New American Cancer Society Guidelines Address Long-Term Needs of Colorectal Cancer Survivors

Recommendations for the essential components of comprehensive cancer survivorship care

New American Cancer Society Cancer Survivorship Care guidelines released on 8 September 2015 provide primary care clinicians with recommendations for providing comprehensive care to survivors of colorectal cancer (CRC). The new guidelines include recommendations for the essential components of comprehensive cancer survivorship care, from screening for recurrence and early detection of second primary cancers, to assessment and management of physical and psychosocial long-term and late effects of CRC and its treatment.

Almost two-thirds of CRC survivors are living 5 years after diagnosis. Survivors are at risk for a CRC recurrence, a new primary CRC, other cancers, as well as both short-term and long-term adverse effects of the CRC and the modalities used to treat it. CRC survivors may also have psychological, reproductive, genetic, social, and employment concerns after treatment.

Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of CRC survivors.

Thanks in large part to increased screening leading to removal of polyps before they turn cancerous, the incidence of CRC has been dropping for two decades. Nonetheless, CRC survivors make up more than 1.2 million (about 9%) of the nearly 15 million cancer survivors alive in the US, making CRC the second most common cancer site among male cancer survivors, and third most common among female survivors.

To develop the guidelines, a multi-disciplinary team led by Dr Khaled El-Shami of the GW Medical Faculty Associates, a haematologist/oncologist with board certification in medical oncology and internal medicine, reviewed relevant literature as well as publically available clinical practice guidelines from the US and around the world. The process is aligned with the American Cancer Society's process for creating cancer screening guidelines, and both ensure alignment with new standards recommended by the Institute of Medicine for how guidelines should be developed. As with the American Cancer Society's cancer screening guidelines, the survivorship care guidelines will be updated every five years as new research is available.

While there are still important gaps in research, the authors believed enough evidence exists to provide these consensus-based guidelines to improve post-treatment care.

Guidelines for the primary care management of CRC survivors: Summary

Surveillance for CRC recurrence

Recommendation 1: Clinical follow-up care provided to CRC survivors should be individualized based on the specific diagnosis and treatment protocol.

Recommendation 2: CRC survivors should receive surveillance colonoscopy according to a schedule based on risk.

Recommendation 3: CRC survivors should receive a history and physical every 3 to 6 months in the first 2 years, and every 6 months in years 3 through 5.

Recommendation 4: Carcinoembryonic antigen testing should be conducted every 3 to 6 months for the first 2 years if a patient is a potential candidate for further intervention and every 6 months for years 3 through 5 if a patient is a potential candidate for further intervention; carcinoembryonic antigen testing is not recommended after 5 years.

Recommendation 5: Chest/abdominal/pelvic computed tomography should be performed every 12 months (stages I-II if at high risk for recurrence and stage III) for up to 5 years; routine positron emission tomography-computed tomography is not recommended at any stage and routine computed tomography is not recommended after 5 years.

Screening for second primary cancers

Recommendation 6: CRC survivors should receive age-appropriate and gender-appropriate screening for patients with an average risk, except for female CRC survivors with Lynch syndrome (see Recommendation 7).

Recommendation 7: Female CRC survivors with Lynch syndrome should receive annual endometrial sampling and transvaginal ultrasound.

Assessment and management of physical and psychosocial long-term and late effects of CRC and its treatment

Bowel/Gastrointestinal issues

Recommendation 8: (a) Ask CRC survivors about whether they are experiencing diarrhea, rectal bleeding, rectal incontinence, or other bowel dysfunction and (b) treat symptoms similar to those in the general population.

Cardiovascular effects

Recommendation 9: Monitor CRC survivors who are obese or who have had prior coronary artery disease and received 5-fluorouracil or capecitabine for cardiovascular disease.

Cognitive function

Recommendation 10: (a) Screen for cognitive problems, (b) assess for depression and anxiety that may worsen cognition, and (c) refer for treatment.

Dental/Oral

Recommendation 11: (a) Ask CRC survivors if they are experiencing symptoms of mucositis, loss of taste, or dry mouth and (b) treat similar to population with average risk.

Distress/Depression/Anxiety

Recommendation 12: (a) Screen CRC survivors for psychosocial distress, depression, and anxiety using a validated screening tool; special attention should be paid to survivors with a stoma and those who report sexual dysfunction. (b) Refer patients to the appropriate mental health professionals or resources in the community as indicated; in addition, follow-up with the survivor to assess adherence and ensure that the need was met, identify potential barriers, and seek alternative approaches as needed.

Fatigue

Recommendation 13: (a) Assess with a validated fatigue instrument, (b) recommend physical activity similar to that recommended for the general population, and (c) refer to specialists for psychosocial support or rehabilitation as indicated.

Neuropathy

Recommendation 14: (a) Assess with Total Neuropathy Score or other validated tool for CRC survivors who received oxaliplatin, and (b) refer to rehabilitation and pain management specialists as indicated.

Ostomy/Stoma

Recommendation 15: For CRC survivors with a stoma, (a) monitor for sexual dysfunction, distress, depression, anxiety, and QoL; (b) refer to specialists for support as indicated.

Pain

Recommendation 16: Monitor patients who received pelvic irradiation for chronic proctitis, and manage symptoms as indicated.

Sexual function/Fertility

Recommendation 17: (a) Address sexual function when managing CRC survivors. For CRC survivors of childbearing age who experience infertility due to treatment, (b) refer for psychosocial support, oral phosphodiesterase-5 inhibitors in men, vaginal moisturizers and lubricants for women

Urinary/Bladder issues

Recommendation 18: (a) Screen CRC survivors for urinary incontinence and retention and (b) manage as you would a patient at average risk of urinary dysfunction.

Health promotion

Recommendation 19: (a) Provide routine general medical care and health promotion recommendations, and (b) continue to treat patients' chronic conditions, recognizing that cancer treatments worsen the severity of many underlying chronic conditions.

Weight; Physical activity; Nutrition; Tobacco cessation; Alcohol use

Care coordination and practice implications

Recommendation 20: (a) Initiate and maintain direct communication with all specialists involved in your patient's oncology care and symptom management; (b) request a treatment summary and follow-up care plan to guide coordination of follow-up care posttreatment.

Treatment summary and survivorship care plan; Care coordination for chronic conditions; Psychosocial referral; Rehabilitation referral; Follow-up care regimen”.

The US National Cancer Survivorship Resource Center (The Survivorship Center) is a collaboration between the American Cancer Society and The George Washington University Cancer Institute funded through a 5-year cooperative agreement with the Centers for Disease Control and Prevention. Its goal is to shape the future of cancer survivorship care and improve the quality of life of cancer survivors as they transition from treatment to long-term survivorship.

The guidelines are supported in part by Cooperative Agreement #5U55DP003054 from the Centers for Disease Control and Prevention.

The contents of the guidelines article are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

Reference

El-Shami K, Oeffinger K, Erb NL, et al. American Cancer Society Colorectal Cancer Survivorship Care Guidelines. CA Cancer J Clin 2015; doi 10.3322/caac.21286 Published early online Sept. 8 2015