Management of Colon Cancer in Low- and Middle-Income Countries: Resource-Stratified Guidelines

Management of Colon Cancer in Low- and Middle-Income Countries: Resource-Stratified Guidelines

Gilberto Lopes, MD, MBA

@GlopesMD
Dec 09, 2015

In Puerto Madero, Buenos Aires' youngest and poshest neighborhood, all streets are named after women. I stayed on Macacha Güemes St., which celebrates the patriot who contributed to the May 1810 revolution that eventually brought independence from Spanish rule in myriad ways, from making uniforms and obtaining intelligence to raising money and negotiating treaties. She also ran the government in Salta province in the struggle that followed independence as the United Provinces of the River Plate were becoming Argentina.

Leaving the neighborhood through the Santiago Calatrava–designed Woman Bridge, one contemplates a large Argentinian flag, with its two light blue stripes intersected by a white one bearing a golden sun emblem, fluttering in front of the presidential palace. The Casa Rosada, the country´s answer to the White House, was appropriately lit pink in October for Breast Cancer Awareness Month.

I was in town for a colorectal cancer event, however. Although my talk specifically was on different options of antiangiogenic agents for the treatment of patients with advanced disease after first-line treatment, the main questions from the audience were—as they usually are when I am lecturing outside the United States and Europe—invariably about access and how to prioritize interventions.

Once the sixth richest country in the world (Argentina fed the hungry masses of post-war Europe and one of the old flour mills that made this possible has gained a new lease on life as the worth-visiting Faena Arts Center in Puerto Madero), after half a century of populist governments which mismanaged the economy, today it is a middle-income nation. Doctors here struggle to treat patients with scarce resources, as many of us do throughout Latin America, Africa, and Asia.

In 2012, in an attempt to answer the call to prioritize interventions, my colleagues and I, with support from the Asian Oncology Summit and Lancet Oncology, discussed and agreed upon a resource-stratified consensus on the management of colon cancer. While ostensibly named as an Asian consensus, the lessons drawn can easily be applied around the world. (See my previous post for a broad discussion of approaches to resource-stratified guidelines.)

We presented our suggestions using Breast Global Health Initiative resource levels, based on a four-tiered system: basic, limited, enhanced, and maximum. Basic level indicates fundamental services that are absolutely necessary for any colon cancer system to function. Limited level are second-tier services that intend to produce major improvements in outcomes and are achievable with scant financial means and modest infrastructure. Enhanced level are third-tier services that are optional in a resource-constrained setting but are important; they should produce further improvements in outcome and increase the number and quality of therapeutic options and patient’s choice. Maximum level represents services that might be used in settings with many resources or that might be recommended in colon cancer guidelines that do not account for resource constraints. Interventions at the maximum level should be judged a lower priority than resources or services listed in the basic, limited, or enhanced categories, on the basis of their great cost or impracticality for broad use in a resource-limited environment. To be useful, resources at the maximum level typically depend on the existence and functionality of all lower-level resources.

The specific recommendations were as follows:

BASIC LEVEL

General

  • Health education about risk factors for colorectal cancer, and development of infrastructure to diagnose and treat the disease, are imperative to reduce mortality in the long term
  • Palliation of symptoms should be provided

LIMITED LEVEL

General

  • Health education about risk factors for colorectal cancer, and development of infrastructure to diagnose and treat the disease, are imperative to reduce mortality in the long term
  • Palliation of symptoms should be provided

Surgical and Adjuvant Treatment

  • Colonoscopy should be used to diagnose disease, and abdominal ultrasound and chest radiography should be done for preoperative staging
  • Patients without metastatic disease should have appropriate oncologic surgery
  • Patients with high-risk stage II and III disease should be offered treatment with bolus fluorouracil

Resectable and Potentially Resectable Metastases

  • Resection of liver and other visceral metastases should be considered, and bolus fluorouracil chemotherapy if resources allow

Palliative Chemotherapy

  • Patients should receive palliative chemotherapy with bolus fluorouracil

ENHANCED LEVEL

General

  • Health education about risk factors for colorectal cancer, and development of infrastructure to diagnose and treat the disease, are imperative to reduce mortality in the long term
  • Palliation of symptoms should be provided

Primary Prevention and Early Diagnosis

  • Consideration should be given to screening programmes that incorporate the faecal occult blood test, colonoscopy, and other methods

Surgical and Adjuvant Treatment

  • CT of the abdomen and pelvis should be used for preoperative staging (addition of chest CT can be considered)
  • Laparoscopic-assisted procedures should be considered when appropriate
  • Patients with high-risk stage II and stage III disease should be offered treatment with a fluoropyrimidine and oxaliplatin
  • Continuous-infusion fluorouracil or capecitabine are preferred options

Resectable and Potentially Resectable Metastases

  • Resectable metastases should be removed and chemotherapy given (a fluoropyrimidine and oxaliplatin)
  • Unresectable disease should be treated with chemotherapy (a fluoropyrimidine and oxaliplatin, irinotecan, or both) in an attempt to make it resectable

Palliative Chemotherapy

  • A fluoropyrimidine and oxaliplatin or irinotecan should be given
  • Second-line treatment should be either irinotecan or oxaliplatin, and a fluoropyrimidine
  • Use of single agents in sequence is acceptable for patients who do not need a faster response or who have poor performance status

MAXIMUM LEVEL

General

  • Health education about risk factors for colorectal cancer, and development of infrastructure to diagnose and treat the disease, are imperative to reduce mortality in the long term
  • Palliation of symptoms should be provided

Primary Prevention and Early Diagnosis

  • Screening once a year with the faecal occult blood test, colonoscopy every 10 years, and other options (CT colonography, sigmoidoscopy, and faecal DNA or immunohistochemistry tests) should be used

Surgical and Adjuvant Treatment

  • CT of the abdomen and pelvis should be used for preoperative staging (addition of chest CT can be considered)
  • PET/CT can be considered when appropriate (eg, patients with potentially curable M1 disease)
  • Laparoscopic-assisted procedures should be considered when appropriate
  • Appropriate patients with high-risk stage II and III disease should be offered treatment with a fluoropyrimidine and oxaliplatin
  • Continuous-infusion fluorouracil or capecitabine are preferred options for the fluoropyrimidine

Liver-Only and Other Potentially Resectable Metastases

  • Resectable liver metastases should be removed and perioperative chemotherapy given, with a fluoropyrimidine and oxaliplatin
  • Unresectable disease should be treated with neoadjuvant chemotherapy with a fluoropyrimidine and either oxaliplatin, irinotecan, a targeted agent, or a combination of these, in an attempt to make the disease resectable (cetuximab or bevacizumab and a doublet are preferred over FOLFOXIRI, a triplet combination of fluorouracil, irinotecan, and oxaliplatin)

Palliative Chemotherapy

  • Chemotherapy and targeted agents should be given according to guidelines
  • Exposure to all active agents (fluoropyrimidines, irinotecan, oxaliplatin, antiangiogenic agents and anti-EGFR monoclonal antibodies for RAS wild-type tumors) correlates strongly with improvements in overall survival

For those who would like to read these suggestions, the full text for the guidelines can be found on The Lancet Oncology.

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