panel 2: optimizing integrated colorectal cancer treatment planning and patient support, dr. michael...
DESCRIPTION
Panel #2 from the 2013 Regional Oncology Conference.TRANSCRIPT
![Page 1: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/1.jpg)
Panel 2:Optimizing Integrated
Colorectal Cancer Treatment Planning and Patient Support
Panelists:
Michael Loreto MD FRCP(C)
Kathleen Callaghan BSC RN ET
Julie Whitten BSc RD
Traci Franklin MSW RSW
![Page 2: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/2.jpg)
Mr. TW: Case History 2
• Colonoscopy reveals a rectal cancer• A rectal MRI for pre-operative staging
reveals Stage III rectal cancer• Pre-operative chemo-radiotherapy, then a
total mesorectal excision followed by post-operative chemotherapy
• Mr. TW has a temporary colostomy, has bowel habit changes and feels depressed
![Page 3: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/3.jpg)
Role of MRI in Staging and Treatment Decisions for Patients
with Rectal Cancer
Dr. Michael Loreto
Associate Radiologist, Health Sciences North
![Page 4: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/4.jpg)
Which patients benefit from a pre-operative MRI?
ALL patients with rectal cancer should have a pre-operative MRI as hi-resolution MRI has become the diagnostic standard for the accurate LOCAL STAGING of rectal cancer.
![Page 5: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/5.jpg)
What information does a pre-operative MRI provide?
• Local staging– primary tumour (T-stage)– regional lymph nodes (N)
![Page 6: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/6.jpg)
Assessment of the Primary Tumour – T-stage
Modified TNM Staging (AJCC)
![Page 7: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/7.jpg)
StageT2
Hi-res T2-weighted axial (short-axis) image Kaur H et al. RadioGraphics (2012)
![Page 8: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/8.jpg)
“early stage” T3 “advanced stage” T3
Kaur H et al. RadioGraphics (2012)
![Page 9: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/9.jpg)
How does rectal MRI influence treatment decisions?
• Identification of patients who may benefit from pre-operative chemoradiation
• Surgical planning
![Page 10: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/10.jpg)
Neo-adjuvant Treatment
• Current Cancer Care Ontario (CCO) guidelines:– Pre-operative chemoradiation for stage II (T3-T4N0) and stage
III (T1-4N1-2) primary rectal cancer
• Recommendations based on multiple RCTs showing that pre-op RT and pre-op CRT significantly reduce the risk of local recurrence
![Page 11: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/11.jpg)
Low Rectal Cancers
• Lower extent between 0 – 5 cm from the anal verge
• Lower extent above the top border of the puborectalis may be amenable to sphincter-sparing surgery
• Lower extent at or below the top border of the puborectalis will require abdominal perineal resection (T1 and early T2), extralevator APR (advanced T2 and T3) or pelvic exenteration (T4)
![Page 12: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/12.jpg)
CCO Synoptic Report for Rectal Cancer
• In an attempt to standardize reporting, CCO has developed an evidence-based synoptic report template that radiologists have been encouraged to utilize
• Report template includes important rectal tumour characteristics that influence neo-adjuvant and surgical treatment decisions
![Page 13: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/13.jpg)
How are rectal cancer treatment decisions made at HSN?
• Rectal cancer cases are discussed at multidisciplinary case conferences (MCC) on a weekly basis
• Imaging is reviewed by the radiologist, and treatment decisions are discussed amongst the attending medical oncologists, radiation oncologists and surgeons
![Page 14: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/14.jpg)
Summary
• Rectal MRI is the diagnostic standard for local staging of primary rectal cancer
• CCO has created an evidence-based synoptic report emphasizing key findings to help identify patients requiring neo-adjuvant treatment and to assist surgeons in determining the type/extent of surgery required
• Multidisciplinary case conferences at HSN ensure that proper discussion occurs between radiologists, oncologists and surgeons prior to a treatment plan being implemented
![Page 15: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/15.jpg)
References
1. Taylor FGM et al. A Systematic Approach to the Interpretation of Preoperative Staging MRI for Rectal Cancer. AJR: 191; pp.1827-1835 (2008).
2. Kaur H et al. MRI Imaging for Preoperative Evaluation of Primary Rectal Cancer: Practical Considerations. RadioGraphics: 32; pp.389-409 (2012).
3. Cancer Care Ontario User’s Guide for the Synoptic MRI Report for Rectal Cancer
(https://www.cancercare.on.ca).
![Page 16: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/16.jpg)
Role of the Enterostomal Therapist
Kathleen Callaghan BScN RN ET
Enterostomal Therapist
Nurse Continence Advisor, HSN
![Page 17: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/17.jpg)
Nutrition Intervention During Rectal Cancer Treatment
Julie Whitten, B.Sc., RD
Supportive Care Program
Northeast Cancer Centre, HSN
![Page 18: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/18.jpg)
Nutrition Intervention During Rectal Cancer Treatment
• Automatic nutrition referral
• Monitor bowel function and nutritional status throughout treatment
![Page 19: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/19.jpg)
Symptom Management Guidelines Nutrition Interventions
![Page 20: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/20.jpg)
Nutrition Interventions
• Low Roughage, Low Fibre Diet – Avoid insoluble fibre – Focus on soluble fibre
• Fluid intake – Increased fluid needs– Avoid hyper-osmotic fluids (fruit drinks, sodas) – Oral rehydration solutions– Parenteral hydration
• Limit caffeine, alcohol, fried/greasy foods, carbonated beverages
• Small, frequent meals at regular times
![Page 21: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/21.jpg)
Symptom Management Guidelines Pharmacological Interventions
![Page 22: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/22.jpg)
Psychosocial Care for Colorectal Cancer
Traci Franklin MSW RSW
Supportive Care Program
Northeast Cancer Centre, HSN
![Page 23: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/23.jpg)
ESAS Guidelines: Depression
![Page 24: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/24.jpg)
Depression in Cancer
• Mood• Affect• Thoughts: hopeless, helpless• Fears:
–Disability, loss of roles, disfigurement, loss of control, loss of support, dying, pain
–Feeling they are being punished
![Page 25: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/25.jpg)
Depression in Cancer
• The prevalence of significant emotional distress, defined as anxiety, depression, and adjustment disorders, ranges from 35% to 45% across studies in North America (Carlson & Bultz, 2003; Zabora, Brintzenhofeszoc, Curbow, Hooker & Piantadosi, 2001)
![Page 26: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/26.jpg)
Psychosocial Factors
Sexual Dysfunction pelvic surgery, radiotherapy
Body Image colostomy
Relational Adjustment Anxiety about bowel incontinence
Financial Concerns Cost of supplies
Coping with Side effects of Treatment
![Page 27: Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin](https://reader036.vdocuments.mx/reader036/viewer/2022081518/54bee23c4a795941318b4623/html5/thumbnails/27.jpg)
ESAS GUIDELINESDepression: 4-6