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COLON CANCER TREATMENT PATHWAYS - THE CRITICAL, YET UNDER APPRECIATED, ROLE OF ENDOSCOPIC THERAPY

R Hollingworth
The Credit Valley Hospital, Mississauga, Ontario

BACKGROUND: Colon cancer is the second leading cause of cancer mortality for Canadians. There has been an increasing focus on colon cancer screening strategies, from both Federal and Provincial bodies. Ministries of Health have dedicated increased funds on several areas including cancer therapy. However, these focused efforts have failed to recognise the utility of endoscopic therapy. Gastroenterologists and endoscopic units are unable to attend to patients with alarm symptoms in a timely fashion (reference PAGE IV abstract). As such, there is enormous difficulty in considering any initiative towards average risk screening strategies. The current perception of "colon cancer screening" programs is that they are diagnostic with the potential preventive role of benign polyp removal. However, the therapeutic role of advanced colonoscopic techniques in modern endoscopic units is a critical and under-appreciated function.
AIM: 1) To document treatment pathways of patients with colon cancer and high-grade neoplastic polyps and 2) to determine the role of endoscopic therapy.
METHODS: Records from all patients diagnosed with colon cancer or high grade dysplastic polyps were reviewed from the pathology database at a large community hospital and regional cancer centre (The Credit Valley Hospital and Peel Regional Cancer Centre, Mississauga, Ontario). The treatment pathways were determined as: endoscopy, surgery, adjuvant therapy (chemo or radiation) and any combination. Not included in this survey were benign polyps.
RESULTS: Over a 16 month period, (Jan 2005-May 2006), a total of 104 patients were diagnosed: colon cancer (n=79), severe dysplastic polyps (n=25). The treatment pathway distribution of these follows:
                                          

	Severe Dysplasia	Cancer	Totals
Endoscopy Only	20	15	35
Surgery Only	5	4	9
Endoscopy and Surgery Only	0	34	34
Endoscopy, Surgery and Oncology	0	20	20
Endoscopy and Oncology only	0	1	1
Surgery and Oncology only	0	5	5

DISCUSSION: This survey reflects the clinical practice spectrum of colon cancer presenting at different stages and requiring different treatment pathways. The role of colonoscopy in the detection and removal of colonic polyps is well established as a cancer prevention strategy. This retrospective survey suggests endoscopic therapy alone is adequate in approximately 1/3 of patients with advanced colonic neoplasms. This underscores the central role modern endoscopic procedures have in the treatment of colon cancer. Clearly these early stage lesions, with a good prognosis were amenable to the endoscopic approach.
CONCLUSIONS: Funding efforts in the area of cancer therapy must include endoscopic therapy. The term colon cancer screening needs to be viewed from a perspective that incorporates the multiple functions of endoscopy including prevention and therapy.

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