Question

When to use local therapy for lung or unresectable liver metastases of colorectal cancer?

Recommendation

Radio Frequency Ablation and Microwave ablation

Local thermal ablation is an important component in the multidisciplinary treatment of patients with relatively small colorectal liver metastases (≤3 cm).

 

Local thermal ablation is not an alternative to surgical resection in patients with resectable liver metastases, but may be used in selected patients in combination with resection to allow resection.

 

Percutaneous local thermal ablation can be used for the local treatment of patients with colorectal liver metastases that are less suitable for surgical resection by high age, comorbidity, an unfavorable location of the lesion before resection, or a history of extensive abdominal surgery.

 

At this time RFA is the local ablation technique of first choice.

 

MW ablation may be a good alternative, especially in tumor localizations when a negative impact of large vessels is expected (heatsink).

 

The working group believes that with the current RFA and MW technologies, no indication for the use of cryotherapy in colorectal liver metastases exists.

 

Isolated hepatic perfusion

Isolated hepatic perfusion should only be offered in clincal studies.

 

Trans arterial chemo embolization

TACE should only be offered in clincal studies.

 

Yttrium-90-radio-embolization

Radio-embolization may be considered as salvage therapy in patients with metastatic disease confined to the liver. In an earlier stage, the value relative to palliative systemic therapy is not sufficiently known.

 

The treatment should be performed in centers with expertise and preferably in clincal studies.

 

Stereotactic radiotherapy

The working group believes that stereotactic radiotherapy may be considered for patients with unresectable colorectal liver metastases where the location for RFA is unfavorable.

Conclusions

Radio-frequency ablation (RFA)
There is limited evidence that radiofrequency ablation added to systemic chemotherapy improves PFS at 3 years in CRC patients with unresectable liver metastases.
Ruers 2012, very low level of evidence

In CRC patients with unresectable liver metastases, an effect on overall survival when adding radiofrequency ablation to systemic chemotherapy could neither be demonstrated nor refuted.
Ruers 2012, very low level of evidence

Hepatic artery (HAI) chemotherapy
In CRC patients with unresectable liver metastases, an effect of HAI compared to systemic chemotherapy on overall survival could neither be demonstrated nor refuted.
Mocellin 2011, very low level of evidence

Chemo-embolization
There are indications that chemo-embolization for the treatment of liver metastases from colorectal cancer may improve progression-free and overall survival.
Very low level of evidence

Radio-embolization, Selective Internal Radiation Therapy (SIRT)
There is limited evidence that SIRT may improve PFS and OS if added to systemic chemotherapy in CRC patient with unresectable liver metastases
Townsend 2009, very low level of evidence

In patients with unresectable liver metastases, an effect of SIRT on PFS or OS when added to hepatic artery infusion could neither be demonstrated nor refuted
Townsend 2009, very low level of evidence

Stereotactic Body Radiation Therapy (SBRT)
In CRC patients with unresectable liver metastases, an effect of stereotactic body radiotherapy on overall survival could neither be demonstrated nor refuted.
Tipton 2011, NHS 2010, very low level of evidence

Literature summary

Treatment (isolated) liver/lung metastases

Radio-frequency ablation (RFA)

Cirocchi et al.1 identified in a Cochrane review 18 studies comparing radio-frequency ablation (RFA) with other treatment modalities among patients with resectable and unresectable liver metastases. Seventeen studies were not randomised with an increased risk for selection bias and an imbalance in the baseline characteristics of the participants included in all studies. All studies were classified as having an elevated risk of bias. Survival and local recurrence vary widely between studies; main results are reported in Table 5. The heterogeneity regarding interventions, comparisons and outcomes rendered the data not suitable for pooling, and the general conclusion of the review was that there is insufficient evidence regarding the use of RFA. Weng et al.2 attempted to pool the same studies but considered this pooling as inappropriate.

A single RCT was included (Ruers 2010) from an abstract of 2010 ASCO Annual Meeting. The final results of the study were published in 2012.3 It compared 60 patients receiving RFA plus CT versus 59 patients receiving CT alone, it showed that PFS at 3 years was significantly higher in the group that received RFA (HR 0.63; 95%CI 0.42-0.95), but no effect on overall mortality could be demonstrated. 30-month OS was high in both groups, 61.7% (95%CI 48.2-73.9%) in the RFA group and 57.6% (95%CI 44.1-70.4%) in the systemic therapy only group.

We updated the systematic review of Cirocchi et al using the same strategy from the search date of the review. No additional RCT’s were found, 3 observational studies case series were excluded as only the abstracts were available and insufficient information was available to assess quality and method.

Hepatic artery (HAI) chemotherapy

Mocellin et al 20114 included 10 RCTs that compared hepatic artery infusion (HAI) with systemic chemotherapy in CRC patients with unresectable liver metastases. HAI regimens were based on fluoxuridine (FUDR), 5-fluorouracil or either one of these two fluoropyrimidines in eight and one RCT, respectively. Systemic chemotherapy (SCT) consisted of FUDR or 5-fluorouracil in three and seven RCT, respectively. Only 2 out of ten studies were considered to be of high quality. Crossover to HAI was reported in 4/10 trials and the proportion of patients who received allocated treatment was often low. By pooling the summary data, tumour response rate resulted in 42.9% and 18.4% for HAI and SCT, respectively (RR = 2.26; 95% CI, 1.80 to 2.84; P < 0.0001). Mean weighted median OS times were 15.9 and 12.4 months for HAI and SCT, respectively: the meta-risk of death was not statistically different between the two treatment groups (HR = 0.90; 95% CI, 0.76 to 1.07; P = 0.24). Subgroup analysis taking into account quality of the studies confirmed this result. No additional RCT’s were identified, starting from the search date (January 2011).

Chemo-embolization

Carter et al 2009 5 did a systematic review on chemo-embolization and identified two abstracts on two small case series. An update starting from the search date (2008) was done (Table 9).

4 case series and 1 phase 3 trial for which at least a full text report existed were identified published since the Carter review (Table 10).

Fiorentini et al. 20126, in an RCT with unclear risk of bias (unclear randomization, no or unclear allocation concealment, no blinding of outcome assessment, albeit only important for progression free survival), randomised 75 patients to either chemo-embolisation with irinotecan eluting beads (DEBIRI) or FOLFIRI. The primary end-point was survival; secondary end points were response, recurrence, toxicity, quality of life, cost and influence of molecular markers. At 50 months, overall survival was significantly longer for patients treated with DEBIRI than for those treated with FOLFIRI (p=0.031, log-rank) Hazard ratio: 0.60 (95%CI 0.37-0.97). Median survival was 22 months (95%CI 21-23 months), for DEBIRI and 15 months (95%CI 12-18 months) for FOLFIRI. Progression-free survival was 7 months (95%CI 3-11 months) in the DEBIRI group compared to 4 months (95%CI 3-5 months) in the FOLFIRI group and the difference between groups was statistically significant (p=0.006, log-rank). Extra-hepatic progression had occurred in all patients by the end of the study, at a median time of 13 (95%CI 10-16) months in the DEBIRI group compared to 9 (95% CI 5-13) months in the FOLFIRI group. A statistically significant difference between groups was not observed (p=0.064, log-rank).The median time for duration of improvement to quality of life was 8 (95%CI 3-13) months in the DEBIRI group and 3 (95%CI 2-4) months in the FOLFIRI group. The difference in duration of improvement was statistically significant (p=0.00002, log-rank).

Martin et al., 20097 reported on 55 cases of unresectable colorectal hepatic metastasis patients who had failed standard therapy who received repeat embolisations with irinotecan loaded beads (max 100 mg per embolization) per treating physician’s discretion. The median disease free and overall survival from the time of first treatment was 247 days and 343 days.

Vogl et al 20098 treated 463 patients (mean age, 62.5 years; range, 34.7-88.1 years) with unresectable liver metastases of colorectal cancer that did not respond to systemic chemotherapy repeatedly treated chemo-embolization in 4-week intervals. In total, 2441 chemo-embolization procedures were performed (mean, 5.3 sessions per patient). The local chemotherapy protocol consisted of mitomycin C alone (n = 243), mitomycin C with gemcitabine (n = 153), or mitomycin C with irinotecan (n = 67). Embolization was performed with lipiodol and starch microspheres for vessel occlusion. Tumour response was evaluated with magnetic resonance imaging. Evaluation of local tumour control resulted in partial response (68 patients [14.7%]), stable disease (223 patients [48.2%]), and progressive disease (172 patients [37.1%]). The 1-year survival rate after chemo-embolization was 62%, and the 2-year survival rate was 28%. Median survival from date of diagnosis of liver metastases was 38 months and from the start of chemo-embolization treatment was 14 months. There was no statistically significant difference between the three treatment protocols.

Albert et al. 20119 reported on 121 patients undergoing chemo-embolization with cisplatin, doxorubicin, mitomycin C, ethiodized oil, and polyvinyl alcohol particles, performed at monthly intervals for 1 to 4 sessions. 2 (2%) had partial response, 39 (41%) stable disease, and 54 (57%) progression. Median time to disease progression (TTP) in the treated liver was 5 months, and median TTP anywhere was 3 months. Median survival was 33 months from diagnosis of the primary colon cancer, 27 months from development of liver metastases, and 9 months from chemo-embolization.

Aliberti et al. 201110 reported on 82 patients presenting with metastatic colorectal carcinoma to the liver after failing chemotherapy undergoing chemo-embolisations with drug eluding beads with irinotecan. The primary endpoints were tumour shrinkage, safety, feasibility, compliance, and overall survival. RECIST was used to assess response. Observed adverse effects were: right upper quadrant pain (40%), fever (80%), nausea (27%) and increased transaminases (70%). The median follow-up was 29 months. After the first treatment, 75 out 82 patients declared an improvement of their well being lasting more than 18 weeks. The median duration of response was 6 (range 3-10) months; the median follow up time was 29 (range 7-48) months. The median survival was 25 (range 6-34) months, with progression free survival at 8 (range 4-16) months.

Radio-embolization, Selective Internal Radiation Therapy (SIRT)

Rizell et al. 201011 identified eight studies on patients with unresectable liver metastases from CRC. Three studies were controlled studies, two of which being randomised (RCT). The two RCT’s were also reported by the Cochrane review of Townsend et al, 200912 which only focussed on RCT’s. Main results of those RCT’s are reported in the evidence profile (Table 4). The other five studies were case series. One of the RCTs was of moderate and the other of low scientific quality. The nonrandomised, controlled study was also of low scientific quality. There was no difference in survival between radio-embolization with 90Yttrium and the control therapy in the RCT of moderate scientific quality or in the non-randomised, controlled study of low scientific quality. The frequency of patients with a complete or partial tumour response varied between 34 – 75 %. Most patients experienced nausea, abdominal pain and extreme fatigue. A serious adverse effect occurred in 2 – 4 % with regard to liver toxicity, in 12 % with regard to bilirubin-toxicity and in 5 – 8 % with regard to gastrointestinal toxicity.

The review was updated from the search date on (January 2010).

Hendlisz et al. 201013 reported on a prospective, multicenter, randomized phase III trial in patients with unresectable, chemotherapy-refractory liver-limited metastatic CRC (mCRC) comparing arm A (fluorouracil [FU] protracted intravenous infusion 300 mg/m 2 days 1 through 14 every 3 weeks) and arm B (radio-embolization plus intravenous FU 225 mg/m2 days 1 through 14 then 300 mg/m2 days 1 through 14 every 3 weeks) until hepatic progression. The primary end point was time to liver progression (TTLP). Cross-over to radio-embolization was permitted after progression in arm A. Forty-six patients were randomly assigned and 44 were eligible for analysis (arm A, n = 23; arm B, n = 21). Median follow-up was 24.8 months. Median TTLP was 2.1 and 5.5 months in arms A and B, respectively (hazard ratio [HR] = 0.38; 95% CI, 0.20 to 0.72; P = .003). Median time to tumour progression (TTP) was 2.1 and 4.5 months, respectively (HR = 0.51; 95% CI, 0.28 to 0.94; P = .03). Grade 3 or 4 toxicities were recorded in six patients after FU monotherapy and in one patient after radio-embolization plus FU treatment (P = .10). Twenty-five of 44 patients received further treatment after progression, including 10 patients in arm A who received radio-embolization. Median overall survival was 7.3 and 10.0 months in arms A and B, respectively (HR = 0.92; 95% CI, 0.47 to 1.78; P = .80). The study had following limitations: trial was prematurely closed (with the number of enrolled patients lower than required (based on power analysis); open- label design; liver progression not documented in 3 pts of arm B; in 4 pts from arm B there was an unjustified change in the treatment allocated by randomization.

Chua et al. 201114 reported on a prospective database of a major yttrium-90 microsphere radio-embolization treatment centre in Sydney, Australia, that included 140 patients with unresectable colorectal liver metastases. One hundred and thirty-three patients (95%) had a single treatment, and seven patients (5%) had repeated treatments. Response following treatment was complete in two patients (1%), partial in 43 patients (31%), stable in 44 patients (31%), and 51 patients (37%) developed progressive disease. Combining chemotherapy with radio-embolization was associated with a favourable treatment response (P = 0.007). The median overall survival was 9 (95%CI 6.4-11.3) months with a 1-, 2-, and 3-year survival rate of 42, 22, and 20%, respectively. Primary tumour site (P = 0.019), presence of extra-hepatic disease (P = 0.033), and a favourable treatment response (P < 0.001) were identified as independent predictors for survival.

Kosmider et al 201115 reported on 19 patients who underwent radio-embolization (RE) plus systemic chemotherapy as a first-line treatment for unresectable liver metastases from colorectal cancer (CRC). Overall response rate according to RECIST was 84% (two complete responses and 14 partial responses). Median progression-free survival (PFS) time was 10.4 months and median overall survival (OS) time was 29.4 months. For patients with disease confined to the liver, PFS improved (10.7 mo versus 3.6 mo; P = .09), with significant prolongation of OS (median, 37.8 mo versus 13.4 mo; P = .03) compared with those who had extra-hepatic disease. Serious treatment-related toxicities included febrile neutropenia with concurrent FOLFOX treatment, a perforated duodenal ulcer, and one death from hepatic toxicity.

Bester et al 201216 reported on a retrospective study including 224 patients with chemotherapy-refractory liver metastases treated with yttrium-90 ( 90Y) resin microspheres, The median OS embolization group was 11.9 months (95% CI: 10.1-14.9 months). A comparison was made to a control group of 29 patients who underwent standard care but we did not consider this comparison as valid.

Martin et al 201217 reported on twenty-four patients with unresectable mCRC with liver metastases treated with yttrium-90 microsphere radio-embolization. 54% had extra-hepatic disease; 67% had bilobar involvement. The patients had received a median of 3 prior therapies. No objective responses were observed. Five patients had a CEA response. Median PFS and OS were 3.9 months (95% CI, 2.4-4.8 months) and 8.9 months (95% CI, 4.2-16.7 months), respectively. Patients older than 65 years had improved PFS (4.6 vs. 2.4 months) and OS (14 vs. 5.5 months) vs. younger patients, likely due to receipt of 90Y treatment earlier in their disease course. The presence of extrahepatic disease and the absence of CEA response appeared negatively predictive of efficacy.

Seidensticker et al. 201218 reported on a matched-pair comparison of patients who received radio-embolization plus best supportive care (BSC) or BSC alone for extensive liver disease. The study included 29 patients who received radio-embolization, retrospectively matched with patients for prior treatments and tumour burden and then 29 patients were consecutively identified with two or more of four matching criteria: synchronous/metachronous metastases, tumour burden, increased ALP, and/or CEA >200 U/ml. Of 29 patients in each study arm, 16 pairs (55.2%) matched for all four criteria, and 11 pairs (37.9%) matched three criteria. Compared with BSC alone, radio-embolization prolonged survival (median, 8.3 vs. 3.5 months; P < 0.001) with a hazard ratio of 0.3 (95% confidence interval, 0.16-0.55; P < 0.001) in a multivariate Cox proportional hazard model. Treatment-related adverse events following radio-embolization included: grade 1-2 fatigue (n = 20, 69%), grade 1 abdominal pain/nausea (n = 14, 48.3%), and grade 2 gastrointestinal ulceration (n = 3, 10.3%). Three cases of grade 3 radiation-induced liver disease were symptomatically managed. This small observational study attempted to control for confounding by matching on a number of criteria but nevertheless there remains a high risk of residual confounding.

 

Stereotactic Body Radiation Therapy (SBRT)

One systematic review of Tipton et al.19 was excluded because no primary results were reported, however the same systematic review was reported in a more detailed way in a HTA report by Agency for Healthcare Research and Quality (AHRQ).20

Two HTA reports were identified. The National Radiotherapy Implementation Group Report from the NHS identified 9 case series on liver metastases, with overall survival ranging from 16 to 92 months and local control ranging from 71 to 92 %.21 In some of those studies colorectal and other metastases are mixed however.

The AHRQ, in the report mentioned above, identified the same studies and added two small cases series with results within the same range. Neither comparative studies nor RCT’s were found after the search date of the AHRQ review (December 2010).

One large case series of Chang et al.22 was identified, reporting 12-month, 18-month, and 24-month OS rates of 72%, 55%, and 38%, respectively and 12-month, 18-month, and 24-month local control rates of 67%, 65%, and 55%, respectively. 

Considerations

Radio Frequency Ablation and Microwave ablation

In patients with resectable liver metastases surgical resection remains the first choice. Patients who are not suitable for surgical resection by age, comorbidity, unfavorable location of the lesion resection, or where a history of extensive abdominal surgery in absence of or stable extra-hepatic disease, RFA can be a good local treatment option with good clinical outcomes.

 

Trans arterial chemo embolization

Partial liver resection is the gold standard. TACE for colorectal liver metastases should (still) be considered as experimental treatment.

 

The role of TACE in patients with non-resectable colorectal liver metastases in comparison with other local treatment techniques or systemic treatment should be adequately studied in randomized trials. At this moment there are no data that the advantages and disadvantages of TACE have compared to other, local non-surgical techniques. There is not enough evidence to apply TACE if there are systemic treatment options.

 

Stereotactic radiotherapy

The role of stereotactic radiotherapy in comparison with other local treatment techniques such as RFA should be investigated in randomized trials. At present there are no data that have the advantages and disadvantages of SRT compared with other local non-surgical techniques.

 

Authorization date and validity

Last review : 16-04-2014

Last authorization : 16-04-2014

The validity of this guideline and its associated modules is five years. For various reasons, it may be necessary to edit modules sooner than intended. The National Working Group on Gastrointestinal Cancers therefore annually assesses the content of the guideline and its associated modules. By 2016 it is decided whether a new multidisciplinary working group should be installed to revise the entire guideline.

Initiative and authorization

Initiative : Nederlandse Vereniging voor Radiotherapie en Oncologie

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging van Maag-Darm-Leverartsen
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Klinische Geriatrie
  • Nederlandse Vereniging voor Nucleaire geneeskunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie
  • Vereniging Klinische Genetica Nederland

General details

All members were mandated by a scientific, professional or patient association. In the composition of the working group we tried to take national distribution, input from participants from both academic and general hospitals and representatives of various disciplines into account. Patients are also represented by delegation into the working group, as well as a focus group meeting.

Scope and target group

Goal

This guideline and its associated modules are - as much as possible - based on scientific research and / or consensus. It is a document with recommendations to support the daily practice of health care professionals involved in patients with (possible) colon cancer, rectal cancer or colorectal liver or lung metastases. It provides recommendations for diagnosis, treatment, follow-up and organization of care. The guideline and its associated modules are thus seeking to improve the quality of care, to increase transparency of choice for treatment and reduce diversity.

 

Target population

Each year colorectal cancer is identified in approximately 13,000 new patients. Rectal carcinoma occurs in about 1 in 3 patients of this. In the Netherlands, the colorectal cancer in both men and women rank third place in incidence of oncological diseases. The expected number of patients diagnosed with colorectal cancer are increased in 2020 to about 17,000, reflecting a slight increase in incidence (especially in men), population growth and aging.

Colorectal cancer is slightly more common in men than in women and ninety percent of patients 55 years or older. More information about the Dutch population can be found at the Netherlands Cancer Registry: www.cijfersoverkanker.nl

This guideline is applicable to all adult patients with (suspected) a primary colorectal carcinoma and patients with metastatic disease. Particular attention is given to the elderly. A separate guideline is available for adult patients with an increased risk of hereditary colon cancer.

Target Audience

This guideline and its associated modules are intended for all professionals involved in the diagnosis, treatment and rehabilitation of patients with (metastatic) colorectal cancer, such as surgeons, general practitioners, consultants, internists, gastroenterologists, (specialist) nurses, clinical geneticists, paramedics, pathologists, radiologists and radiotherapists. The complete guideline is used to develop a patient education text from the Dutch patients Consumer Federation (NPCF).

 

Members of the guideline panel

Name

Function

Hospital

Mandated

Mw. prof. dr. C.A.M. Marijnen chair

Radiotherapist

LUMC Leiden

NVRO

Mw. prof. dr. R.G.H. Beets-Tan

Radiologist

MUMC Maastricht

NVVR

Mw. S. de Bruijn

Specialist nurse

Renier de Graaf hospital Delft

V&VN

Mw. dr. A. Cats

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Prof. dr. E.F.I. Comans

Nuclear doctor

VUMC Amsterdam

NVNG

Dr. A.R. van Erkel

Intervention radiologist

LUMC Leiden

NVVR

Mw. dr. M.A.M. Frasa

Clinical chemist

Groene Hart hospitalGouda

NVKC

Mw. C. Gielen

Specialist nurse

MUMC Maastricht

V&VN

Dr. E.J.R. de Graaf

Surgeon

IJsselland hospital Capelle a/d IJssel

NVVH

Mw. dr. M. Hamaker

Geriatrician

Diakonessenhuis Utrecht

NVKG

Mw. dr. J.E. van Hooft

Gastroenterologist

AMC Amsterdam

NVMDL

Mw. H.J.A.M.. Kunneman

Researcher

LUMC Leiden

n.v.t.

Mw. dr. M.E. van Leerdam

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Dr. H. Martijn

Radiotherapist

Catharina-hospital Eindhoven

NVRO

Mw. dr. A.M. Mendez

Romero

Radiotherapist

EMC Cancer Insititute Rotterdam

NVRO

Mw. prof. dr. I.D. Nagtegaal

Pathologist

UMCN St Radboud Nijmegen

NVVP

Dr. L.A. Noorduyn

Pathologist

Lab. Voor Pathologie Dordrecht e.o.

NVVP

Mw. A. Ormeling

Patient

Stomavereniging

NFK

Drs. T.A.M. van Os

Klinisch Geneticus

AMC Amsterdam

VKGN

Dr. F.T.M. Peters

Gastroenterologist

UMCG Groningen

NVMDL

Mw. J. Pon

Patient

NFK/SPKS

NFK

Mw. dr. J.E.A. Portielje

Medical oncologist

Haga hospital Den Haag

Gerionne

Prof. dr. C.J.A. Punt

Medical oncologist

AMC Amsterdam

NIV

Mw. dr. H. Rütten

Radiotherapist

UMCN Radboud Nijmegen

NVRO

Prof. dr. H.J.T. Rutten

Surgeon

Catharina-hospitalEindhoven

NVVH

Prof. dr. J. Stoker

Radiologist

AMC Amsterdam

NVVR

Dr. P.J. Tanis

Surgeon

AMC Amsterdam

NVVH

Dr. J.H. von der Thüsen

Pathologist

MC Haaglanden Den Haag

NVVP

Prof. dr. H.M.W. Verheul

Medical oncologist

VUMC Amsterdam

NIV

Prof. dr. C. Verhoef

Surgeon

EMC Cancer Insititute Rotterdam

NVVH

Dr. Tj. Wiersma

General practitioner

NHG

NHG

 

 

Name

Function

Location

Mw. drs. A.Y. Steutel

process manager

Utrecht

Drs. T. van Vegchel

process manager

Amsterdam

Mw. S. Janssen-van Dijk

secretary

Rotterdam

M.P.  van den Berg

Researcher

Bilthoven

P.F. van Gils

Researcher

Bilthoven

Mw. J. Robays

Methodologist

Brussels

Mw. drs. Y Smit

Methodologist

Germany

Mw. A. Suijkerbuijk

Researcher

Bilthoven

Mw. dr. L. Veerbeek

Methodologist

Groningen

Mw. dr. L. Verheye

Methodologist

Brussels

Mw. dr. G.A. de Wit

Researcher

Bilthoven

 

Patient involvement

Two patient experts have been part of the guideline development group. One on behalf of the Dutch Ostomy Association and on behalf of SPKS/NFK. Based on a focus group meeting experiences of patients regarding care were collected. The guideline also has been used to develop a patient education text for the Dutch patients Consumer Federation (NPCF).

Method of development

Evidence based

Implementation

Promoting the use of recommendations begins with a broad (digital) distribution of the guideline, using direct mailing and an article published in the Dutch Journal of Oncology. In other journals or training sessions, for example, the guideline is brought to the attention. An implementation plan for this guideline contains the key recommendations and an overview of barriers and facilitators for implementation.

Methods and proces

The working group met in July 2012 for the first time. Based on an initial list of problems by working group members a survey among professionals involved in patients with colorectal carcinoma was held. Through this survey, sixty professionals supplied and prioritized possible subjects for revision. Also, a focus group meeting was held, collection patients' experiences. The eleven most relevant questions were answered, and translated into English. Also, alle recommendations were translated into English.

 

Each clinical question was andwered by a subgroup within the development group. External methodologists provided the literature search, review, critical assessment, evidence tables and a draft literature review. Workgroup members suggested other considerations and recommendations.

Responsibility

The Comprehensive Cancer Organisation the Netherlands (IKNL) promotes that people with cancer and their families have access to a consistent and qualitatively adequate care as close to home as possible. IKNL was established to improve treatment, care and clinical research in oncology. It also has a role in setting up and supporting networks for palliative care. IKNL supports multidisciplinary guideline development for oncology and palliative care and facilitates the maintenance, management, implementation and evaluation of these guidelines.

AGREE was used to check the methodological quality of the guideline.

Search strategy

Searches are available upon request. Please contact the Richtlijnendatabase.