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11/05/03

Colorectal Consensus Conference on the Treatment of Colorectal Cancer

5th Annual Western Canada
Colorectal Consensus Conference on the Treatment of Colorectal Cancer Consensus Statements 2003

Following review of the best available evidence, provincial breakout discussions and whole group debate, consensus was achieved on most items, as detailed below.

1. Adjuvant stage II colon cancer management:

a. Should we be treating all stage II colon cancer patients with adjuvant therapy?

The available evidence does not support the use of adjuvant chemotherapy in all Stage II patients.

b. If not are there sub-groups with Stage II colon cancer who should receive therapy?

An analysis was presented of pooled data from 7 randomized trials aimed at better understanding the benefits from adjuvant therapy. This analysis suggests that some patients with Stage II disease may have a higher risk of recurrence.

These patients should be considered for adjuvant therapy. Discussion should include estimated risk of recurrence, potential benefit of chemotherapy and possible toxicities of treatment, identifying comorbidities, which may influence each of these in the individual patient. Patients should be encouraged to make an "educated" and individualized decision.

The Mayo clinic is working on an Internet tool, which might be helpful for estimating risks and benefits.

The evidence supports the use of the following risk factors as prompts for a discussion about adjuvant therapy in Stage II patients:
? T4 status and or perforation1
? High grade1
? Less than 8 nodes identified in surgical specimen , , (ideally we should have ? 12 or more nodes)

No consensus was reached on the following factors:
? LVI
? Ploidy
? Obstruction
? Age

2. Adjuvant chemotherapy for bowel cancer
a. What adjuvant therapy should we be using in colon cancer?

DeGramont presented results from the MOSAIC trial at ASCO, which randomized stage II and III colon cancer patients to either FOLFOX4 or infusional 5FU/LV (LV5FU2). The overall disease free survival at 3yrs was 77.8% vs. 72.9% (p<0.01) for FOLFOX and LV5FU2 respectively. As yet there is no statistically significant survival difference.

Although this data was thought to be interesting, pending demonstration of a survival advantage, the standard for adjuvant therapy remains 5FU modulated with leucovorin.

3. Regional therapies in the management of liver metastases from colorectal cancer.
a. Surgical resection

Surgical resection is considered to be the gold standard for the management of resectable liver metastases from colorectal cancer. Although no randomized trials have been done, multiple series have reported 5-year survival rates of 20-40% , , , .

b. Radiofrequency ablation (RFA)

Radiofrequency ablation has been used in the management of liver metastases from colorectal cancer, but there is a paucity of long-term results and no direct, randomized comparisons to surgical resection. The group thought there is a role for this modality in management, although surgical extirpation remains the gold standard.

RFA would be appropriate to consider in inoperable patients with otherwise resectable liver metastases and in select cases as an adjunct to resection. There is no role for RFA in patients with more widespread metastases within, and especially beyond the liver.

c. Other therapies

There is no role for hepatic artery infusion or chemo-embolization outside of clinical trials.

d. Multidisciplinary team

Participants agreed that decision making in the management of patients with liver metastases should incorporate a multidisciplinary team, including, if available, a hepatobiliary surgeon.

4. Surveillance of colorectal cancer:
a. Is there a role for serial imaging in the surveillance of colorectal patients who have received curative therapy?

The group reviewed the recent data from the BMJ meta-analysis and the ASCO guideline . Although there is some indication from the meta-analysis that serial imaging (SI) may be helpful, this modality was not separated from CEA and the meta-analysis was unable to distinguish the separate contributions of each investigation. Two out of the five trials in the BMJ meta-analysis did not have CEA in the control arm. The ASCO guideline panel did not recommend SI.

It was felt that this evidence is not strong enough to make a recommendation for standard use of SI in the surveillance of colorectal patients following curative therapy.

Serial imaging should be performed in those with a pre-existing potentially malignant abnormality for follow-up purposes.

Serial imaging may also be considered in those with a previous curative resection of either lung or liver metastases, in whom the risk of recurrence approaches 75%.

References: Gill et al. Using a pooled analysis to improve the understanding of adjuvant therapy (AT) benefit for colon cancer. Proc ASCO; 22:253a 2003 (A1014). Prandi et al. Prognostic evaluation of stage B colon cancer patients is improved by an adequate lympadenectomy: results of a secondary analysis of a large scale adjuvant trial. Ann Surg 235:458-63; 2002.

Swanson et al. The prognosis of T3N0 colon cancer is dependent on the number of lymph nodes examined. Ann Surg Oncol. 10:655-71; 2003.

Le Voyer et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol. 21:2912-9; 2003.

DeGramont et al. Oxaliplatin/5-FU/LV in adjuvant colon cancer: Results of the international randomized mosaic trial. Proc ASCO; 22:253a 2003 (A1015).

Jamison et al. Hepatic resection for metastatic colorectal cancer results in cure for some patients. Arch Surg. 132:505-10; 1997.

Bachellier et al. Long-term survival following resection of colorectal hepatic metastases. Association Francaise de Chirurgie. Br J Surg 84:977-80; 1997.

Weber et al. Survival after resection of multiple hepatic colorectal metastases. Ann Surg Oncol. 7:643-50; 2000.

Choti et al. Trends in long-term survival following liver resection for hepatic colorectal metastases. Ann Surg 235:759-66; 2002.

Renehan et al. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomized trials. BMJ 324:1-8; 2002.

Benson et al. 2000 Update of American Society of Clinical Oncology Colorectal Cancer Surveillance Guidelines. J Clin Oncol 18:3586-3588; 2000. _


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