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Colon Cancer Care Found Lacking

By Lauran Neergaard
Associated Press

WASHINGTON, September 10, 2008 – Nearly two-thirds of hospitals fail to check colon cancer patients well enough for signs that their tumor is spreading, says a study that advises patients to ask about this mark of quality care before surgery. National guidelines say that when colon cancer is removed, doctors should check at least 12 lymph nodes for signs of spread. Checking fewer than 12 isn't considered enough to be sure the cancer is contained.

But a study of nearly 1,300 hospitals found that overall, just 38 percent fully comply with the guideline, Northwestern University researchers reported yesterday in the Journal of the National Cancer Institute. "It's a fairly simple thing we can do to try to improve care for our patients," said lead author Dr. Karl Bilimoria, of Northwestern and the American College of Surgeons. Colorectal cancer is the nation's second leading cancer killer, set to claim almost 50,000 lives this year.

Some 148,000 Americans are diagnosed annually. For many, the node check can be crucial. Whether cancer has entered these doorways to the rest of the body is an important factor in long-term survival - and thus helps doctors decide who gets chemotherapy after surgery and who can skip it. "Patients who could benefit from additional chemotherapy may not be getting complete treatment and have a higher chance of relapse," said Dr. Durado Brooks of the American Cancer Society, who wasn't involved with the study. "It is something that consumers need to begin asking. . . . Frankly, that is most likely to change medical practice."

To check enough nodes, surgeons must remove enough of the fat tissue by the colon where they hide, and pathologists must painstakingly dissect that tissue to find the tiny nodes.

Surgeons frequently tell of getting a pathology report of four clean nodes and asking the pathologist to find more, "and lo and behold, one of those additional nodes turns out to be positive," Bilimoria said.

PET Scans and Metastatic Disease

Guest Editor Dr. John Marshall MD
Oncology Desk Reference Published Sept. 2008 Excerpt from the 44th annual Meeting of the American Society of Clinical Oncology

“Clearly the role of PET scanning in the management of colorectal liver metastasis is controversial (abstract 4004). We must applaud the authors for performing truly the ideal study. Certainly the bias within the United States would be to do PET scanning, but I interact with several surgeons who do not feel that PET scanning is useful. I, myself, find PET scanning quite confusing in patients, as there is a relatively high false-positive and false-negative rate in patients with metastatic disease.

The level of detection of PET is quite low and the tumor size must be of at least 1cm to be reliably detected. Many low grade tumors are not PET avid even when of larger size. It is also important to recognize that PET scanning as a technique is not uniformly applied or understood across all radiology groups. Differences in machines and computing power make for dramatic differences in reading and inter-observer variations. However, despite all of those problems, this well performed randomized trial does suggest that PET scanning can prevent patients from undergoing futile surgeries. However, even with PET scanning, in this study there still was a 28% rate of futile surgery performed. Therefore, it is clear that we need even better imaging techniques to assist our decision making when attempting aggressive, invasive, although curative in intent, operations.“

Dr. John L. Marshall M.D. is an Associate Professor of Medicine, and serves as the Division Chief of Hematology/Oncology at Georgetown University Hospital. Dr Marshall is also the Director of Clinical Research at Lombardi Comprehensive Cancer Center.