Palliative care and end-stage colorectal cancer management: the surgeon meets the oncologist

Abstract

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Keywords: Chemotherapy; Colorectal cancer; Multimodal treatment; Palliative care; Radiotherapy; Stenting; Surgery.

Figure 1

Algorithm for the management of incurable asymptomatic (or minimally symptomatic) stage IV colorectal cancer patients. ¹Depending on the regimen previously administered. KRAS-WT: KRAS-wild type; KRAS-MT: KRAS-mutation; FOLFOX: 5-Fluorouracil + Oxaliplatin; FOLFIRI: 5-Fluorouracil + Irinotecan; NRAS-WT = NRAS-wild type; CRC: Colorectal cancer; CHT: Chemotherapy.

Figure 2

Algorithm for the management of severely symptomatic incurable stage IV colorectal cancer patients (including emergency cases).

Figure 3

Improvement of survival after various chemotherapic regimens for incurable stade IV colorectal cancer patients through the last three decades. BSC: Best supportive care; 5-FU: 5-Fluorouracil; FOLFIRI: 5-Fluorouracil + Irinotecan; FOLFOX: 5-Fluorouracil + Oxaliplatin; IFL: 5-Fluorouracil bolus; CAPEOX: Capecitabine + Oxaliplatin; FA: Folic acid (Leucovorin); OS: Overall survival.