
patients who could potentially
benefit from those therapies
actually receive them.
After many years in which
minimal benefit was achieved
with chemotherapy in Stage IV
disease, improvements have
been seen in survival times in
clinical trials. Improvements
are anticipated in the general
cancer population from the
application of the treatment
regimens that are recommended
by the DSG practice guidelines.
A variety of fluoropyrimidine-
based therapies either alone or
in combination with irinotecan
or oxaliplatin can be used to
palliate symptoms and prolong
survival. Practices in regional
cancer centres appear to be
generally consistent with
evidence-based practice
guidelines. However, there
are no data to inform us as
to whether all candidates
who could benefit from these
therapies actually receive them.
FOCUS ON COLORECTAL CANCER IN ONTARIO
Glossary of Terms
Adenocarcinoma
Cancer that begins in cells that line
certain internal organs and that have
glandular (secretory) properties.
Adenomatous Polyp
A non-cancerous growth that
protrudes from the bowel wall.
Adjuvant chemotherapy
The use of anti-cancer drugs after
surgery to decrease the chance of
the cancer coming back.
Adjuvant therapy
A treatment method used in addition
to the primary therapy; used to
increase the effectiveness of treatment.
Age-standardized rate
The number of new cases of cancer
or cancer deaths per 100,000 that a
population would have if it had a
standard age structure. Standardization
is necessary when comparing several
populations that differ with respect to
age because age has such a powerful
influence on mortality and morbidity.
Age-specific rate
The number of new cases of cancer
or cancer deaths during the year,
expressed as a rate per 100,000
persons in a given age group.
Chemotherapy
Treatment using a drug or combination
of drugs to kill cancer cells.
Combined modality (or multimodality)
therapy
Two or more types of treatment are
given either at the same time or in
sequence; may include combinations
of radiation, chemotherapy, surgery,
or others.
Five-year relative survival
A measure of the reduction in life
expectancy due to a diagnosis of
cancer. Relative survival is estimated
from life tables as the ratio of the
observed survival of cancer cases
five years after diagnosis to the
expected survival of individuals of
the same age in the general population.
First-line therapy
The first type of therapy given for a
condition or disease.
Fraction
Dose of radiation for a single treatment.
Incidence
A rate showing how many new cases
of a disease occurred in a population
during a specified interval of time
(usually expressed as number of new
cases per unit time per fixed number
of people; e.g., number of new cases
of cancer per 100,000 persons in
one year).
Locally advanced cancer
Cancer that has spread only to nearby
tissues or lymph nodes.
Lymph node
Small bean-shaped organ that acts as
a filter to collect bacteria and other
foreign substances from the lymphatic
system to be processed by the immune
system.
Metastasis
The spread of cancer cells from the
original site to other parts of the body.
Modality
A type or kind of treatment (surgery,
chemotherapy, radiotherapy).
Neoadjuvant therapy
Therapy given before the primary
treatment to treat a cancer to improve
the effectiveness of the primary
treatment; neoadjuvant therapy can
be chemotherapy or radiation therapy.
New Drug Funding Program
A program to provide equal access
to new effective agents for eligible
patients throughout the province.
As a result, access to expensive
drugs is not limited by place of
residence or a health care facility’s
drug budget. New treatments are
introduced in a standard manner
on a provincial basis.
Ontario Cancer Registry
The population-based database that
includes information on all diagnoses
of cancer reported in Ontario since
1964. It includes limited data about
diagnosis (date, type of cancer), death
(date, cause), treatment, and the
individual (date of birth, sex, census
division of residence at diagnosis/
death) for all cancer patients. It does
not include data on risk factors, stage,
grade, or non-melanoma skin cancers.
Palliative treatment
Treatment given to relieve the
symptoms and reduce the suffering
caused by cancer and other lifethreatening diseases. Palliative cancer
therapies are given together with
other cancer treatments, from the
time of diagnosis, through treatment,
survivorship, recurrence or advanced
disease, and at the end of life.
Prevalence
The total number of active cancer
cases in the population at the current
moment in time.
Radiation treatment
The use of high-energy radiation
from x-rays, gamma rays, neutrons,
and other sources to kill cancer
cells and shrink tumors.
Radical treatment
Treatment given with the intent of
curing the disease.
Regimen
The plan that outlines the dosage,
schedule and duration of treatment.
Regional involvement
The spread of cancer from its original
site to nearby surrounding areas.
Risk factors
Anything that may increase a person’s
chance of developing cancer. It may
be an activity, such as smoking, diet,
family history, environmental agents
or many other things.
Second-line therapy
Treatment that is given when initial
treatment (first-line therapy) doesn’t
work, or stops working.
Side effect
An effect on the body caused by
cancer treatment other than the
effect on the cancer; also called
an adverse reaction.
Squamous cell cancer
Cancer that begins in squamous
cells, which are thin, flat cells that
look like fish scales. Squamous cells
are found in the tissue that forms the
surface of the skin, the lining of the
hollow organs of the body, and
the passages of the respiratory
and digestive tracts. Also called
epidermoid carcinoma.
Staging
A method to describe the extent of a
cancer inside the body. If the cancer
has spread, the stage describes how
far it has spread from the original
site to other parts of the body.
Standard treatment
Treatment that has been proven
effective and is commonly used.
Surgical resection
Removing tissue from the body
through a surgical procedure.
Systemic disease
Disease that affects the whole body
rather than only an organ.
Systemic treatment
Treatment that reaches cells all over
the body by travelling through the
bloodstream.
Three-year moving average
Rate calculated using the sum of
the new cases of cancer or cancer
deaths for a three-year period and
the population estimates for those
same years. Three-year moving
average rates are shown on all
graphs describing trends in order
to smooth out annual fluctuation.
Tumour histology
The type of cancer as classified by
its appearance under the microscope.
Many of the terms here were defined with the assistance of the National Cancer Institute’s cancer dictionary,
accessible at http://www.nci.nih.gov/dictionary.
25
References
1. Winawer SJ, Zauber AG, Ho MN, O’Brien MJ, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond
JH, Panish JF, Ackroyd F, Shike M, Kurtz RC, Hornsby-Lewis L, Gerdes H, Stewart ET. Prevention of
colorectal cancer by colonoscopic polypectomy. N Engl J Med 1993;329:1977-81.
2. Winawer SJ, Fletcher RH, Miller L. Godlee F, Stolar M, Mulrow C, Woolf SH, Glick S, Ganiats TG,
Bond JH, Rosen L, Zapka JG, Olsen SJ, Giardello FM, Sisk JE, Van Antwerp R, Bown-Davis C,
Marciniak DA, Mayer RJ. Colorectal cancer screening: Clinical guidelines and rationale.
Gastroenterology 1997;112:594-642.
3. Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L,
Litin S, Simmang C. Colorectal cancer screening and surveillance: Clinical guidelines and rationaleUpdate based on new evidence. Gastroenterology 2003;124:544-560.
4. Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, Chejfec G. Use of colonoscopy to screen
asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J
Med 2000;343:162-68.
5. Colorectal Cancer Screening: Recommendation statement from the Canadian Task Force on
Preventive Health Care. CMAJ 2001;165:206-8.
6. Vinden C, Schultz S, Rabeneck L. Patterns of Colonic Evaluation Procedure Utilization in Ontario,
1996-2001: An ICES Research Atlas; in press.
7. Rabeneck L, Paszat LF. Population-based estimate of the extent of colorectal cancer screening in
Ontario. Am J Gastroenterol; in press.
8. Simunovic M, Gagliardi A, McCready D, Coates A, Levine M, DePetrillo D. A snapshot of waiting times
for cancer surgery provided by surgeons affiliated with regional cancer centres in Ontario. Can. Med.
Assoc. J., Aug 2001; 165: 421 – 425.
9. Goldinger M. Colorectal Cancer – An Overview. Available: http://home.swipnet.se/~w-15548/crc.htm
(Accessed 2004 Jan 19).
10. American Cancer Society. Available: http://www.cancer.org (Accessed 2004 Feb 15).
11. National Cancer Institute. Available: http://www.nci.nih.gov (Accessed 2004 Feb 15).
12. Colorectal Cancer Network. Available: http://www.colorectal-cancer.net (Accessed 2004 Feb 15).
13. BC Cancer Agency. Available: http://www.bccancer.bc.ca (Accessed 2004 Feb 15).
14. Mitry E, Barthod F, Penna C, Nordlinger B. Surgery for Colon and Rectal Cancer. Best Practice &
Research Clinical Gastroenterology, Volume 16, Issue 2, April 2002, Pages 253-265.
26
FOCUS ON COLORECTAL CANCER IN ONTARIO
Practice Guideline Publications of the Gastrointestinal Disease Site Group
1. Figueredo A, Germond C, Maroun J, Browman G, Walker-Dilks C, Wong S and the Gastrointestinal
Cancer Disease Site Group. Adjuvant Therapy for Stage II Colon Cancer Following Complete
Resection. Cancer Prevention and Control, 1997; 1(5): 379-92.
2. Figueredo A, Fine S, Maroun J, Walker-Dilks C, Wong S and the Gastrointestinal Cancer Disease Site
Group. Adjuvant Therapy for Stage III Colon Cancer Following Complete Resection. Cancer
Prevention and Control, 1997; 1(4): 304-19.
3. Figueredo A, Germond C, Taylor B, Maroun J, Agboola O, Wong R et al and the Gastrointestinal
Cancer Disease Site Group. Post-operative adjuvant radiotherapy or chemotherapy for resected stage
II or III rectal cancer. Current Oncology 2000;7(1):37-51.
4. Figueredo A, Rumble RB, Maroun J, Earle CC, Cummings B, McLeod R, Zuraw L, Zwaal C, and the
members of Cancer Care Ontario’s Program in Evidence-based Care’s Gastrointestinal Cancer Disease
Site Group. Follow-up of patients with curatively resected colorectal cancer: a practice guideline.
Cancer. 2003, 3:26 (6 October 2003).
5. Figueredo A, Zuraw L, Wong RKS, Agboola O, Rumble RB, Tandan V, the members of Cancer Care
Ontario’s Program in Evidence-based Care’s Gastrointestinal Cancer Disease Site Group. The use
of preoperative radiotherapy in the management of patients with clinically resectable rectal cancer:
a practice guideline. Medicine 2003, 1:1 (24 November 2003).
6. Figueredo A, Moore M, Germond C, Kocha W, Maroun J, Zwaal C, and the Gastrointestinal Cancer
Disease Site Group. Use of irinotecan in second-line treatment of metastatic colorectal carcinoma.
Current Oncology 2000;7(1):29-36.
7. Jonker D, Earle C, Kocha W, Moore M, Maroun J, Zuraw L, and the Gastrointestinal Cancer Disease
Site Group. Use of irinotecan combined with 5-fluorouracil and leucovorin as first-line therapy for
metastatic colorectal cancer. Curr Oncol 2001;8:60-8.
8. Germond C, Maroun J, Zwaal C, Wong S, and the Gastro-intestinal Disease Site Group. Use of
raltitrexed in the management of metastatic colorectal cancer. Curr Oncol 1999;6(4):217-23.
9. Figueredo A, Zuraw L, Wong RKS, Agboola O, Rumble RB, Tandan V, and the members of
the Gastrointestinal Cancer Disease Site Group. The Use of Preoperative Radiotherapy in
the Management of Patients with Clinically Resectable Rectal Cancer: A Practice Guideline.
BMC Medicine 2003;1:1.
27
Appendix A
Key Map of Ontario Regions
E
Thunder Bay
Sudbury
Ottawa
CE
Kingston
SE
Hamilton
London
CW
Windsor
SW
S
28
This document is intended for use by persons involved in the provision of care to colorectal
cancer patients and for persons responsible for managing aspects of the cancer system
relative to colorectal cancer patients in Ontario. Care has been taken in the preparation of
the information contained in this document. Nonetheless, any person seeking to apply or
consult the information herein is expected to use independent medical judgement in the
context of individual clinical circumstances. Cancer Cancer Ontario makes no representation
or warranties of any kind whatsoever regarding this information or use and disclaims any
responsibility for their use in any way.
Cancer Cancer Ontario retains all copyright in this material, including all text and graphic images.
No portion of this material may be used or reproduced, other than for personal use, or distributed,
transmitted or “mirrored” in any form, or by any means, without the prior written permission
of Cancer Care Ontario.
Cancer Care Ontario
620 University Avenue
Toronto, ON M5G 2L7
www.cancercare.on.ca
Phone: 416-971-9800
E-mail: [email protected]