Colon Cancer
Colorectal cancer is the third most frequently diagnosed cancer in men and women in the United States. An estimated 112,340 new cases of colon cancer will occur in 2007 and an estimated that 52,180 people will die from colon and rectal cancer in that same year. Despite these statistics, mortality from colon cancer has decreased over the past 30 years, possibly because of earlier diagnosis through screening and better treatment modalities. These guidelines begin with the clinical presentation of the patient to the primary care physician or gastroenterologist and address diagnosis, pathologic staging, surgical management, adjuvant treatment, management of recurrent and metastatic disease, and patient surveillance. Important updates for the 2.2007 version of the guidelines include a new page on treatment recommendations for documented metachronous liver or lung metastases. Other updates involve changes in recommendations for chemotherapy, including the addition of panitumumab and capeOX as treatment options in some situations.

Rectal Cancer
In 2007, an estimated 41,420 new cases of rectal cancer will occur in the United States (23,840 cases in men; 17,580 cases in women). The guidelines for rectal cancer overlap considerably with those for colon cancer, and the panel unanimously endorses patient participation in a clinical trial over standard or accepted therapy in both. This is especially true for cases of advanced disease and for patients with locally aggressive colorectal cancer who are receiving combined modality treatment. In addition, both guidelines adhere to the TNM (tumor, node, and metastasis) staging system. Important updates to the 1.2007 version of the rectal cancer guidelines include a new Principles of Pathologic Review and several updates to the recommendations for chemotherapy for advanced or metastatic disease.

Anal Carcinoma
An estimated 4650 new cases (1900 men and 2750 women) of anal cancer (involving the anus, anal canal, or the anorectum) will occur in the United States in 2007, and an estimated 690 deaths due to the disease will also occur. Although anal cancer is considered to be rare, its incidence in the United States increased by approximately 2-fold for men and 1.5-fold for women between 1973 to 1979 and 1994 to 2000. This manuscript summarizes the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for managing squamous cell anal carcinoma, the most common histologic form of the disease.

Special Features

Oncologic Emergencies: The Anesthesiologist’s Perspective

Michael W. Lew, MD; Andres Falabella, MD; Earl Moore-Jeffries, MD; Russell J. Gray, MD; and Michael J. Sullivan, MD
During the course of treatment, a cancer patient may present emergently to the hospital because of either the cancer itself or a manifestation of cancer therapy. Though the situation is rare, patients with cancer can present to the operating room with several emergent conditions that will require an anesthesiologist. The main oncologic emergencies that require the anesthesiologist are related to airway obstruction, cardiac, neurologic, gastrointestinal, and endocrine-related conditions. Mismanagement of these crises can increase morbidity and mortality. This article addresses emergencies in cancer patients and how they relate to anesthetic care.

Original Articles

Development and Implementation of a Medical Oncology Quality Improvement Tool for a Regional Community Oncology Network: The Fox Chase Cancer Center Partners Initiative
Margaret A. O’Grady, RN, MSN, OCN; Elena Gitelson, MD, PhD; Ramona F. Swaby, MD; Lori J. Goldstein, MD; Elaine Sein, RN, BSN, OCN; Patricia Keeley, RN, MSN, APRN, BC; Bonnie Miller, RN, BSN, OCN; Tianyu Li, MS; Alan Weinstein, MD, FACP; and Steven J. Cohen, MD
Fox Chase Cancer Center Partners (FCCCP) is a community hospital/academic partnership consisting of 25 hospitals in the Delaware Valley, which was created in 1986 to promote quality community cancer care through education, quality assurance, and access to clinical trial research. An important aspect of quality assurance is a yearly medical oncology audit that benchmarks quality indicators and guidelines and provides a roadmap for quality improvement initiatives in the community oncology clinical office setting. Each year, the FCCCP team and the Partner Medical Oncologists build disease site– and stage-specific indicators based on National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. A report for each FCCC Partner medical oncology practice summarizes documentation, screening recommendations, new drug use, and research trends in a particular disease site. 

Adjuvant Therapy for Stage II Colon Cancer: Prognostic and Predictive Markers
Brian Vicuna, MD, and Al B. Benson III, MD
The treatment for stage II colon cancer is a controversial issue that has persisted for the last decade. It is important for clinicians to understand that the key to identifying patients who will benefit from treatment lies in the accurate assessment of risk factors. In addition, distinct pathologic factors characterize a high-risk stage II patient. More recent retrospective data have suggested that molecular markers and gene expression microarrays may be valuable as both prognostic and predictive tests. Two recent clinical trials, National Surgical Adjuvant Breast and Bowel Project C-07 and MOSAIC, have provided more insight into defining the optimal treatment approach. With the development of the newer therapeutic agents, oxaliplatin and bevacizumab, ongoing trials such as Intergroup E5202 should help answer the question of risk versus benefit of chemotherapy in the adjuvant treatment of stage II colon cancer.

Targeted Strategies in the Treatment of Metastatic Colon Cancer
Diane Reidy, MD, MS, and Leonard Saltz, MD
Advances in the understanding of tumor biology have led to the identification of important cellular processes involved in the pathogenesis of colon cancer. Drugs that interfere with these critical pathways are known as targeted agents. Some of these targeted agents have made important, albeit modest, contributions to the treatment of patients with metastatic colorectal cancer. However, activity levels with the currently available targeted therapies are far lower than experts had hoped, and toxicities are often nontrivial. This article reviews the available therapies, the data that justify their use, and the challenges of optimizing targeted therapies through combinations with cytotoxic chemotherapies and other targeted agents. Finally, the article discusses newer drugs and strategies currently being tested in clinical trials.

Pathologic Issues in the Treatment of Endoscopically Removed Malignant Colorectal Polyps
Harry S. Cooper, MD
Endoscopically removed malignant colorectal polyps are early-stage cancers for which treatment depends on histopathologic findings. Polyps with grade I or II cancer, no lymphovascular invasion, and a negative resection margin can be successfully treated with endoscopic polypectomy, whereas those with grade III cancer, lymphovascular invasion, or a positive or close margin require definitive surgical resection after endoscopic polypectomy. Potentially new significant parameters for patient management are depth of invasion and tumor budding. The pathologist must differentiate invasive adenocarcinoma from intramucosal adenocarcinoma and pseudo-invasion.