FORT LAUDERDALE, FlaMore patients are candidates for
sphincter-saving operations under the revised National Comprehensive
Cancer Network (NCCN) practice guidelines for rectal cancer.
For colon cancer, the updated guidelines eliminate routine computed
tomography (CT) scans for surveillance after treatment and remove
levamisole as a chemotherapeutic agent. Recent studies have also
strengthened the NCCN recommendation for the use of laparoscopic
surgery as an option for the treatment of polypoid cancer and
The revised NCCN practice guidelines for colorectal cancer were
presented by Paul F. Engstrom, MD, senior vice president for
populations science, Fox Chase Cancer Center, and professor of
medicine, Temple University; Krystyna Kiel, MD, assistant professor
of radiology, Robert H. Lurie Comprehensive Cancer Center of
Northwestern University; and John M. Skibber, MD, associate professor
of surgical oncology, M.D. Anderson Cancer Center. They spoke at the
NCCNs Fifth Annual Conference.
Rectal Cancer Guidelines
The NCCN guidelines for the primary treatment of rectal cancer allow
for a variety of options. Dr. Engstrom encouraged the medical team to
include the patient when choosing a treatment pathway. Its
truly a multidisciplinary discussion, with the patient involved in
the decision-making, he said.
The revised practice guidelines for rectal cancer now recommend that
clinicians consider lesions within 10 cm of the anal verge for local
excision if they are also less than 40% of the circumference of the
bowel and less than 4 cm in size. The lesions must also be mobile and nonfixed.
The guidelines recommend the use of endorectal ultrasound to
determine the extent of disease in the workup for rectal cancer. In
previous guidelines, endorectal ultrasound was a category
2 recommendation, meaning that it was judged somewhat
controversial by the committee.
Endorectal ultrasound, which is 70% to 90% accurate for T stage
disease, is at its best when determining whether disease is
confined to the bowel wall (T1 or T2 tumor) or whether it goes
through the bowel wall (T3), Dr. Skibber said.
The workup must also include pathology review. Pathology review
is important if local excision is being considered, because it should
not be considered for patients with poor differentiation, lymphatic
or vascular invasion, and poor prognostic signs Dr. Skibber said.
The majority of patients with fixed lesions or multivisceral
involvement should be treated with preoperative chemotherapy and
radiotherapy, Dr. Skibber said. The guidelines recommend continuous
or bolus fluorouracil (5-FU)/radiotherapy followed by resection.
Interest in preoperative radiation is growing, Dr. Kiel said, as it
induces a reduction in tumor size that results in an increase in
sphincter-saving operations and a decrease in small bowel morbidity.
Further trials will show whether downstaging affects survival and
whether the clinician can make postoperative decisions based upon
preoperative responses, Dr. Kiel said. I think we will see a
trend toward preoperative radiation now that we have endorectal
ultrasound to provide more accurate staging.
Patients with advanced metastatic disease can be managed
nonsurgically with stenting, laser photocoagulation, or 5-FU/radiotherapy,
Dr. Skibber said.
Recent trials have clearly shown that after primary treatment,
chemotherapy in addition to radiation improves survival.
Adjuvant therapy for rectal cancer is changing, Dr.
Engstrom said. The recommendations in the updated guidelines for
adjuvant therapy for T1-3, N1-2, or T3, N0 disease now carry a
category 1 designation, which means the recommendation is
based upon high-level evidence.
In these studies, it was the addition of chemotherapy to
radiotherapy that really had an impact on outcomes, Dr. Kiel
said. The North Central Cancer Treatment Groups (NCCTG) examined
radiotherapy alone vs radiotherapy with 5-FU. They found that with
the addition of 5-FU chemotherapy, local failure decreased and
survival increased. As long as its 5-FU based
chemotherapy, youre fine, Dr. Kiel said.
When patients undergo surgery for locally recurrent cancer, they
should be considered for 5-FU/radiotherapy if not given previously,
Dr. Skibber said.
The guidelines have also added a treatment pathway for patients who
have an isolated pelvic recurrence. The guidelines recommend
preoperative bolus or continuous IV 5-FU plus radiotherapy and
resection, if feasible. Dr. Skibber cited a study that found 21% to
58% 5-year survival for patients with local recurrence who underwent
Colon Cancer Guidelines
For the treatment of colon cancer, the NCCN guidelines now offer two
surgical options: colectomy with en bloc removal of regional lymph
nodes (sometimes referred to as hemicolectomy) or lapa-roscopic
surgery if a protocol is available. This is a stronger recommendation
than the previous guidelines, which designated laparoscopic surgery
as a category 2 recommendation.
To explain the recommendation, Dr. Skibber showed the results of 12
studies published between 1993 and 1998 that compared open surgical
techniques with laparoscopy. In studies that examined lymph node
harvest, laparoscopic surgery retrieved an average of 11.3 lymph
nodes vs 11.0 for open techniques.
The Clinical Outcomes of Surgical Therapy group is currently
conducting a trial that randomizes patients between open colectomy
and laparoscopic colectomy. This trial will look at port site
recurrence, a specific concern in laparo-scopic surgery, as well as
short-term survival, Dr. Skibber said. In the short term, at
least, there doesnt appear to be any obvious difference in
survival, he said. Our recommendation is that patients
who undergo laparoscopy be put in that clinical trial.
Recommendations for adjuvant therapy that included levamisole as one
option for patients with stage II (T4, N0) or stage III (any T, N1-2)
cancers have been changed. The use of 5-FU/levamisole fell by
the wayside based on newer data, Dr. Engstrom said. The NCCN
guidelines now recommend 5-FU/leucovorin with or without radiotherapy.
An issue that continues to be a concern to the committee is the
role of radiotherapy in colon cancer, Dr. Engstrom said.
Unfortunately, the prospective trial that was intended to evaluate
radiation therapy as an adjuvant for colon cancer was stopped because
of accrual problems, Dr. Kiel said.
However, retrospective studies suggest that while there is no
benefit for [Dukes] B2 lesions, for B3 lesions, radiotherapy
did improve local control and survival. These limited
retrospective studies suggest the use of radiation, but the physician
should evaluate each patient individually, she said.
In patients who present with liver metastases and undergo liver
resection for possible cure, its important to consider
postoperative treatment, Dr. Engstrom said. The guidelines list
several options. Right now, the committee feels that if
its appropriate, the patient should have intrahepatic artery
infusional therapy along with systemic therapy, Dr. Engstrom said.
Irinotecan in Combination
Irinotecan (Camptosar), for the first time, is being recommended for
use as part of a chemotherapy combination in patients with advanced
but potentially controllable disease. This option is based on a study
presented at the 1999 ASCO meeting.
Were not recommending 5-FU/leucovorin/irinotecan as
standard adjuvant therapy for your Dukes C colon cancer
patients, but in those patients with stage IV disease, there was
evidence from that report that patients had a longer disease-free
survival, although not necessarily longer overall survival, Dr.
Engstrom said. The data are not in on that yet.
The NCCN committee has removed the use of routine CT scans of the
abdomen for surveillance after primary treatment for colon cancer.
There are no data to show that doing prospective CT scans
enables a clinician to pick up an earlier, more operable lesion,
Dr. Engstrom said. The use of chest x-rays has also been eliminated.
The committee followed the American Society of Clinical Oncology
(ASCO) recommendations for the use of carcino-embryonic antigen (CEA)
screening: every 3 months for 2 years, then every 6 months for 3
years. The biggest problem is when you have a rising CEA but
your work-up is negative, Dr. Engstrom said.
A Negative Workup
The committee disagreed somewhat over how to handle a negative
workup. In that situation, the guidelines recommend repeating CT
scans every 3 months. At this time, the value of using newer imaging
techniques, such as PET (positron emission tomography), in the workup
is unproven, Dr. Skibber said. He had other reservations as well.
My concern as a surgeon is that they tend to be rather poor in
terms of anatomic location, he said.
When patients have evidence of resectable disease on conventional
imaging, surgical exploration can be considered, Dr. Skibber said. He
cited one study in which second-look operations were performed on 72
patients after recurrences were detected by CEA monitoring and
Only one patient had no detectable disease in the second-look
operation; 39 patients had all of their disease resected. The
resectable group had a significantly better 5-year survival than the
unre-sectable group (41.3% vs 5.2%).