Colorectal cancer - suspected

Transcription

1 Background information Information resources for patients and carers Updates to this care map Anticipate all investigations to be complete within 31 days to enable treatment planning Note: this care map is currently under local review within Derbyshire History Colorectal cancer - clinical presentation Examination, including rectal examination Treatment to start within 31 days of decision to treat being made (62 days total) Full blood count, coeliac screen if anaemic (tissue transglutaminase test) Consider differential diagnoses RED FLAG! Bleeding, obstruction, perforation, or peritonitis Consider urgent referral - 2 week wait Low risk features Follow-up and review Refer as emergency for investigations and specialist management Admit Go to colorectal cancer - emergency R Refer urgently - 2 week wait Refer urgently (2 week wait) for investigation and specialist assessment Investigations or colonoscopy R RED FLAG! Symptoms change or develop Clinical assessment Consider routine referral to a colorectal specialist if symptoms persist Routine referral to colorectal specialist R Go to colorectal cancer - management Watch and wait Page 1 of 9

2 1 Background information Scope: presentation, investigation, staging, and management (including surgical and adjuvant chemo- and radiotherapy) of colorectal cancer, in adults and the elderly primary and secondary care settings Out of scope: screening and detection end of life care (see 'End of life care in adults' care map) management of Familial Adenomatous Polyposis (FAP), Hereditary Nonpolyposis Colon Cancer (HNPCC) previous cancer anal cancer Definition: most cases of colorectal cancer evolve from polyps (outgrowths of the bowel wall) a malignant polyp is defined as cancer if it invades the muscularis mucosae and penetrates the submucosa Incidence and prevalence: in the UK: colorectal cancer is the third most common cause of cancer related deaths [1] approximately 100 new cases of colorectal cancer are diagnosed each day [1] 5 year survival rates are approximately 45% [2] 50-60% of patients diagnosed with colorectal cancer will develop metastases [3] Preventative factors: pharmacological interventions: studies have indicated a protective role of the following drugs in the development of colorectal cancer: non-steroidal anti-inflammatory drugs (NSAIDs), eg aspirin cyclo-oxygenase-2 inhibitors NSAIDs and cyclo-oxygenase-2 inhibitors are associated with cardiovascular events and gastrointestinal (GI) harm long-term follow-up studies are required to establish the effects of less frequent doses and lower doses of such interventions hormone replacement therapy (HRT) benefits should be balanced against the possible risk of breast cancer, stroke, and pulmonary embolism (PE) Risk factors: increasing age hereditary disease high intake of processed meat and red meat low intake of vegetables smoking obesity (especially men) low levels of physical activity alcohol consumption male population history of inflammatory bowel disease (IBD) References: [2] National Institute for Health and Clinical Excellence (NICE). Improving outcomes in colorectal cancers. London: NICE; [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version Fort Washington, PA: NCCN; Page 2 of 9

3 [5] Dai Z, Xu YC, Nui L. Obesity and colorectal cancer: a meta-analysis of cohort studies. World J Gastroenterol 2007; 21: [6] Flossmann E, Rothwell PM. Effects of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies. Lancet 2007; 369: [7] Larsson SC, Wolk A. Meat consumption and risk of colorectal cancer: a meta-analysis of prospective studies. AM J Clin Nutr 2007; 86: [8] Nguyen SP, Bent S, Chen YH et al. Gender as a risk factor for advanced neoplasia and colorectal cancer: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2009; 7: [9] Rostom A, Dube C, Lewin G et al. Nonsteroidal anti-inflammatory drugs and cylo-oxygenase-2 inhibitors for primary prevention of colorectal cancer: a systematic review prepared for the US prevention services task force. Ann Intern Med 2007; 146: [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; Information resources for patients and carers The following resources have been produced by organisations certified by The Information Standard: 'Bowel cancer' (URL) from Bupa at 'Bowel cancer (colorectal cancer)' (URL) from Cancer Research UK at 'Colon cancer' (URL) from Macmillan Cancer Support at 'Colorectal cancer' (URL) from Datapharm at 'Colon cancer' (URL) from Datapharm at 'Rectal cancer' (URL) from Datapharm at 'Hereditary non-polyposis colorectal cancer (HNPCC)' (URL) from Macmillan Cancer Support at 'Treating rectal cancer' (URL) from Macmillan Cancer Support at 'Colorectal (bowel) cancer' (PDF) from Patient UK at 'Healthcare services for bowel (colorectal) cancer: Understanding NICE guidelines information for the public' (PDF) from National Institute for Health and Clinical Excellence (NICE) at Information for carers and people with disabilities is available at: 'Caring for someone' (URL) from Directgov at 'Disabled people' (URL) from Directgov at Explanations of clinical laboratory tests used in diagnosis and treatment are available at Understanding Your Tests (URL) from Lab Tests Online-UK at NB: This information appears on each page of this care map. 3 Updates to this care map Date of publication: 17-June-2011 This care map was created in line with the following references: [3] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer. Version Fort Washington, PA: NCCN; [5] Dai Z, Xu YC, Niu L. Obesity and colorectal cancer risk: a meta-analysis of cohort studies. World J Gastroenterol 2007; 13: Page 3 of 9

4 [6] Flossmann E, Rothwell PM. Effect of aspirin on long-term risk of colorectal cancer: consistent evidence from randomised and observational studies. Lancet 2007; 369: [7] Larsson SC, Wolk A. Meat consumption and risk of colorectal cancer: a meta-analysis of prospective studies. Int J Cancer 2006; 119: [8] Nguyen SP, Bent S, Chen YH et al. Gender as a risk factor for advanced neoplasia and colorectal cancer: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2009; 7: [9] Rostom A, Dube C, Lewin G et al. Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors for primary prevention of colorectal cancer: a systematic review prepared for the U.S. Preventive Services Task Force. Ann Intern Med 2007; 146: [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; [11] Ballinger A, Clark S, Wexner S. Colorectal cancer. BMJ Best Practice; [12] Map of Medicine (MoM). London: MoM; [13] Contributors to the international care map, invited by Map of Medicine (MoM) [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version Fort Washington, PA: NCCN; [15] Abraham NS, Byrne CM, Young JM et al et al. Meta-analysis of non-randomized comparative studies of the short-term outcomes of laparoscopic resection for colorectal cancer. ANZ J Surg 2007; 77: [16] Zhang C, Chen Y, Xue H. Diagnostic value of FDG-PET in recurrent colorectal carcinoma: a meta-analysis. Int J Cancer 2009; 124: [17] Cao Y, Tan A, Gao F et al. A meta-analysis of randomized controlled trials comparing chemotherapy plus bevacizumab with chemotherapy alone in metastatic colorectal cancer. Int J Colorectal Dis 2009; 24: [18] Wagner AD, Arnold D, Grothey AA. Anti-angiogenic therapies for metastatic colorectal cancer. Cochrane Database Syst Rev 2009; 3: CD [19] Tilney HS, Lovegrove R, Purkayastha S et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 2007; 21: [20] The Royal College of Physicians (RCP), the Academy of Medical Royal Colleges (AMRC). A clinician s guide to record standards Part 1: Why standardise the structure and content of medical records? London: Digital and Health Information Policy Directorate; [21] The Royal College of Physicians (RCP), the Academy of Medical Royal Colleges (AMRC). A clinician s guide to record standards Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital. London: Digital and Health Information Policy Directorate; [22] Bridgelal Ram M, Carpenter I, Williams J. Reducing risk and improving quality of patient care in hospital: the contribution of standardized medical records. Clin Risk 2009; 15: [23] Derbyshire colorectal pathway group; NB: This information appears on each page of this care map. 5 Note: this care map is currently under local review within Derbyshire For further information, please contact Anne Hayes, NHS Derbyshire County Public Health Specialist 6 Colorectal cancer - clinical presentation Most patients with colorectal cancer will present with: rectal bleeding (with or separate from the faeces) changes in bowel habit, such as: increased frequency of defaecation looser stools non-specific symptoms, ie tiredness due to undetected blood loss abdominal pain Other presenting complaints include: feeling of bloatedness Page 4 of 9

5 weight loss malaise or mucus in the faeces Patients with cancers proximal to the sigmoid colon may present with: intestinal obstruction iron deficiency anaemia (haemoglobin less than 10g/100mL in postmenopausal women) abdominal mass This information was drawn from the following references: [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; History Ask patient about history of: risk factors, eg inflammatory bowel disease (IBD) rectal bleeding changes in bowel habit rectal mass abdominal mass positive family history of colorectal cancer This information was drawn from the following reference: [11] Ballinger A, Clark S, Wexner S. Colorectal cancer. BMJ Best Practice; 2009 [accessed Jan-2009]. 9 Examination, including rectal examination Examination should include: assessment of the presence of a palpable rectal mass (if there is uncertainty regarding the mass, the patient should be reexamined after treatment with laxatives) digital rectal examination (DRE), if the patient: is age 40 years or older has persistent symptoms has symptoms suspicious of colorectal cancer palpation for abdominal mass vaginal examination Assess patient for: weight loss and anorexia signs of cachexia anaemia abdominal distension palpable lymph nodes signs of obstruction or acute abdomen This information was drawn from the following references: Page 5 of 9

6 [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; [11] Ballinger A, Clark S, Wexner S. Colorectal cancer. BMJ Best Practice; 2009 [accessed Jan-2009]. [12] Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; [13] Contributors invited by the Map of Medicine; Consider differential diagnoses Differential diagnoses include: inflammatory bowel disease (IBD): Crohn's disease (see 'Crohn's disease' care map) ulcerative colitis (UC; 'Ulcerative colitis' care map) irritable bowel syndrome (IBS; must not have bleeding; see 'Irritable bowel syndrome' care map) haemorrhoids (see 'Haemorrhoids' care map) benign polyps non-pathological constipation or faecal incontinence infective colitis coeliac disease (see 'Coeliac disease' care map) medication related, eg erythromycin use anal cancer This information was drawn from the following references: [12] Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; RED FLAG! Bleeding, obstruction, perforation, or peritonitis An emergency referral should be made if there is evidence of [1]: obstruction: distension vomiting high pitched bowel sounds evidence of acute bleeding evidence of perforation peritonitis An urgent referral should be made in [1]: patients age 40 years or older with rectal bleeding and a change in bowel habits persisting for 6 weeks or more patients age 60 years or older with rectal bleeding persisting for 6 weeks or more patients age 60 years or older with a change in bowel habits with or without rectal bleeding persisting for 6 weeks or more patients with a right lower abdominal mass [2] suggestive of large bowel involvement patients with a palpable intraluminal rectal mass [2] men with unexplained iron deficiency anaemia and a haemoglobin of 11g per 100mL or less non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 11g per 100mL or less [2] patients with faecal incontinence and passing mucus References: Page 6 of 9

7 13 Low risk features Features indicating a low risk of colorectal cancer include: rectal bleeding with anal symptoms [1,2] rectal bleeding with an external visible cause, such as [1]: prolapsed piles rectal prolapse anal fissures change in bowel habit (decreased frequency of defaecation and harder stools) for less than 6 weeks [1,2] abdominal pain without iron deficiency anaemia or palpable abdominal mass [1] abdominal pain without evidence of intestinal obstruction [2] GP or practice nurse should discuss how to reduce the risk of developing colorectal cancer by offering lifestyle guidance, such as [1]: encouraging the patient to give up smoking encouraging regular exercise encouraging weight loss dietary advice (eg reducing intake of processed meat and increasing intake of vegetables) References: 14 Consider urgent referral - 2 week wait Consider urgent referral (2 week wait) for patients with persistent low-risk features if there are worrying factors, such as [1]: positive family history a positive faecal occult blood (FOB) test Reference: 15 Follow-up and review Advise should be given on appropriate diet and maintaining adequate fluid intake [13]. Reference: [13] Contributors to the international care map, invited by Map of Medicine (MoM); Refer urgently - 2 week wait An urgent referral (2 week wait) should be made for [1]: patients age 40 years or older with rectal bleeding and a change in bowel habits persisting for 6 weeks or more patients age 60 years or older with rectal bleeding persisting for 6 weeks or more Page 7 of 9

8 patients age 60 years or older with a change in bowel habits with or without rectal bleeding persisting for 6 weeks or more patients with a right lower abdominal mass [2] suggestive of large bowel involvement patients with a palpable intraluminal rectal mass [2] men with unexplained iron deficiency anaemia and a haemoglobin of 11g per 100mL or less non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 11g per 100mL or less [2] patients with faecal incontinence and passing mucus References: 19 Consider routine referral to a colorectal specialist if symptoms persist Review patient and if symptoms persist, consider non-urgent referral for further assessment [13]. Reference: [13] Contributors to the international care map, invited by Map of Medicine (MoM); Admit Emergency presentation includes evidence of [1]: obstruction: distension vomiting high pitched bowel sounds on auscultation evidence of acute bleeding evidence of perforation peritonitis Reference: 24 Investigations or colonoscopy Consider the following investigations for suspected colorectal cancer (type of examination may vary depending on availability and expertise): flexible or rigid sigmoidoscopy and colonoscopy [4,10]: permits biopsy and histopathological assessment [1,2] polyps can be removed [1,2,10] rigid sigmoidoscopy can be used to assess the distance of the tumour from the anal verge [14] CT colonography [1,2,4,10]: should replace barium enema, if an experienced radiologist and facilities are available [2] if abnormal findings are revealed the patient may require colonoscopy [2] CT pneumocolon [10]: can be used to stage malignant disease useful in frail, elderly patients Page 8 of 9

9 high quality double contrast barium enema [2,4]: is a less sensitive diagnostic tool [2] does not permit biopsy or polyp removal [2] confirm iron deficiency anaemia by: hypochromic, microcytic anaemia [23] low iron saturation [4] magnetic resonance (MR) colonography experimental approach that is currently being evaluated [4] Confirm colon cancer by histology, unless [1]: lesion has been detected by: high quality double contrast barium enema; or CT colonography and patient is iron-deficient and colonoscopy is not possible [23] Confirm histology if [1]: rectal cancer surgery may result in a permanent stoma or ultra-low anterior resection preoperative radiotherapy is being considered [14] References: [10] Scottish Intercollegiate Guidelines Network (SIGN). Management of colorectal cancer A national clinical guideline. SIGN publication no. 67. Edinburgh: SIGN; [14] National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Rectal cancer. Version Fort Washington, PA: NCCN; [23] Derbyshire colorectal pathway group; Watch and wait Adopt a watch and wait approach if [2]: cancer and significant polyps are not detected by sigmoidoscopy; and there are no signs of right-sided disease Decisions on performing further investigations should be made by the specialist and patient [2]. Reference: Page 9 of 9

10 Colorectal cancer Oncology / Oncology Provenance certificate Overview Editorial methodology Overview This document describes the provenance of the Derbyshire Health Community Colorectal cancer care map. This care map has been localised by Derbyshire Health Community, under the lead of Anne Hayes, NHS Derbyshire County Public Health Specialist. The care map has been reviewed by Derbyshire stakeholders and has been approved by relevant members of the Health Community-wide Clinical Effectiveness and Guideline Group (CEGG). Published: 17 th June 2011 Next scheduled update: 31 st December 2011 Editorial methodology The Map of Medicine Editorial Team have undertaken the localisation editing of the care map. The text is based on the Map of Medicine international care map, which was created in line with the Map of Medicine editorial methodology.