Current Diagnostic and Treatment Algorithm for Colorectal Cancer
Colorectal cancer (CRC) is a major worldwide health problem owing to its high prevalence and mortality rates. If diagnosed early CRC is also one of the most curable types of cancer with cure rates as high as 90%. Evidence shows that the majority of CRCs could be prevented by applying existing knowledge of cancer prevention and by increasing the use of established screening tests.
Advances in the diagnosis and treatment of CRC have had a major impact on the management of this malignancy. Developments in screening, prevention, biomarker and genomic analysis, stem-cell research, personalized therapies, and chemotherapy have improved detection and mortality statistics.
The personalized care plan is the cornerstone of the successful treatment of cancers in Germany. Each patient receives an individualized treatment plan depending on their tumour type and its stage of progression. In this procedure, the identification of tumour histology and staging of the tumour is of fundamental importance for the successful planning of treatment options. This is a key factor in the German Health Advisors’ daily work.
For each patient with a tumour, we attempt to initially fulfill these two aspects in collaboration with our patients and local colleagues. We then discuss the case with the specialists, or, at the multidisciplinary tumour boards at our partner clinics in Germany. If any problems arise, we communicate this to our patients and try to find solutions. This usually happens when we get incorrect or incomplete pathology or radiology reports (discussed in details below).
Initial Staging and Risk Assessment
Colorectal cancer is treated based on the stage of cancer. Staging identifies the severity of the cancer (Stages I-IV). The various stages of a colorectal cancer are determined by the depth of invasion through the wall of the intestine; the involvement of the lymph nodes (the drainage nodules); and the spread to other organs (metastases).
The staging for overseas patients is usually not complete when they contact us for a second opinion and/or any subsequent treatment recommendations. The system employed by German Health Advisors, however, allows for the completion of this stage while the patients are in their homeland. It is not necessary to come to Germany for cancer staging. You will be informed if there are any obstacles in the staging process. For the staging of breast cancer, please bear in mind the following:
- Family history, physical examination, blood count and differential, tumor markers, liver and renal function tests (see the request form for German Health Advisors). This will usually be carried out by our local colleagues and documented in the form of a doctor’s letter.
- Endoscopy of large intestine. Your large intestine has probably already been examined with Endoscope by your endoscopist. Currently, all endoscopic equipment have video recording option. If your endoscopist took a video during the endoscopic procedure, please forward it to us. You can send your video data using German Health Advisors’ secure data transfer system
- Pathology of Colorectal cancer. Colorectal cancer is usually diagnosed by colonoscopy and your local doctor has already took biopsy and sent it to the pathologist. Please, keep this report to send it to us later on (when you get the results). In some cases, when our specialists are not satisfied with the quality of a pathology report, we will contact you with recommendations for further steps. You may have to send us the frozen/paraffin embedded tissue samples for further histologic examination at one of German Health Advisors’ partner laboratories in Germany.
- The following imaging tests might be required: X-rays, CT-Scan, MRI scan, PET scan, Ultrasound. Please, note that MRI plays an increasingly pivotal role in the clinical staging of rectal cancer in the baseline and post-treatment settings. MRI facilitates the accurate assessment of mesorectal fascia and the sphincter complex for surgical planning. Therefore, our experts give great value to the careful performed MRI scan of pelvis. You can send the DICOM files of CTscans using German Health Advisors’ secure data transfer system. Our experience shows that the quality of radiology images might not be good enough to correctly stage the cancer. In such cases, we will contact you to find a solution. It is of a great importance for us to have high quality radiology images from our local colleagues. This greatly assists in defining the diagnostic and treatment plan in timely fashion and helps to avoid unnecessary expenses.
Treatment of Colorectal Cancer
In our partner clinics in Germany, usually, a multidisciplinary team of gastroenterologists, surgeons, oncologists, radiologists, and pathologists discuss each case to define the best treatment strategy for the patients. If there is a need for other specialists (i.e. gynecologic or urologic surgeons, medical geneticist), they will be involved in the decision-making process. Below we list the main current treatment options:
- Surgery is the only curative modality for localized colon cancer (stage I-III). Surgical resection potentially provides the only curative option for patients with limited metastatic disease in the liver and/or lung (stage IV disease), but the proper use of elective colon resections in nonobstructed patients with stage IV disease is a source of continuing debate. The decisions in such cases are taken individually after discussion at the Tumor Boards and taking into account the patient´s consent.
- Superficially invasive, small rectal adenocarcinomas may be effectively managed with limited surgical procedures, such as local excision. However, the majority of patients have more deeply invasive tumors that require more extensive transabdominal surgery, such as low anterior resection (LAR) or abdominoperineal resection (APR).
- Tumors in the upper and middle rectum can usually be managed with low anterior resection, coloanal anastomosis, and preservation of the anal sphincter. Although the resulting anorectal function may be imperfect, the risk of postoperative sexual and urinary dysfunction may be diminished with preservation of the pelvic autonomic nerves. This is possible in most cases, particularly with the use of total mesorectal excision (TME). Management of adenocarcinomas in the lower rectum (tumors within 5 cm of the anal verge poses major challenges in terms of local tumor control and preservation of the anal sphincter. In such cases, the neoadjuvant (preoperative) radiotherapy can be effective.
- Chemotherapy for colon cancer is usually given after surgery if cancer has spread to lymph nodes. In this way, chemotherapy may help reduce the risk of cancer recurrence and death from cancer. Sometimes chemotherapy may be used before surgery as well, with the goal of shrinking the cancer before an operation. Chemotherapy before surgery is more common in rectal cancer than in colon cancer.
- Targeted drug therapy.Drugs that target specific malfunctions that allow cancer cells to grow are available to people with advanced colon cancer, including Bevacizumab (Avastin), Cetuximab (Erbitux), Panitumumab (Vectibix), Ramucirumab (Cyramza) Regorafenib (Stivarga), Ziv-aflibercept (Zaltrap). Targeted drugs can be given along with chemotherapy or alone. Targeted drugs are typically reserved for people with advanced colon cancer.
- Immunotherapy. Some patients with advanced colon cancer have a chance to benefit from immunotherapy with antibodies such as pembrolizumab (Keytruda) and nivolumab (Opdivo). Whether colon cancer has the chance to respond to these immunotherapies can be determined by a specific test of the tumor tissue.
- Proton beam therapy. One of the newest radiation therapies is proton beam therapy can benefit children, young adults, and those with cancers located close to critical organs and body structures.
Follow-Up After Treatment of Colorectal Cancer
Majority of recurrences will occur within 2 years of surgery and 90% by 5 years. Therefore, follow up controls are essential. Follow-up should be tailored to the individual patient and the stage of the disease. Partner clinics of German Health Advisors schedule the follow-up controls usually as follows:
- Every 6 months for 2 years after the initial treatment: physical examination, blood count and differential, liver and renal function tests, tumor markers, ultrasonography and/or computed tomography (CT) scan of the abdomen.
- A minimum of two CTs of the chest, abdomen, and pelvis in the first 3 years and regular serum CEA tests (at least every 6 months in the first 3 years)
- A completion colonoscopy within the first year if not done at the time of diagnostic work-up.
- History and colonoscopy with resection of colonic polyps every 5 years up to the age of 75 years
The patients, who got their treatments in Germany, usually do not need to come for the follow-up controls to Germany. German Health Advisors will provide you with follow-up care through its Telemedicine platform.
Keywords: colorectal cancer, rectal cancer, cytoreductive surgery, HIPEC, targeted therapy,
- Rectal Cancer: ESMO Clinical Practice Guidelines. Ann Oncol (2017) 28 (suppl 4): iv22–iv40
- Metastatic Colorectal Cancer: ESMO Clinical Practice Guidelines. Ann Oncol (2014) 25 (suppl 3): iii1-iii9