National Comprehensive Cancer Network

Clinical Recommendations

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents - Volume 7, Number 8 September 2009

• NCCN Clinical Practice Guidelines in Oncology™
• Colon Cancer
• Rectal Cancer
• Featured Articles
• The Challenges of Colorectal Cancer Survivorship
• Concordance with NCCN Colorectal Cancer Guidelines and ASCO/NCCN Quality Measures: An NCCN Institutional Analysis

NCCN Clinical Practice Guidelines in Oncology™

Colon Cancer

Colorectal cancer is the fourth most frequently diagnosed cancer and the second leading cause of cancer death in the United States. In 2009, an estimated 106,100 new cases of colon cancer and approximately 40,870 cases of rectal cancer will occur, and 49,920 people will die from colon and rectal cancer. Despite these statistics, mortality from colon cancer has decreased slightly over the past 30 years, possibly because of earlier diagnosis through screening and better treatment modalities. This manuscript summarizes the NCCN clinical practice guidelines for managing colon cancer. The 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.

Rectal Cancer

In 2009 an estimated 40,870 new cases of rectal cancer will occur in the United States (23,580 cases in men; 17,290 cases in women). Although colorectal cancer is ranked as the fourth most frequently diagnosed cancer and the second leading cause of cancer death in the United States, mortality from colorectal cancer has decreased during the past 30 years. This decrease may be because of earlier diagnosis through screening and better treatment modalities. The clinical practice guidelines for managing rectal cancer overlap considerably with those for colon cancer. The NCCN Rectal Cancer Guidelines panel believes that a multidisciplinary approach, including representation from gastroenterology, medical oncology, surgical oncology, radiation oncology, and radiology is necessary for treating patients with rectal cancer.

Featured Articles

The Challenges of Colorectal Cancer Survivorship
Crystal S. Denlinger, MD, and Andrea M. Barsevick, RN, PhD

With advances in treatment, colorectal cancer is being transformed from a deadly disease into an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. Research has shown that physical and mental quality of life for colorectal cancer survivors was inferior compared with age-matched individuals without cancer. Although issues and symptoms were most prominent during the first 3 years, long-term effects of treatment can persist and include fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. The unique challenges and issues of colorectal cancer survivors can and should be addressed by health care providers and the research community to ensure effective interventions and models of care to manage these problems. This article discusses what is known about the long-term effects of colorectal cancer treatment on quality of life, the care of survivors, and existing models of survivorship care.

Concordance with NCCN Colorectal Cancer Guidelines and ASCO/NCCN Quality Measures: An NCCN Institutional Analysis
Dorothy Romanus, RPh, MSc; Martin R. Weiser, MD; John M. Skibber, MD; Anna Ter Veer, MS; Joyce C. Niland, PhD; John L. Wilson, PhD; Ashwani Rajput, MD; Yu-Ning Wong, MD, MSCE; Al B. Benson III, MD; Stephen Shibata, MD; and Deborah Schrag, MD

The National Comprehensive Cancer Network (NCCN) Outcomes Database was created to assess concordance to evidence- and consensus-based guidelines and to measure adherence to quality measures on an ongoing basis. The Colorectal Cancer Database began in 2005 as a collaboration among 8 NCCN centers. Files for newly diagnosed colon and rectal cancer patients presenting to 1 of 8 NCCN centers between September 1, 2005, and May 21, 2008, were analyzed for concordance with NCCN treatment guidelines for colorectal cancer and with a set of quality metrics jointly developed by ASCO and NCCN in 2007. Adherence rates were determined for each metric. The authors found that adherence to guidelines and quality measures is generally high at institutions participating in the NCCN colorectal database. Lack of documentation, patient refusal, delayed treatment initiation, and lack of consensus about whether treatment was essential were the primary reasons for nonconcordance. Measurement of concordance and the reasons for nonconcordance enable participating centers to understand and improve their care delivery systems.