Intended Patient Population: Common Peristomal Skin Conditions Bowel Dysfunction

QUICK REFERENCE GUIDE for COLORECTAL CANCER WELL FOLLOW-UP CARE QUICK REFERENCE GUIDE for COLORECTAL CANCER Carcinoembryonic Antigen (CEA): Interpretation and Ordering WELL FOLLOW-UP CARE Interpretation of serum CEA results: Intended Patient Population: Normal or minimally-elevated serum CEA: • Stage II or III colorectal cancer. Individuals with resected Stage I disease have very favourable outcomes with surgery alone. • Most healthy subjects (97%) have a serum CEA of ≤ 3.0 ng/mL Current evidence supports Stage I surveillance with periodic colonoscopy and clinical visits. • Nonsmokers: ≤ 3.0 ng/mL • Completed active therapy (i.e. surgery/chemotherapy and/or radiation therapy) with curative intent. • Some smokers may have an elevated serum CEA, usually < 5.0 ng/mL • Been assessed as without evidence of colorectal cancer at the time of transition of care from the oncologist. Elevated serum CEA: Individuals may still be under surveillance care by the treating surgeon and shared-care with an oncologist. • After removal of a colorectal tumour, the serum CEA level should normalize within six weeks (a persistently elevated serum CEA Bowel Dysfunction indicates the possibility of residual tumour). Diarrhea: Frequent and/or Urgent Bowel Movements or Loose Stools • A single serum CEA value is less informative than changes in serum CEA levels assessed over time. • Serum CEA values are method-dependent; therefore, the same method should ideally be used to serially monitor patients. Treatment approach to diarrhea: • Serum CEA level results alone neither prove nor disprove recurrent disease (some colorectal cancers do not produce CEA, Rule out other causes (e.g. spinal cord or cauda equina lesion, infection (e.g. Clostridium difficile), severe colonic stool overloading) therefore can recur without causing elevation of the serum CEA). Serum CEA should be used in conjunction with clinical Dietary interventions for diarrhea: evaluation of the patient and other diagnostic procedures to assess the likelihood of recurrence. • Limit caffeine-containing foods and beverages (e.g. coffee, tea, soft drinks), alcoholic and/or carbonated beverages. Grossly elevated serum CEA values (> 20 ng/mL) in a patient with symptoms consistent with disease recurrence are • If diarrhea occurs following consumption of milk products, try low-fat milk or consuming milk products with meals. If no strongly suggestive of cancer recurrence. Consult the treating surgeon or oncologist. improvement occurs, try lactose-free milk or milk substitutes such as soy milk. Contact the Cancer Centre for Elective Cancer Care if the CEA is < 20 ng/ml, but rising and of concern. • Limit foods high in insoluble fibre (e.g. legumes, seeds, nuts, fruit/vegetable skins, whole grains, wheat bran). ® Ordering a serum CEA: • Include foods high in soluble fibre (e.g. cooked potatoes/carrots, white rice, tapioca, apple sauce, bananas, oatmeal, Cheerios ). • Avoid hyperosmotic fluids (fruit drinks and soft drinks). Dilute fruit juices with water. In North East Ontario, the following will help ensure that patients with Stage II and III colorectal cancer on surveillance have funded • Maintain fluid intake of 2-2.5 L/day, adding 1 additional cup of fluid for each additional diarrheal stool. ® ® access to the serum CEA test when they present to a commercial lab (e.g. Lifelabs , Dynacare ) or outpatient hospital lab. • If fluid losses are high, provide an oral rehydration recipe (e.g. 2 cups Gatorade®, 2 cups water, ½ tsp salt) or suggest commercial Provide the patient with the following completed, signed requisitions with the advice that they bring BOTH to the lab: oral rehydration solutions. • The ‘CEA Requisition Form’ can be downloaded from a commercial lab website or HSN website at: • Periodic monitoring of serum sodium and potassium levels may be required to determine whether or not repletion is necessary. www.hsnsudbury.ca/portalen/rcp/ForHealthcareProfessionals/ReferralForms Pharmacological interventions: • On the ‘CEA Requisition Form’ check the box next to ‘Patient is currently receiving adjuvant therapy or follow-up First-line agent: loperamide (Imodium®) 2 mg tablets; 2 mg/15 ml solution of Stage II or III colorectal cancer’ • 2 mg given after each loose stool, up to 16 mg per day • See the back sleeve of the Guide for the HSN-NECC sample form Second-line agent: diphenoxylate/atropine (Lomotil®) 2.5/0.25 mg tablets • An Ontario Ministry of Health and Long-Term Care Laboratory Requisition with ‘CEA’ written in the ‘Other Tests’ field • 1-2 tablets orally as needed, up to 4 times per day (maximum 20 mg diphenoxylate/day) Third-line agents include opioids or octreotide (Sandostatin®) Need Help with Colorectal Cancer Well Follow-Up Care? Chronic Radiation Colitis/Proctitis: Rectal Ulceration, Stricture and Bleeding Cancer Centre Contacts: Northeast Cancer Centre (NECC), Sudbury Algoma District Cancer Program (ADCP), Sault Ste. Marie Emergency/Urgent Cancer Care: → primary care provider should refer within 24 hours to: Due to the nature of the symptoms of radiation proctitis (bleeding, pain), and the risk of late secondary cancers Local Emergency Department (e.g. spinal cord compression, acute bowel obstruction) OR developing in the radiation therapy treatment field, it is advised that evaluation by an endoscopist precede treatment. Cancer Centre for oncology review (e.g. pathological fracture, new liver and/or lung metastases) NECC: Call (Toll-free): 1-877-228-1822 or (705) 522-6237 ext. 7305 OR Common Peristomal Skin Conditions Complete and submit a New Patient Referral Form indicating “Recurrent or Progressive Disease”. Conditions Symptoms and Signs Treatment Form available at: www.hsnsudbury.ca/portalen/rcp/ForHealthcareProfessionals/ReferralForms Irritant dermatitis Itchiness, burning, erythema, • Refer to enterostomal therapist for pouch/stoma review ADCP: Call: (705) 541-7807 OR (705) 759-3434 ext. 4450 (e.g. from stool leakage) maceration, bleeding • Ostomy powders, Maalox® or Calamine™ lotion may help Complete and submit a New Patient Referral Form available at: New Patient Referral Office 705-541-7807 Contact (allergic) Itchiness, erythema, blistering • Refer to enterostomal therapist for pouch/ stoma review Elective Cancer Care: → primary care provider will receive a response within seven days dermatitis corresponding to the shape of • A topical beclomethasone spray (e.g. Flovent®) may be tried, (e.g. surveillance test intervals, interpretation of serum CEA, low to moderate grade side effects of cancer therapy) the appliance’s adhesive contact as it does not interfere with appliance adhesion. Prolonged NECC: NEW!! Dedicated “Primary Care Line”: directed to an oncologist surface steriod use may lead to skin atrophy Call (Toll-free): 1-877-228-1822 ext. 6322 OR (705) 522-6237 ext. 6322 • Consider dermatology consult if dermatitis persists ADCP: Call New Patient Referral Office: (705) 541-7807, ask for oncologist on-call or patient’s previous medical oncologist Candidiasis Itchiness, erythema, maceration, • Check for candidiasis at other sites irregular border, odour and • Silver-based powder (e.g. Arglaes® Powder) or antifungal spray Psychosocial Oncology and Supportive Care: → social work, psychology, nutrition, physiotherapy possible satellite lesions (e.g. Micatin® foot spray) may help NECC: Call (Toll-free): 1-877-228-1822 ext. 2175 OR (705) 522-6237 ext. 2175 Peristomal irritation, ulceration or bleeding causing severe pain or difficulty with appliance changes should be Fax: (705) 523-7355 reviewed with the surgeon or enterostomal therapist. Secondary seeded tumour deposits may occur on the peristomal ADCP: Call (705) 759-3434 ext. 4450 skin. If these are suspected, the patient should be referred to the Cancer Centre or surgeon for assessment. April 2016 *For more information go to the Colorectal Cancer Well Follow-Up Care - A Guide for Primary Care Providers in North East Ontario 2016 available in hard copy, pdf at www.hsnsudbury.ca/NECCprimarycareresources or wellfollowup.hsnsudbury.ca/colorectal Well Follow-Up Surveillance Recommendations For Colon Cancer Well Follow-Up Surveillance Recommendations For Rectal Cancer

The majority of recurrences are not detected during routine follow-up, but rather between routine visits, when patients present with The majority of recurrences are not detected during routine follow-up, but rather between routine visits, when patients present with new symptoms. Patients should be encouraged to report new and persistent or worsening symptoms promptly, without waiting new symptoms. Patients should be encouraged to report new and persistent or worsening symptoms promptly, without waiting for a scheduled follow-up appointment. The percentage of colon cancer patients with recurrence at five years by recurrence site is: for a scheduled follow-up appointment. The percentage of rectal cancer patients with recurrence at five years by recurrence site is: Liver (35%), Lung (20%), Brain and Bone (<5%). Liver (30%), Lung (30%), Brain and Bone (<5%). Well Follow-Up Surveillance after a Colon Cancer Diagnosis* Year after Diagnosis Well Follow-Up Surveillance after a Rectal Cancer Diagnosis Year after Diagnosis Clinical Test Year 1-3 Year >3-5 Clinical Test Year 1-3 Year >3-5 History: Ask about History: Ask about For cancer recurrence: For cancer recurrence: (35% of rectal cancers have locoregional recurrence by year 5) • Unexplained weight loss (e.g. >10 lbs (4.5 kg) over 3 months) • Unexplained weight loss (e.g. >10 bs (4.5 kg) over 3 months) • Vague constitutional symptoms such as fatigue or nausea • Vague constitutional symptoms such as fatigue or nausea • Dry cough • Dry cough • Abdominal pain, particularly the right upper quadrant or flank (liver area) • Abdominal pain, particularly the right upper quadrant or flank (liver area) For long-term or late effects of treatment ask about or assess for: • Pelvic pain, sciatica • Emotional distress, quality of life • New onset of difficulty with urination, defecation or sexual function Related to surgery: For long-term or late effects of treatment ask about or assess for: • Bowel dysfunction (e.g. frequent, urgent or loose bowel movements, gas or bloating, anal • Emotional distress, quality of life Every 6 Every 6 incontinence) Related to surgery: *Also related to radiation therapy months months • Bowel obstruction • * Bowel dysfunction (e.g. frequent, urgent or loose bowel movements, gas or bloating, anal • Urogenital dysfunction incontinence) • Incisional or parastomal hernia • * Bowel obstruction Every 6 Every 6 • * Urogenital dysfunction • For ostomy patients: stoma care and lifestyle adjustments months months Related to chemotherapy: • Incisional or parastomal hernia • Chemotherapy-induced peripheral neuropathy (e.g. oxaliplatin) • For ostomy patients: stoma care and lifestyle adjustments • Cognitive function Related to chemotherapy: Physical Examination: Include • Chemotherapy-induced peripheral neuropathy (e.g. oxaliplatin) • Abdominal exam (e.g. surgical scars, organomegaly, incisional/parastomal hernias) • Cognitive function • Respiratory exam Related to radiation therapy: Carcinoembryonic antigen (CEA) blood test (assess for rising levels) • Localized skin changes in radiation therapy treatment field Every 6 Every 6 CEA Requisition Form: www.hsnsudbury.ca/portalen/rcp/ForHealthcareProfessionals/ReferralForms • Rectal ulceration/bleeding (radiation colitis/proctitis) months months Check (√) “follow-up of Stage II or III colorectal cancer” • Secondary primary cancer in radiation field (typical onset ~7 years after radiation) • Pelvic insufficiency fractures (e.g. sacrum) Abdominal CT If local resources or patient preference preclude CT imaging, then replace CT Every 12 Physical Examination: Include Chest CT abdomen and chest with abdominal ultrasound and chest X-ray, every 6-12 Not routine months • Abdominal exam (e.g. surgical scars, organomegaly, incisional/parastomal hernias) months for 3 years then annually year 4 and 5. • Inguinal lymph nodes, digital rectal exam Colonoscopy: At approximately 1 year following surgery. The frequency of subsequent colonoscopies should be dictated by the • Respiratory exam findings of the previous colonoscopy, but generally should be performed every 5 years if the findings of the previous colonoscopy Carcinoembryonic antigen (CEA) blood test (assess for rising levels) were normal. CT colonography may be considered in select patients who are not good medical candidates for, who can’t withstand, Every 6 Every 6 CEA Requisition Form: www.hsnsudbury.ca/portalen/rcp/ForHealthcareProfessionals/ReferralForms or refuse colonoscopy. months months Check (√) “follow-up of Stage II or III colorectal cancer“ TESTS NOT RECOMMENDED: Routine blood work (e.g. CBC, liver function tests) aside from CEA, are NOT recommended. Abdominal CT If local resources or patient preference preclude CT imaging, then replace Every 12 A Fecal Occult Blood Test is NOT recommended for routine surveillance. Not routine Chest CT CT abdomen, chest and pelvis with abdominal ultrasound, chest X-ray, and months *A small subgroup of colon cancer patients may be offered radiation therapy. Pelvic CT pelvic ultrasound every 6-12 months for 3 years then annually year 4 and 5. Colonoscopy: At approximately one year following surgery. The frequency of subsequent colonoscopies should be dictated by the Surgical Resection for Colorectal Cancer Metastases findings of the previous colonoscopy, but generally should be performed every five years if the findings of the previous colonoscopy Unlike many other types of cancer, the presence of distant metastases does not preclude curative treatment in select patients. were normal. CT colonography may be considered in select patients who are either not good medical candidates for, or who can’t Patients found to have liver and/or lung metastases from colorectal cancer should be referred promptly to withstand, or refuse colonoscopy. the treating surgeon or the Cancer Centre. These referrals are reviewed at Multidisciplinary Cancer Conferences to Rectosigmoidoscopy (for rectal cancer): For rectal cancer patients who are considered at high risk of local recurrence by the determine if the patient is a candidate for liver and/or lung metastasectomy. Health Sciences North is the North East regional treating physician, sigmoidoscopy may be considered at intervals less than 5 years. designated Thoracic Cancer Surgery Centre and Hepato-Pancreatic Biliary Cancer Surgery Centre, allowing surgical treatment TESTS NOT RECOMMENDED: Routine blood work (e.g. CBC, liver function tests) aside from CEA, are NOT recommended. of patients with lung and/or liver metastases closer to their home. A Fecal Occult Blood Test is NOT recommended for routine surveillance. QUICK REFERENCE GUIDE for COLORECTAL CANCER WELL FOLLOW-UP CARE QUICK REFERENCE GUIDE for COLORECTAL CANCER Carcinoembryonic Antigen (CEA): Interpretation and Ordering WELL FOLLOW-UP CARE Interpretation of serum CEA results: Intended Patient Population: Normal or minimally-elevated serum CEA: • Stage II or III colorectal cancer. Individuals with resected Stage I disease have very favourable outcomes with surgery alone. • Most healthy subjects (97%) have a serum CEA of ≤ 3.0 ng/mL Current evidence supports Stage I surveillance with periodic colonoscopy and clinical visits. • Nonsmokers: ≤ 3.0 ng/mL • Completed active therapy (i.e. surgery/chemotherapy and/or radiation therapy) with curative intent. • Some smokers may have an elevated serum CEA, usually < 5.0 ng/mL • Been assessed as without evidence of colorectal cancer at the time of transition of care from the oncologist. Elevated serum CEA: Individuals may still be under surveillance care by the treating surgeon and shared-care with an oncologist. • After removal of a colorectal tumour, the serum CEA level should normalize within six weeks (a persistently elevated serum CEA Bowel Dysfunction indicates the possibility of residual tumour). Diarrhea: Frequent and/or Urgent Bowel Movements or Loose Stools • A single serum CEA value is less informative than changes in serum CEA levels assessed over time. • Serum CEA values are method-dependent; therefore, the same method should ideally be used to serially monitor patients. Treatment approach to diarrhea: • Serum CEA level results alone neither prove nor disprove recurrent disease (some colorectal cancers do not produce CEA, Rule out other causes (e.g. spinal cord or cauda equina lesion, infection (e.g. Clostridium difficile), severe colonic stool overloading) therefore can recur without causing elevation of the serum CEA). Serum CEA should be used in conjunction with clinical Dietary interventions for diarrhea: evaluation of the patient and other diagnostic procedures to assess the likelihood of recurrence. • Limit caffeine-containing foods and beverages (e.g. coffee, tea, soft drinks), alcoholic and/or carbonated beverages. Grossly elevated serum CEA values (> 20 ng/mL) in a patient with symptoms consistent with disease recurrence are • If diarrhea occurs following consumption of milk products, try low-fat milk or consuming milk products with meals. If no strongly suggestive of cancer recurrence. Consult the treating surgeon or oncologist. improvement occurs, try lactose-free milk or milk substitutes such as soy milk. Contact the Cancer Centre for Elective Cancer Care if the CEA is < 20 ng/ml, but rising and of concern. • Limit foods high in insoluble fibre (e.g. legumes, seeds, nuts, fruit/vegetable skins, whole grains, wheat bran). ® Ordering a serum CEA: • Include foods high in soluble fibre (e.g. cooked potatoes/carrots, white rice, tapioca, apple sauce, bananas, oatmeal, Cheerios ). • Avoid hyperosmotic fluids (fruit drinks and soft drinks). Dilute fruit juices with water. In North East Ontario, the following will help ensure that patients with Stage II and III colorectal cancer on surveillance have funded • Maintain fluid intake of 2-2.5 L/day, adding 1 additional cup of fluid for each additional diarrheal stool. ® ® access to the serum CEA test when they present to a commercial lab (e.g. Lifelabs , Dynacare ) or outpatient hospital lab. • If fluid losses are high, provide an oral rehydration recipe (e.g. 2 cups Gatorade®, 2 cups water, ½ tsp salt) or suggest commercial Provide the patient with the following completed, signed requisitions with the advice that they bring BOTH to the lab: oral rehydration solutions. • The ‘CEA Requisition Form’ can be downloaded from a commercial lab website or HSN website at: • Periodic monitoring of serum sodium and potassium levels may be required to determine whether or not repletion is necessary. www.hsnsudbury.ca/portalen/rcp/ForHealthcareProfessionals/ReferralForms Pharmacological interventions: • On the ‘CEA Requisition Form’ check the box next to ‘Patient is currently receiving adjuvant therapy or follow-up First-line agent: loperamide (Imodium®) 2 mg tablets; 2 mg/15 ml solution of Stage II or III colorectal cancer’ • 2 mg given after each loose stool, up to 16 mg per day • See the back sleeve of the Guide for the HSN-NECC sample form Second-line agent: diphenoxylate/atropine (Lomotil®) 2.5/0.25 mg tablets • An Ontario Ministry of Health and Long-Term Care Laboratory Requisition with ‘CEA’ written in the ‘Other Tests’ field • 1-2 tablets orally as needed, up to 4 times per day (maximum 20 mg diphenoxylate/day) Third-line agents include opioids or octreotide (Sandostatin®) Need Help with Colorectal Cancer Well Follow-Up Care? Chronic Radiation Colitis/Proctitis: Rectal Ulceration, Stricture and Bleeding Cancer Centre Contacts: Northeast Cancer Centre (NECC), Sudbury Algoma District Cancer Program (ADCP), Sault Ste. Marie Emergency/Urgent Cancer Care: → primary care provider should refer within 24 hours to: Due to the nature of the symptoms of radiation proctitis (bleeding, pain), and the risk of late secondary cancers Local Emergency Department (e.g. spinal cord compression, acute bowel obstruction) OR developing in the radiation therapy treatment field, it is advised that evaluation by an endoscopist precede treatment. Cancer Centre for oncology review (e.g. pathological fracture, new liver and/or lung metastases) NECC: Call (Toll-free): 1-877-228-1822 or (705) 522-6237 ext. 7305 OR Common Peristomal Skin Conditions Complete and submit a New Patient Referral Form indicating “Recurrent or Progressive Disease”. Conditions Symptoms and Signs Treatment Form available at: www.hsnsudbury.ca/portalen/rcp/ForHealthcareProfessionals/ReferralForms Irritant dermatitis Itchiness, burning, erythema, • Refer to enterostomal therapist for pouch/stoma review ADCP: Call: (705) 541-7807 OR (705) 759-3434 ext. 4450 (e.g. from stool leakage) maceration, bleeding • Ostomy powders, Maalox® or Calamine™ lotion may help Complete and submit a New Patient Referral Form available at: New Patient Referral Office 705-541-7807 Contact (allergic) Itchiness, erythema, blistering • Refer to enterostomal therapist for pouch/ stoma review Elective Cancer Care: → primary care provider will receive a response within seven days dermatitis corresponding to the shape of • A topical beclomethasone spray (e.g. Flovent®) may be tried, (e.g. surveillance test intervals, interpretation of serum CEA, low to moderate grade side effects of cancer therapy) the appliance’s adhesive contact as it does not interfere with appliance adhesion. Prolonged NECC: NEW!! Dedicated “Primary Care Line”: directed to an oncologist surface steriod use may lead to skin atrophy Call (Toll-free): 1-877-228-1822 ext. 6322 OR (705) 522-6237 ext. 6322 • Consider dermatology consult if dermatitis persists ADCP: Call New Patient Referral Office: (705) 541-7807, ask for oncologist on-call or patient’s previous medical oncologist Candidiasis Itchiness, erythema, maceration, • Check for candidiasis at other sites irregular border, odour and • Silver-based powder (e.g. Arglaes® Powder) or antifungal spray Psychosocial Oncology and Supportive Care: → social work, psychology, nutrition, physiotherapy possible satellite lesions (e.g. Micatin® foot spray) may help NECC: Call (Toll-free): 1-877-228-1822 ext. 2175 OR (705) 522-6237 ext. 2175 Peristomal irritation, ulceration or bleeding causing severe pain or difficulty with appliance changes should be Fax: (705) 523-7355 reviewed with the surgeon or enterostomal therapist. Secondary seeded tumour deposits may occur on the peristomal ADCP: Call (705) 759-3434 ext. 4450 skin. If these are suspected, the patient should be referred to the Cancer Centre or surgeon for assessment. April 2016 *For more information go to the Colorectal Cancer Well Follow-Up Care - A Guide for Primary Care Providers in North East Ontario 2016 available in hard copy, pdf at www.hsnsudbury.ca/NECCprimarycareresources or wellfollowup.hsnsudbury.ca/colorectal