management of rectal cancer - cecentral.com

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1. Assess the impact of rectal cancer on Kentucky. 2. Discuss the diagnosis and management of rectal cancer. 3. Outline the measures of quality in rectal cancer care.
Improve care of the surgical patient
Safeguard standards of care
Civic and Military Collaboration and Partnership Physician Support
Community Support and…..
1917: Issued minimum standards for hospitals; “Joint Commission” 1922: Commission on Cancer
1950: Committee on Trauma 1998: American College of Surgeons Oncology Group (ACOSOG)
2004: ACS NSQIP 2005: National Accreditation Program for Breast Cancers
…. Children’s Surgery Verification + MBSAQIP + Coalition for Quality in Geriatric Surgery + Surgeon Specific Registry….
Significant variability in rectal cancer treatment + outcomes
Treatment Options - Utilization of Adjuvant Therapy - Surgical Technique Post-Op Mortality - Local Recurrence - Stoma Incidence - 5Y Survival
specialization AND training AND volume
…..common purpose improving the quality of rectal cancer care via
standard care pathways of evidence based treatment….
1. Total Mesorectal Excision (TME) 2. Specific pathology assessment to measure quality of surgery 3. Specialist imaging techniques to identify high risk of local recurrence 4. Utilization of effective neo-adjuvant and adjuvant therapy 5. MDT approach to patient care
….expectation to reproduce European success
22 Proposed Standards
Program Management (7) Clinical Services (13) Quality Improvement (2)
APR Rate Anastomotic Leak Rate 30-Day Mortality Involved CRM Involved Distal Margin
Reoperation Rate Mesorectal Grade LN Yield > 12 Rate Local Recurrence Rate 3-Year DFS Rate
Quality Indicators
National level…..
How Experienced is the Typical US Rectal Cancer Hospital?
70% of hospitals treat < 20 patients/year 6% hospitals treat > 50 patients/year
[75%] [8%]
High-Volume Surgeon Improved Oncologic Outcome
LN Retrieval 5Y Recurrence
5-Year Overall Survival…
NACRT 72.4% Adjuvant CRT 70.9% Surgery Alone 44.9% CRT Alone 48.8%
(HR 1.66)
Increased Utilization NACRT + Decreased Utilization of Adjuvant CRT + Decreased Surgery Alone
Low- and Medium volume facilities are less likely to offer patients standard treatment: o African American or Hispanic o Lack of private insurance o Residence in a neighborhood with lower educational background
Low- and Medium volume facilities have significantly lower 5Y DFS. o Is my neighborhood a worse prognostic indicator than tumor grade or LN (+)????
Important?....
….via collaborative efforts
Colorectal Cancer Burden
In Kentucky 2017…. 2,250 Diagnosed with Colon and Rectal Cancer Of Which….550+ Rectal Cancers
Colon and Rectal Cancer Incidence Rank #1
U.S. 39.8/KY 50.0
U.S. 14.8/KY 17.2
…. CRC decreasing 3.1% annually while
Y-CRC increasing 1.5% annually…
If you were born in 1890, your risk of colorectal cancer would be…?
…proportion of rectal cancer diagnosed in < 50Y increased from 14.5% to 29.2%
…..about the same as today….
colorectal cancer risk for “millennials” has escalated back to the level of those born in the late
1800s
“Y-CRC” in Summary
3.2% annual percentage increase for rectal cancer in individuals less than 50Y o Median age 44 o Mucinous or signet cell pathology
Over next 10 years, 124% increase in rectal cancer incidence in 20-34Y 1 in 4 rectal cancers will be diagnosed in people younger than the traditional screening age Cause?.....
“Y-CRC” in Summary
29M 48F 42M 44F 34F 18M 22F 50M 42F 39M 26F 50M
1. JM 2. EC 3. TJ 4. SH 5. VC 6. AL 7. BA 8. SB 9. PB 10. KG 11. AS 12. RO …..the most vulnerable patients are still being defined….
Increasing incidence in < 50Y; 2nd in US Stable mortality in < 50Y; 17th in US
All-Site Cancer Burden
1st in U.S. Lung and Bronchus 1st Larynx 2nd Kidney and Pelvis 3rd Oral Cavity and Pharynx 3rd Colon and Rectum 7th Brain 7th Non-Hodgkin's Lymphoma 8th Melanoma 9th Cervix
1st Cancer All-Site Incidence 1st Cancer All-Site Death
Genetics Health Literacy,
Unhealthy Choices, and
High School Completion Rates in Appalachia 2011–2015
Chart1
82.9724231515
80.0853136043
82.9618521399
78.5813420363
82.7495122939
86.3759986279
86.4474372331
73.2922518503
73.7223117621
78.1777726205
69.0488497206
65.6266133389
67.8264079656
70.9268460262
84.6945831019
Percent High School Education
Percent Colorectal Cancer Screening
66.8471248947
57.6487405963
62.7227553559
56.0316787336
59.6405057897
67.3478788709
64.6271030126
54.456975444
55.7652363431
59.9636189463
55.719408543
50.7991215824
54.4162354969
55.5479513788
67.3136674459
SMOKE06-10
OBESE
EXERCISE
Pencent of adults who participated in physical activity or exercise during the last 30 days for year 2006-2010
MAMMOGRAM
Percent of women aged 40 years or older who report that they have had a mammogram within the past two years for year 2006-2010
PAPTEST
Percent of women who reported that they had a PAP Smear test within the last three years for year 2006-2010
COLONOSCOPY
Percent of adults aged 50 years or older who have ever had a sigmoidoscopy or colonoscopy for year 2006-2010
ModDat&Charts
RawData
Sheet3
Percent College Education
College Education vs Smoking Rate in 2006-2010
Percent Poverty
Smoking Rate
Poverty vs Smoking Rate in 2001-2005
Percent Poverty
Smoking Rate
High School Education vs Obesity Rate
College Education vs Obesity Rate
Poverty vs Obesity Rate
College Education vs Exercise Rate
Poverty vs Exercise Rate
College Education vs Mammography Rate
Poverty vs Mammography Rate
College Education vs Pap Smear Rate
Pap Smear Rate
Poverty vs Pap Smear Rate
Percent Poverty
High School Education vs Colorectal Cancer Screenng
Colorectal Cancer Screening Rate
College Education vs Colonoscopy Rate
Poverty vs Colonoscopy Rate
College Education vs Poverty Rate
Percent Smoker (2001-2005)
Obesity vs Exercise Rate
Percent Exercise
Percent Pap Smear
Percent Exercise
Percent Exercise
Percent Mammography
Mammography vs Colonoscopy Rate
Percent Pap Smear
Smoking (2006-2010) vs Pap Smear Rate
Pap Smear Rate
Smoking (2006-2010) vs Colonoscopy Rate
Smoking (2001-2005) vs Pap Smear Rate
Pap Smear Rate
Smoking (2001-2005) vs Colonoscopy Rate
Exercise vs Obesity Rate
High School Education vs Smoking Rate in 2001-2005
High School Education vs Obesity Rate
High School Education vs Exercise Rate
High School Education vs Mammography Rate
Percent Colorectal Cancer Screening
Mammography vs Pap Smear Rate
Percent Mammography
Mammography vs Colorectal Cancer Screening
Percent Mammography
Smoking (2001-2005) vs Exercise Rate
Poverty vs Mammography Rate
Percent Poverty
Poverty vs Colorectal Cancer Screening Rate
Percent Poverty
add2
add
30.40
26.42
30.28
73.54
76.23
81.84
62.22
1st in Tobacco Use; 28% Obesity 32% No Physical Activity 30%
50th in U.S. Cancer Deaths 50th Preventable Hospitalizations 49th Smoking 49th High Cholesterol 48th Cardiac Heart Disease/Death 47th High Blood Pressure 47th Personal Income 46th Obesity 44th Air Pollution 41st Low Birth Weight 40th Children in Poverty 40th Stroke 38th Adult Diabetes 36th Occupation Fatalities 32nd High School Graduation
Genetics Health Literacy,
Unhealthy Choices, and
Speed or Velocity
Oxford comma
The “Trials”….
Swedish Rectal Cancer Trial: RT improves OS + DFS + LR Dutch TME Trial: RT + TME > TME alone (to reduce local recurrence) German Rectal Cancer Trial: Pre-op RT > Post-op RT PROPSECT Trial ?
The “Papers”….
Local Recurrence = 6% After TME Cancer-Specific Survival = 70% @ 5Y After TME
Author Conclusion: 70-80% rectal cancer can be cured with TME alone
Complete TME
High ligation of IMA + splenic flexure mobilization Complete sigmoid colon resection Identify left ureter (pelvic brim) Sharp dissection of presacral plane anterior to the endopelvic fascia and outside the mesorectal membrane Protect the fascia propria Identify and avoid hypogastric plexus/nerves Sharp dissection posterior to anterior to avoid “coning-in” and positive radial margin Identify and avoid sacral nerves at pelvic brim and pelvic floor (posterior and lateral); nervi erigentes Continue posterior dissection to pelvic; divide Waldyers fascia at inferior border of mesorectum Sharp dissection of lateral attachments towards anterior Anterior dissection includes intact Denonvilliers fascia and peritoneal reflection Divide rectum at appropriate level and maintain bi-lobed, intact appearance of mesorectum by protecting
fascia propria
Not graded by pathologist Higher leak rate with incomplete mob splenic flexure Higher leak rate/stricture with using sigmoid colon as anastomosis
Local recurrence 80% v. 10%
Survival(+) CRM = < 1mm
(+) CRM equates to 12x risk for local recurrence o 9% v. 64%
(+) CRM is an independent determinant for survival (as is LN involvement) o 24% v. 74%
High frequency and wide variation in recurrence endorses “specialists”
MRI best selects patients for NACRT and best selects patients in which NACRT can be safely avoided with the same expectation of curative surgery
All patients with rectal cancer should undergo pre-operative MRI Widest range of survival is demonstrated in patients with T3 tumors (most common; 80%) MR LN evaluation is most sensitive/specific with irregular border and mixed signal intensity (not size) MR can assess distance from tumor edge to potential CRM; predictive of local recurrence MR can assess EMVI, an important independent prognostic factor associated with local recurrence
Proposed by Brown Typical
Important?....
What is the CoC Proposing?…. Develop of a Rectal Cancer Multi-Disciplinary Team (RC-MDT)
o Defined members o Meet at least 2x/month
Refine Clinical Services for Rectal Cancer Patients o Review pathology specimens to confirm diagnosis o Complete systemic and local tumor staging (CT/MRI) prior to tx o Standardize MRI reporting with critical elements o CEA o RC-MDT treatment plan discussed and summarized o Definitive treatment timing within 60 days of initial clinical visit o TME o Standardized operative and pathology reporting, including photo-document o RC-MDT outcomes discussed and summarized o Adjuvant therapy (50% of patients within 8 weeks of surgery)
o Quality Improvement
Inconsistent management and variable outcomes validates the need for standardized and centralized rectal cancer care in the US
Quality improvement is ever more important in the setting of increased incidence of rectal cancer in the young population less than 50 years of age
In addition to the significant benefits of NACRT and TME, the multi- disciplinary management of the rectal cancer patients will further improve clinical outcomes, survival, and research efforts
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management of rectal cancer - cecentral.com

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