Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) – Surgical Management

Abstract

The Department of Health published national referral guidelines in 2000 for suspected cancers, based on high-risk symptoms and signs, the so called ‘2 week rule’. The recommendation was that units should see in excess of 95% of referrals within 2 weeks. This recommendation has successfully improved service delivery and patient processing within the NHS, although evidence of improved outcomes is unproven (Hitchins et al., 2014; Patel et al., 2014; Schneider et al., 2013). In 2005, the NHS National Cancer Plan produced treatment targets for colorectal cancer, consisting of 62 days from ‘2 week’ referral and 31 days from the ‘decision to treat date’ (Department of Health, 2006). However, the health service's primary emphasis should be on quality and outcomes, rather than on time to treatment (Murchie et al., 2014). Treatment should begin within 31 days of the decision to treat. Recommendation grade D A colorectal cancer MDT serving a population of 200 000 is expected to manage around 120 new patients per year. Quality cancer treatment depends on coordination between multiple treatments and treatment providers, the exchange of technical information, and effective communication between clinical, nursing and other disciplines involved in the patients’ management. Multidisciplinary teams (MDTs) should improve coordination, communication, and decision making between health-care team members and patients, and produce better outcomes. This can be achieved by reflective practice, audit, patient surveys, MDT ‘away days’ to develop the service delivered. Feedback should be systematically evaluated and any changes made to the care for both the general patient population and for individual patients, should be subsequently reviewed and evaluated by the team to see if improvement has been achieved. Despite the standardization of delivery of cancer services via this method, research showing the effectiveness of MDT working is scarce (Fennell et al., 2014; Fleissig et al., 2006). The ACPGBI ‘Resources for Coloproctology 2015’ document (Association of Coloproctology of Great Britain and Ireland, 2015) informs clinicians, managers, medical directors, chief executives and politicians, to address any existing inequalities in care for patients and achieve uniform standards nationally. The core colorectal MDT should include; The extended MDT members should include; The management plans for all colorectal cancer patients should be reviewed by a Colorectal MDT. Recommendation grade C There have been a number of reports assessing effects of surgical specialization and patient throughput (both the number of cases treated per surgeon and per hospital) on outcomes in colorectal cancer (Etzioni et al., 2014). The NICE colorectal cancer guidance (2004) identified 6 systematic reviews and 28 other studies in this field. The evidence indicates that better surgical specialization and training is associated with improved outcomes, particularly in rectal cancer (Archampong et al., 2012; Etzioni et al., 2014). These benefits of surgical specialization appear more pronounced for rectal cancer than for colon cancer. In rectal cancer, 11 of 13 studies reported that more specialized surgeons achieved better outcomes. Six out of eight good quality studies showed significant effects on one or more of the following measures; survival rates (up to 5 years), quality of surgery (assessed by complication rates or tumour-free excision margins) and local recurrence rates (Archampong et al., 2012). Greater specialization is also associated with shorter in-patient stay and less frequent use of stomas (National Institute for Health and Clinical Excellence, 2004). It is advised that each surgeon in the MDT should ideally carry out a minimum of 20 radical colorectal cancer resections per annum (The Association of Coloproctology of Great Britain and Ireland, 2012). Surgery for colorectal cancer should be performed by surgeons with appropriate training and experience, working within an MDT. Recommendation grade B The 2000 NHS Cancer Plan (Department of Health, 2000) initially highlighted the important role of the CNS within the pathway for cancer patients. The initial paper stressed that CNSs were needed to provide psychological support but subsequent papers acknowledge the wider contribution to the overall quality and effectiveness of patients’ cancer management (Department of Health, 2011a). National cancer patient surveys demonstrate that by having access to a CNS, patients’ cancer experiences are much better co-ordinated, leading to better outcomes (Quality Health.). The colorectal CNS works autonomously and uses their training and experience of colorectal cancer to assist patients with their concerns and problems, whilst they are undergoing assessment, diagnosis, treatment and follow up of their disease. The CNS is seen as the key worker or patient advocate and is the person within the MDT who is most accessible to patients, working closely with them and their families/carers to provide information and constant support at each stage of their care (National Cancer Action Team, 2010). Their role is pivotal to coordinate access to different services and clinicians during individual patients’ clinical journey. As well as being a clinical expert within colorectal cancer, the CNS should possess a first level degree and have completed or is working towards, post-registration learning, specific to their specialism and role, such as advanced communication skills, leadership, management, teaching and research (Macmillan, 2015). The CNS will have a role in transforming patients’ experiences of cancer care by CNS-led activities such as improving quality and experience of care, reinforcing safety, increasing efficiency and demonstrating management and leadership (National Cancer Action Team, 2010). The intention of treatment, whether curative, potentially curative or palliative should be discussed in the MDT and communicated to the patient and primary care team. However, surgery for colorectal cancer should be avoided if the risks are deemed to outweigh the potential benefits, such as when the patient has major co-morbidity or the tumour is deemed unresectable. In this situation, a further opinion from another surgeon, or surgeons, or other relevant professionals, is encouraged if there are ongoing concerns about this decision in the mind of the surgeon, the patient, relatives or carers. 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