Colorectal Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative evaluation for extent of disease, and role of the surgeon in diagnosis and treatment. Separate sections on adjuvant therapy, follow-up programs, or management of recurrent cancer have been intentionally omitted. Where appropriate, perioperative adjuvant combined-modality therapy is discussed under surgical management. Each guideline is presented in minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aim of the Society, the extensive development cycle necessary to produce evidence-based practice guidelines did not apply. We used the broad clinical experience residing in the membership of the Society, under the direction of Alfred M. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer Center, to produce guidelines that were not likely to result in significant controversy.

Following each guideline is a brief narrative highlighting and expanding on selected sections of the guideline document, with a few relevant references. The current staging system for the site and approximate 5-year survival data are also included.

The Society does not suggest that these guidelines replace good medical judgment. That always comes first. We do believe that the family physician, as well as the health maintenance organization director, will appreciate the provision of these guidelines as a reference for better patient care.

Society of Surgical Oncology Practice Guidelines: Colorectal Cancer

Symptoms and Signs

Early-stage disease

• Change in frequency, consistency, and shape of bowel movements
• Bleeding: overt or occult

Advanced-stage disease

• For colon carcinoma:
1. Colicky abdominal pain
2. Abdominal distention, nausea, vomiting
3. Obstruction/perforation
4. Palpable or visible mass
5. Weight loss
6. Anemia
• For rectal carcinoma:
1. Rectal bleeding, mucus discharge
2. Tenesmus
3. Rectal pain
4. Weight loss
5. Constipation
6. Diarrhea
7. Anemia

Evaluation of the Symptomatic Patient

Work-up

• If the patient presents with one episode of bright red blood on toilet paper, a rectal examination, proctosigmoidoscopy, and reassurance are all that are needed.
• If the patient has had more than one episode of bleeding, is older than age 30, has a family history of colon cancer, has a diagnosis of inflammatory bowel disease, has other gastrointestinal symp- toms or a change in bowel habits, or is anemic, the following examinations should be performed in sequence until a diagnosis is reached:
1. Rectal examination
2. Proctosigmoidoscopy and/or flexible sigmoidoscopy with biopsy
3. Colonoscopy with biopsy (preferred) or double-contrast barium enema
• If the patient presents with occult bleeding or overt bleeding mixed with stools; a change in the frequency, consistency, and shape of bowel movements; any of the symptoms of advanced- stage disease, with the exception of obstruction or perforation, the following examinations should be performed in sequence until a diagnosis is reached:
1. Rectal examination
2. Proctosigmoidoscopy and/or flexible sigmoidoscopy with biopsy
3. Colonoscopy with biopsy (preferred) or double-contrast barium enema
• When the patient presents with intestinal obstruction:
1. Examine for peritoneal signs.
2. An abdominal x-ray (flat and upright) will usually reveal the site of the obstruction.
3. A water-soluble contrast enema will clarify the nature of the obstructing lesion.
• The occurrence of free intestinal perforation is usually confirmed by free air under the diaphragm, best demonstrated in an upright chest, upright abdominal, or a left decubitus abdominal x-ray.

Appropriate timeliness of surgical referral

• A rectal examination with stool occult blood must be part of the initial evaluation.
• Proctosigmoidoscopy and flexible sigmoidoscopy are office-based procedures that require minimal preparation, and one or both procedures can be performed at the time of the original visit.
• A colonoscopy or double-contrast barium enema requires a complete mechanical bowel preparation. It should be performed at the patient's earliest convenience.
• If a barium enema is obtained, it must be complemented by sigmoidoscopy or at least rigid proctoscopy.

Preoperative Evaluation for Extent of Disease

Physical examination

Chest x-ray

CBC and chemistry profile

• The value of carcinoembryonic antigen is unproven.

Abdominal CT scan or liver ultrasound (both unproven)

Rectal cancer

• Pelvic CT in selected patients
• Endorectal ultrasound if treatment will be altered by better definition of the T-stage.

Colonoscopy or double-contrast barium enema

• To evaluate the rest of the colon