BOWEL CANCER TREATMENT IN GERMANY

• In Western countries colorectal cancer (CRC) is the second most common of all cancers and, as a rule, develops from an adenomatous polyp.

• Right-sided tumours more often present with signs of blood loss and anaemia; left-sided tumours – with signs of bowel obstruction (in particular a change in stool frequency and colicky abdominal pain).

• Routine screening of patients at average risk of cancer should begin at the age of 50; the generally accepted screening methods are the faecal occult blood test (FOBT) and/or endoscopy.

• During follow-up after treatment for CRC, monitoring of the CEA level helps to detect recurrence. In CRC the level of carcinoembryonic antigen (CEA) is often raised, but this marker is not sufficiently specific and cannot be used for screening.

• Treatment involves resection of the bowel, sometimes combined with chemotherapy and/or radiotherapy; outcomes vary considerably depending on the stage of the disease.

• urgent arrangement of an appointment with leading German experts, gastrointestinal oncologists ;
• diagnosis and treatment exclusively at certified university cancer centres;
• selection of the optimal individual therapy: the treatment strategy for every patient is determined at a multidisciplinary tumour board attended by oncologists, surgeons, chemotherapists, radiologists, pathologists and radiation oncologists;
• innovative diagnostic techniques;
• precise pathological diagnosis at certified institutes of pathology;
• treatment started without delay once the work-up is complete;
• adherence to the international treatment protocols recommended by the European Society for Medical Oncology (ESMO) and the German Cancer Society (DKG);
• the full range of radical and palliative operations;
• continuous monitoring of the tumour's response to drug therapy, which allows oncologists to change the treatment regimen in good time and to select more effective agents, ensuring a high survival rate in cancer patients even at an advanced stage;
• treatment with genuine latest-generation cytostatic drugs;
• adjuvant chemotherapy;
• the highest quality standards in medical care;
• early postoperative rehabilitation of patients;
• the use of minimally invasive surgical techniques wherever possible;
• implantation of a port system for infusion chemotherapy to avoid damage to the peripheral veins;
• supportive therapy to minimise the side effects of chemotherapy and radiotherapy.

When radical surgery is not feasible or the patient is at high perioperative risk, a limited palliative procedure may be undertaken (for example to relieve obstruction or to resect a perforated segment); median survival is 7 months. Some obstructing tumours can be reduced in size by endoscopic laser treatment, electrocoagulation or the placement of stents. Chemotherapy helps to shrink the tumour and prolongs life by several months.

Newer drugs used as monotherapy or in combination include capecitabine (a precursor of 5-fluorouracil), irinotecan and oxaliplatin. Monoclonal antibody agents such as bevacizumab, cetuximab and panitumumab also have some efficacy. No regimen is more effective than the others at prolonging life in metastatic colorectal cancer, although some have been shown to slow the progression of the disease. In advanced colon cancer, chemotherapy should be given under the supervision of an experienced chemotherapist who works with investigational drugs.

When liver metastases are present, infusion of floxuridine or radioactive microspheres into the hepatic artery (intermittently in the radiology department, or continuously by means of a pump implanted under the skin or an external pump attached to the patient's belt) has proved more effective than systemic chemotherapy. The advantages of these methods, however, have not been sufficiently studied. If extrahepatic metastases are present as well, transarterial intrahepatic chemotherapy offers no advantage over systemic chemotherapy.

After surgery, colonoscopy should be performed annually for the first 5 years and, if no polyps or tumours are found, thereafter at 3-year intervals. If a complete colonoscopy could not be carried out before the operation because the tumour obstructed the lumen, this examination must be performed 3 months after surgery.

Additional surveillance for signs of recurrence should include history taking, physical examination and laboratory tests (in particular a full blood count and liver function tests). The surveillance schedule is every 3 months for the first 3 years, then every 6 months for 2 years. Imaging (CT or MRI) is usually recommended annually, but its value in routine surveillance, when examination and blood tests reveal no abnormalities, has not been established.

• surgical – resection, in some cases – combined with radiotherapy, chemotherapy or both.

Surgical treatment

Surgery can be undertaken in 70% of patients with no evidence of metastatic disease. The radical approach involves wide resection of the tumour together with the regional lymphatic pathways and anastomosis of the segments of the large bowel. If the length of uninvolved bowel wall between the edge of the tumour and the anus is ≤ 5 cm, abdominoperineal excision with a permanent colostomy is performed.

When the number of liver metastases is limited (1–3), liver resection is subsequently recommended in selected patients who show no signs of debilitation. Liver resection is performed in patients whose primary tumour has been resected, whose metastatic lesions are confined to one lobe and who have no extrahepatic metastases. Only a small proportion of patients with liver metastases meet these criteria; 5-year survival after the operation is 25%.

Adjuvant therapy

Chemotherapy (usually with 5-fluorouracil and leucovorin) increases survival in patients with colon cancer and evidence of lymph node metastases from 10 to 30%. In patients with rectal cancer in whom 1 to 4 lymph nodes are involved, the course of the disease improves with a combination of radiotherapy and chemotherapy; when > 4 lymph nodes are involved this combined approach is less effective. Preoperative radiotherapy and chemotherapy are worthwhile, as they increase the resectability of rectal cancer and reduce the risk of lymph node metastasis.

• biopsy at colonoscopy;
• CT to assess the growth and spread of the tumour.

A positive faecal occult blood test, or the detection of a lesion at sigmoidoscopy or by other imaging methods, must be followed by colonoscopy. Any lesion should be removed completely and examined histologically. If a lesion is sessile or cannot be removed at colonoscopy, surgical excision is strongly recommended.

Barium enema, especially with double contrast, detects many lesions but is less accurate than colonoscopy; it is not the preferred method for investigating patients with a positive FOBT result.

Once cancer has been diagnosed, abdominal CT, chest radiography and standard laboratory tests should be performed to look for signs of metastatic disease and anaemia and to assess the patient's general condition.

The level of carcinoembryonic antigen (CEA) is raised in 79% of patients with CRC, but this test is not specific and is therefore not recommended for screening. However, if the CEA level is raised before surgery and falls after removal of the colon tumour, serial CEA monitoring helps to detect recurrence earlier. The tumour markers CA 19-9 and CA-125 can also be used for this purpose.