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Panel 2:
Optimizing Integrated
Colorectal Cancer Treatment
Planning and Patient Support
Panelists:
Michael Loreto MD FRCP(...
Mr. TW: Case History 2
• Colonoscopy reveals a rectal cancer
• A rectal MRI for pre-operative staging
reveals Stage III re...
Role of MRI in Staging and
Treatment Decisions for Patients
with Rectal Cancer
Dr. Michael Loreto
Associate Radiologist, H...
Which patients benefit from a
pre-operative MRI?
ALL patients with rectal cancer should have a pre-operative
MRI as hi-res...
What information does a preoperative MRI provide?
• Local staging
– primary tumour (T-stage)
– regional lymph nodes (N)
Assessment of the Primary
Tumour – T-stage
Modified TNM Staging (AJCC)
StageT2

Hi-res T2-weighted axial (short-axis) image
Kaur H et al. RadioGraphics (2012)
“early stage” T3

Kaur H et al. RadioGraphics (2012)

“advanced stage” T3
How does rectal MRI influence
treatment decisions?
• Identification of patients who may benefit from preoperative chemorad...
Neo-adjuvant Treatment
• Current Cancer Care Ontario (CCO) guidelines:
– Pre-operative chemoradiation for stage II (T3-T4N...
Low Rectal Cancers
•

Lower extent between 0 – 5 cm from the anal verge

•

Lower extent above the top border of the pubor...
CCO Synoptic Report for Rectal Cancer
• In an attempt to standardize reporting, CCO has
developed an evidence-based synopt...
How are rectal cancer treatment
decisions made at HSN?
• Rectal cancer cases are discussed at multidisciplinary
case confe...
Summary
• Rectal MRI is the diagnostic standard for local staging of primary
rectal cancer
• CCO has created an evidence-b...
References
1.

Taylor FGM et al. A Systematic Approach to the Interpretation of Preoperative
Staging MRI for Rectal Cancer...
Role of the Enterostomal
Therapist
Kathleen Callaghan BScN RN ET
Enterostomal Therapist
Nurse Continence Advisor, HSN
Nutrition Intervention During
Rectal Cancer Treatment
Julie Whitten, B.Sc., RD
Supportive Care Program
Northeast Cancer Ce...
Nutrition Intervention During Rectal
Cancer Treatment
• Automatic nutrition referral

• Monitor bowel function and nutriti...
Symptom Management Guidelines
Nutrition Interventions
Nutrition Interventions
• Low Roughage, Low Fibre Diet
– Avoid insoluble fibre
– Focus on soluble fibre

• Fluid intake
–
...
Symptom Management Guidelines
Pharmacological Interventions
Psychosocial Care for
Colorectal Cancer
Traci Franklin MSW RSW
Supportive Care Program
Northeast Cancer Centre, HSN
ESAS Guidelines: Depression
Depression in Cancer
•
•
•
•

Mood
Affect
Thoughts: hopeless, helpless
Fears:
– Disability, loss of roles, disfigurement,
...
Depression in Cancer
• The prevalence of significant emotional
distress, defined as anxiety, depression,
and adjustment di...
Psychosocial Factors
 Sexual Dysfunction
 pelvic surgery, radiotherapy
 Body Image
 colostomy
 Relational Adjustment
...
ESAS GUIDELINES
Depression: 4-6
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Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin

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Panel #2 from the 2013 Regional Oncology Conference.

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Panel 2: Optimizing Integrated Colorectal Cancer Treatment Planning and Patient Support, Dr. Michael Loreto, Ms. Kathleen Callaghan, Ms. Julie Whitten, Ms. Traci Franklin

  1. 1. 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
  2. 2. 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 postoperative chemotherapy • Mr. TW has a temporary colostomy, has bowel habit changes and feels depressed
  3. 3. Role of MRI in Staging and Treatment Decisions for Patients with Rectal Cancer Dr. Michael Loreto Associate Radiologist, Health Sciences North
  4. 4. 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.
  5. 5. What information does a preoperative MRI provide? • Local staging – primary tumour (T-stage) – regional lymph nodes (N)
  6. 6. Assessment of the Primary Tumour – T-stage Modified TNM Staging (AJCC)
  7. 7. StageT2 Hi-res T2-weighted axial (short-axis) image Kaur H et al. RadioGraphics (2012)
  8. 8. “early stage” T3 Kaur H et al. RadioGraphics (2012) “advanced stage” T3
  9. 9. How does rectal MRI influence treatment decisions? • Identification of patients who may benefit from preoperative chemoradiation • Surgical planning
  10. 10. 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
  11. 11. 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 sphinctersparing 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)
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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).
  16. 16. Role of the Enterostomal Therapist Kathleen Callaghan BScN RN ET Enterostomal Therapist Nurse Continence Advisor, HSN
  17. 17. Nutrition Intervention During Rectal Cancer Treatment Julie Whitten, B.Sc., RD Supportive Care Program Northeast Cancer Centre, HSN
  18. 18. Nutrition Intervention During Rectal Cancer Treatment • Automatic nutrition referral • Monitor bowel function and nutritional status throughout treatment
  19. 19. Symptom Management Guidelines Nutrition Interventions
  20. 20. 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
  21. 21. Symptom Management Guidelines Pharmacological Interventions
  22. 22. Psychosocial Care for Colorectal Cancer Traci Franklin MSW RSW Supportive Care Program Northeast Cancer Centre, HSN
  23. 23. ESAS Guidelines: Depression
  24. 24. 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
  25. 25. 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)
  26. 26. 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
  27. 27. ESAS GUIDELINES Depression: 4-6

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