Transcript 科學展覽專案 - Introduction

Evidence-base approach in the
perioperative management and
follow-up strategy for colon cancer
Hester YS Cheung
Department of surgery
Pamela Youde Nethersole Eastern Hospital
Common scenario




M/54
No family history of carcinoma of colon
Presented with dizziness
P/E Pale looking, left upper quadrant mass
Blood test
Hb 4g/dL
Liver function test normal
Carcinoma of transverse colon
Pre-operative assessment
CT scan
Chest
X-ray
CEA
Carcinoma of colon
Prophylactic
Antibiotic
Bowel
Preparation
Blood
Transfusion
Carcinoembryonic antigen (CEA)
 Elevated in a variety of conditions
 Proximal gastrointestinal cancer, lung and breast cancers,
smoking etc.
 Proven useful in individuals diagnosed with
colorectal cancer
Recommended before resection of colorectal cancer
Level of evidence Class II A
Graham RA, Ann Surg 1998
Wiratkapun S. Dis Colon Rectum 2001
Pre-operative CEA
 Returning to normal after operation is associated
with complete tumor resection
 Persistently elevated values indicate the presence of
visible or occult residual disease
Lavin PT. Cancer 1981
Steele G. Ann Surg 1982
Pre-operative CEA
 An independent prognostic indicator of poor
outcome
 Predictive of poor survival
 shorter disease-free survival
Harrison LE. J Am Coll Surg 1997
 Metastases in 37% patients with elevated preoperative CEA vs.
7.5% in patients with normal CEA
Wiratkapun S. Dis Colon Rectum 2001
Chest x-rays
 Overall pre-operative assessment
 Evaluate lungs for metastatic disease
Low cost
Low yield for
metastatic disease
Routine pre-operative chest x-ray is acceptable
Level of evidence Class III C
The Standards Practice Task Force
Dis Colon Rectum 2004
Computed tomography (CT scan)
 Evaluate local extension of tumor, regional
lymphadenopathy and the presence of hepatic
metastases
 Accuracy of CT scan
Sensitivity
Local extension
Metastatic lymphadenopathy
Liver metastases >1cm
Limited data
19-67%
90-95%
McAndrew MR. Am Surg 1999
Hundt W. Eur Radiol 1999
Ward J. Radiology 1999
Computed tomography (CT scan)
 No impact on the decision to operate
 Not affect the operative approach
 Information readily obtained at the time of
surgery
Routine pre-operative CT scan is optional
Level of evidence Class II B
The Standards Practice Task Force
Dis Colon Rectum 2004
Computed tomography (CT scan)
Used in selected patients for pre-operative planning
 Suspicion of invasion of adjacent organs
 Palpable mass
 Unexplained biochemical abnormalities
 Nearly obstructing cancer
The Standards Practice Task Force
Dis Colon Rectum 2004
Peri-operative blood transfusion
Is it harmful?
 Established immunosuppressive effect
 Higher incidence of infection
 Wound infection
 Intra-abdominal sepsis
 Pneumonia
 Greater risk of cancer recurrence
 Decreased survival
Jensen LS. Br J Surg 1992
Van Twuyver E. N Eng J med 1991
Perioperative blood transfusion
Randomized controlled trials
STUDIES
Patients
5-year
Survival
Disease-free
Survival
Van de Watering LM
2001
697
↓
SAKK
1997
450
↓
↓
Cancer
Recurrence
Local
Recurrence
Post-operative
Infection
↑
↑
Hobiers JG
1997
697
Busch OR
1994
420
Heiss MM
1994
120
Dose response
RR 1.6 (1-3U)
RR 3.6 (>3U)
↑
↓
↑
Perioperative blood transfusion
Meta-analyses
STUDIES
Papers
Amato AC
Dis Colon Rectum 1998
32
McAlister FA
Br J Surg 1998
8
Vamvakas EC
Transfusion 1995
60
Fernadez L
Rev Esp Enferm Dig 1992
Survival
Cancer
Recurrence
↑
Odds ratio 1.68
No
difference
Poor
Prognostic
Factor
Post-operative
Infection
√
No
difference
Discrepancies explained by study design and confounding factors
No
difference
Perioperative blood transfusion
Meta-analyses
 Strongly questioned whether there is a true causal effect
 Factors in patients requiring transfusion might be the
cause for increased recurrence
 Extent of resection
 Location of tumor
 Experience of surgeon
The Standards Practice Task Force
Dis Colon Rectum 2004
Perioperative blood transfusion
Red Blood Cell Administration Practice Guideline Development Task
Force of the College of American Pathologists
Peri-operative transfusion
Asymptomatic anaemia and haemoglobin ≤ 7 g/dL
may need to be transfused if:
A. Scheduled surgery is expected to produce significant blood loss
B. Risks associated with general anaesthesia are high
Simon TL. Arch Pathol Lab Med 1998
Pre-operative blood transfusion
Blood transfusion should be based on physiological need
e.g. starting haemoglobin, physiological status and extent of intra-operative blood loss
Level of evidence Class III C
Vignali A. Eur J Surg 1995
Houbiers JG. Lancet 1994
The Standards Practice Task Force Dis
Colon Rectum 2004
Mechanical bowel preparation
 No definite benefit for pre-operative mechanical
preparation of bowel
 9 RCTs showed no decrease in
 Infection rate
 Leakage rate
 Mortality rate
Year
Anastomostic Leakage
Wound Infection
Prep
No Prep
Prep
No Prep
Brownson et al
1992
8/67
1/67
5/86
7/93
Burke et al
1994
3/82
4/87
4/82
3/87
Santos et al
1994
7/72
4/77
17/72
9/77
Fillmann et al
1995
2/30
1/30
1/30
2/30
Miettinen et al
2000
5/138
3/129
5/138
3/129
Tabusso et al
2002
5/24
0/23
2/24
0/23
Zomera et al
2003
7/187
4/193
12/187
11/193
Bucher et al
2003
4/47
1/46
4/47
1/46
Fa-Si-Oen et al
2003
7/125
6/125
9/125
7/125
Mechanical bowel preparation
 Ease of handling prepared colon
 Proven safety for colon cleansing
 Low cost
Mechanical bowel preparation is nearly universally used
in elective surgery
Level of evidence Class II A
The Standards Practice Task Force
Dis Colon Rectum 2004
Prophylactic antibiotics
 Proven effectiveness in decreasing
 Infective complications
 Mortality
 Cost of hospitalization after colonic resection
Baum ML. N Eng J Med 1981
 Parenteral antibiotic regimen
 Given before the start of operation
Stone HH. Ann Surg 1976, Polk HC. Surgery 1969
 Need not be continued longer than 24 hours post-operatively
Stone HH. Ann Surg 1979
 Single dose of Cefotaxime and Metronidazole is as effective as
3 doses
Rowe-Jones DC. BMJ 1990
Prophylactic antibiotics
Prophylactic antibiotics are recommended for
patients undergoing colon resection
Level of evidence Class I A
The Standards Practice Task Force
Dis Colon Rectum 2004
Post-operative surveillance
Laboratory
Tests
Imaging
Carcinoma of colon
Follow-up
Colonoscopy
Intensive follow-up
Frequency
Duration
 85% recurrences diagnosed within the first 3 years after
resection of primary tumor
Sargent DJ. J Clin Oncol 2004
American Society of Clinical Oncology Practice Guideline
Follow-up strategy
First 3 years
4th and 5th year
After 5th year
Every 3-6 months
Every 6 months
Discretion of surgeon
Desch et al. J Clin Oncol 2005
Post-operative follow-up
 Intensive follow-up
 3 high-quality meta-analyses
 20-30% reduction in risk of death from all causes for patients
who received more intensive follow-up
Intensive follow-up
 Earlier documentation of recurrences
 Increase in operability of recurrent disease
Desch et al. J Clin Oncol 2005
 Patient health-related quality of life (HRQL)
 Limited data
 No difference in cohort studies
Stiggelbout AM. Br J Cancer 1997
Kjeldsen BJ. Scand J Gastroenterol 1999
Laboratory tests
 Haemoglobin
 1% recurrence
 No survival benefit
 Liver function test
Kjelden BJ. Br J Surg 1997
Goldberg RM. Ann Intern med 1998
Peethambaram P. Oncology 1997
 < 10% recurrence
 Resectable recurrence: 2-3 patients per 1000 followed-up
 Faecal occult blood test
Graffner H. J Surg Oncol 1985
Jahn H. Dis Colon Rectum 1992
 10-30% recurrence/metachronous lesions
 Resectable recurrence: 0-9 per 1000 patients followed-up
Not recommended for routine blood test
Level of evidence Class II A
Laboratory tests
 Carcinoembryonic antigen (CEA)
Pros
 Positive predictive value of 70-80% for recurrent disease if level >
5ng/ml
McCall JL. Dis Colon Rectum 1994, Moertel CG. JAMA 1993
 First indicator of recurrence
 First abnormal test in 38-66% recurrences
Ohlsson B. Dis Colon Rectum 1995
 Lead-time 4-6 months
McCall JL. Dis Colon Rectum 1994
Cons
 Survival advantage not demonstrated
 False positive rate 7-16%
Used as a part of follow-up
Level of evidence Class II B
The Standards Practice Task Force
Dis Colon Rectum 2004
Laboratory tests
 Carcinoembryonic antigen (CEA)
American Society of Clinical Oncology Practice Guideline
Post-operative CEA testing
Every 3 months in patients with
Stage II/III disease for at least 3 years
Candidate for surgery or systemic therapy
Imaging
 Computed tomography (CT scan)
 2 RCTs addressed the impact of CT scan on
survival
STUDIES
Patients
Asymptomatic
Hepatic
Metastases
Hepatic
Resection
Rate
Survival
Chau I
J Clin Oncol 2004
530
No difference
↑
↑
Schoemaker D
Gastroenterology 1998
325
↑
60%
No difference
No difference
 25% lower mortality
Desch et al. J Clin Oncol 2005
Imaging
American Society of Clinical Oncology Practice Guideline
CT in colon cancer surveillance (2005)
Annual CT for 3 years after primary therapy
For patients with
Higher risk of recurrence
Candidates for curative-intent surgery
Colonoscopy
 Identify metachronous cancers and polyps
American Society of Clinical Oncology Practice Guideline
Endoscopic surveillance
Following surgery
High-risk genetic syndromes
At 3 years
if normal, then every 5 years
In conclusions
Pre-operative




CEA is recommended
CXR
CT abdomen is optional
Mechanical bowel
preparation is still a common
practice
 Prophylactic antibiotics is
recommended
 Blood transfusion based on
physiological need
Post -operative




high risk patients &
candidates for curative
surgery or systemic
treatment
Intensive follow up
CEA
Annual CT scan
Surveillance colonoscopy at
3 years and then 5 years
Thank you
Level of evidence