Panel #2 from the 2013 Regional Oncology Conference.

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. 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. Role of MRI in Staging and
Treatment Decisions for Patients
with Rectal Cancer
Dr. Michael Loreto
Associate Radiologist, Health Sciences North

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. What information does a preoperative MRI provide?
• Local staging
– primary tumour (T-stage)
– regional lymph nodes (N)

6. Assessment of the Primary
Tumour – T-stage
Modified TNM Staging (AJCC)

7. StageT2
Hi-res T2-weighted axial (short-axis) image
Kaur H et al. RadioGraphics (2012)

8. “early stage” T3
Kaur H et al. RadioGraphics (2012)
“advanced stage” T3

9. How does rectal MRI influence
treatment decisions?
• Identification of patients who may benefit from preoperative chemoradiation
• Surgical planning

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. 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. 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. 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. 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. 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. Role of the Enterostomal
Therapist
Kathleen Callaghan BScN RN ET
Enterostomal Therapist
Nurse Continence Advisor, HSN

17. Nutrition Intervention During
Rectal Cancer Treatment
Julie Whitten, B.Sc., RD
Supportive Care Program
Northeast Cancer Centre, HSN

18. Nutrition Intervention During Rectal
Cancer Treatment
• Automatic nutrition referral
• Monitor bowel function and nutritional
status throughout treatment

19. Symptom Management Guidelines
Nutrition Interventions

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. Symptom Management Guidelines
Pharmacological Interventions

22. Psychosocial Care for
Colorectal Cancer
Traci Franklin MSW RSW
Supportive Care Program
Northeast Cancer Centre, HSN

23. ESAS Guidelines: Depression

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. 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. 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. ESAS GUIDELINES
Depression: 4-6