Supportive care

In providing supportive care, attention should be given to the specific care needs of the patient treated for a colorectal malignancy and their family.

 

From the moment ‘colorectal carcinoma' is diagnosed, a contact person can be assigned to the patient who can function as ‘Case manager’ and who can be easily consulted during the care path.

 

Within the centre in which patients with a colorectal malignancy are being treated, it must be assured that the stoma care is in accordance with the recommendations in the guideline ‘Stomazorg Nederland’ (‘Stoma care The Netherlands’).

 

As a standard and structural and preferably at different moments in the entire care process, it is recommended that patients with a colorectal malignancy are screened for ‘distress’, by means of a validated measuring instrument call the Distress Thermometer.

 

After treatment of rectal carcinoma (by rectal surgery, in combination or not in combination with (chemo)radiation of the lesser pelvis), there should be specific attention for faecal or urinary incontinence and sexual dysfunction.

 

Referral to a specialised pelvic physiotherapist should occur on indication.

 

Follow-up

General

  • It should be clear per hospital and per patient who coordinates follow-up.
  • Half-yearly follow-up consult for 2 to 3 years, and then annually until 5 years after surgery.

 

CEA and imaging for stage I-III

  • Ultrasound of the liver or abdominal CT half-yearly for a duration of 1 to 2 years, and then annually until 5 years after surgery CT scan is indicated if it is difficult technically to perform an ultrasound, or CT may be considered if there is a high-risk of recurrence given higher sensitivity
  • Three- to six-monthly CEA determination for 3 years, then half-yearly until 5 years after treatment
  • With rectal carcinoma, a chest X-ray or chest CT may be considered, possibly dependent on the risk of recurrence
  • With pT1N0 stage, CEA and imaging can be omitted due to low yield

 

Colonoscopy

  • Colonoscopy 1 year after surgery, subsequently surveillance according to the Dutch guideline Coloscopy Surveillance (an interval of 3 or 5 years is recommended on the basis of the number, size, and localisation of the polyps)
  • If a (complete) colonoscopy is not performed prior to surgery (in the case of a perforated tumour or stenosing non-passable tumour or synchronous polyps which were not removed), a colonoscopy follows 3 months after a resection This examination is not required if the colon segment proximal to the obstructing malignancy has been included in the resection sample
  • If a complete colonoscopy is not possible, CT colography is an alternative
  • After poliepectomy of a T1 carcinoma, a colonoscopy after 3 and subsequently after 6 months is recommended, followed by routine colonoscopy surveillance according to the guideline
  • Endoscopic inspection of the scar after rectum-sparing treatment should be performed 3 to 6 monthly for a duration of 2 to 3 years, followed by routine colonoscopy surveillance according to the guideline

 

Detecting and treating the consequences of colorectal carcinoma

Faecal incontinence

Patients with faecal incontinence should receive guidance from a surgeon or in collaboration with a nurse specialist with relevant expertise.

The nature of the faecal continence problems (frequency, consistency, discrimination, uncontrollable loss, imperative urge to defaecate and fragmentation) must be ascertained in order to be able to explain the underlying cause to patients.

If the problems are not understood, imaging may help and other causes may be excluded.

Loperamide, fibre supplements, irrigation and pelvic physiotherapy may also be employed as supporting treatment.

Neurostimulation should only be offered within a trial context.

 

Miction problems after rectal surgery

The guidance of patients with miction issues after treatment of a rectal carcinoma can be provided by a surgeon and/or a nurse specialist. Dysfunction in the area of urinating after rectal surgery should be specifically raised with the patient for further details in order to determine possible causes.

 

Referral to a urologist should be considered for the purpose of additional diagnostics and possible supportive treatments.

 

Sexual dysfunction after treatment of a rectal carcinoma

Sexual dysfunction after treatment of rectal carcinoma in the preoperative phase should be discussed with the patient, also within the framework of fertility.

 

During the aftercare and follow-up phase, specific questions should be asked in relation to possible problems in the area of sexuality, so that a focused referral to a urologist or sexologist can take place. 

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

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