Chapter 2 Colorectal Cancer

CANCERS

Team Leader: Dr. Gordon Avery

Date of Completion: 17.09.98

Colorectal Cancer is the second most common cancer experienced by males in Wales. In the 5 year period 1986-1990 there was an average of 880 new registrations per annum for colorectal cancer in men in Wales.¹
The annual average registration rate for 1984-1988 was 33.6 per 100,000 this being the highest registration rate for any of the regions in England and Wales.² Registrations have been fluctuating for many years.
The average annual number of deaths from colorectal cancer in males in Wales during the 5 year period 1992-1996 was 548 and the annual average age standardised death rate for the same period was 16.2 per 100,000.³ The death rate in Wales is amongst the highest in the United Kingdom. It remains relatively static.
Colorectal cancer in women is almost as common as it is in men. It is the third most common cancer (after breast and lung) experienced by women.
In the 5 year period 1986-1990 there was an average of 870 new registrations per annum for colorectal cancer in women in Wales.¹ The average Annual Registration Rate for 1984-1988 was 31.1 per 100,000, this being amongst the highest for the regions of England and Wales.² Registrations of colorectal cancer in women in Wales have been static in recent years.
The average number of deaths from colorectal cancer in women in Wales during the 5 year period 1992-1996 was 489 and the average annual age standardised death rate for the same period was 10.0 per 100,000.³ The death rate in Wales is among the highest in the UK but remains static.
The 5 year survival rate for colorectal cancer in Wales was 33% for cancers diagnosed between 1984 and 1988. ²
Colorectal death and registration rates may well be influenced by dietary changes in the future, especially if the population take on advice about increasing their fruit and vegetable intake.

Welsh Cancer Intelligence & Surveillance Unit: Cancer Registrations in Wales 1974-1990. Cardiff: WCISU,1998.
Welsh Health Common Services Authority. Cancer Registrations in Wales 1984-1988. Cardiff: Welsh Office, 1994.
Welsh Health Common Services Authority. Health Show. Welsh Public Health Common Data Set. Cardiff: WHCSA, 1997.

A source document for several statements in this chapter (Cancer Guidance Sub -Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997) http://www.doh.gov.uk/canc/colrecs.htm is summarised in an Effective Health Care bulletin (NHS Centre for Reviews and Dissemination, University of York. The management of colorectal cancer. Effective Health Care. 1997; 3(6)) http://www.york.ac.uk/inst/crd/ehc36.htm

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This bulletin is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.

The Statements

The Evidence

2.1 RISK FACTORS & PREVENTION

2.1a. Diet and Nutrition

· A diet high in fibre (fruit and vegetables) and low in fat has the potential for preventing a number of cancers, including colorectal ^{i, ii}

· An intake of whole grain is associated with a reduced risk for colorectal cancer^{i, ii}

· The avoidance of obesity may help to prevent colorectal cancer.^{i, ii}
(Health gain notation - 2 "likely to be beneficial")

i Department of Health. Committee on Medical Aspects of Food and Nutrition Policy. Working Group on Diet and Cancer. Report on Health and Social Subjects No. 48. London: The Stationery Office, 1998
(Type V evidence - expert opinion based on observational studies)
ii World Cancer Research Fund/ American Institute of Cancer Research. Food Nutrition and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 1997
(Type V evidence - expert opinion based on observational studies)

2.1b. Male homosexuals experiencing anal sex are at a higher risk of developing anal cancer. ⁱ
(Health gain notation - 6 "likely to be harmful")

i. World Cancer Research Fund/American Institute of Cancer Research. Food Nutrition and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 1997
(Type V evidence - expert opinion based on observational studies)

2.1c. Several studies have shown the prophylactic beneficial effect of non-steroidal anti-inflammatory drugs (NSAIDs) in reducing the risk of colorectal cancer.ⁱ
Caveat: The optimum duration of treatment and dose of NSAID are still to be ascertained and further research is required
(Health gain notation 3 "trade off between beneficial and adverse effects")

i. IARC Handbooks of Cancer Prevention. Volume 1. Non-Steroidal Anti-Inflammatory Drugs. Lyon: International Agency for Research on Cancer, 1997.
(Type IV evidence - observational studies )

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2.1d. Specified Genetic Factors
A clearly defined genetic predisposition is found in up to 6% of patients with colorectal cancer.
Hereditary non-polyposis colorectal cancer (HNPCC) affects 2-5% of colorectal cancer patients. This is associated with an 80% lifetime risk of developing colorectal cancer. ^{i,
ii}
Familial adenomatous polyposis (FAP) affects 1% of colorectal cancer patients. Offspring of a parent with FAP have a 50:50 chance of inheriting the mutation. ^i,ii100% of individuals with the mutation will develop colorectal cancer.

i. Cancer Guidance Sub -Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence - expert opinion based on well designed observational studies. Described in Hall NR, Finan PJ, Ward B, Turner G, Bishop DT. Genetic susceptibility to colorectal cancer in patients under 45 years of age. British Journal of Surgery 1994; 81: 1485-9)
ii. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence - expert opinion based on well designed observational studies)

2.1e. Familial Risk Factors
There are also familial (as distinct from specific genetic) risk factors. The risk to any individual increases with age and the strongest risk factor is having a relative diagnosed with colorectal cancer before the age of 45 years. People with more than one affected relative have an increased risk over those with only one affected relative, especially when one or more is diagnosed at a young age.
People with a single relative diagnosed with colorectal cancer over the age of 60 have the same risk as the general population.^{i, ii, iii}

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence - case-control study. Described in St John DJ, McDermott FT, Hopper JL, Debney EA, Johnson WR, Hughes ES. Cancer risk in relatives of patients with common colorectal cancer. Annals of Internal Medicine. 1993; 118: 785-90)
ii. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence - observational studies. Described in Fuchs CS, Giovannucci EL, Colditz GA, Hunter DJ, Speizer FE, Willett WC. A prospective study of family history and the risk of colorectal cancer. New England Journal of Medicine 1994; 331: 1669-74)
iii. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type V evidence - expert opinion based on a range of studies)

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2.2 SCREENING

2.2.1 The general population

2.2.1a. Population screening of the over 50s for occult blood in faeces can reduce the colorectal cancer death rate, by picking up cancers at an earlier stage.^{i, ii, iii}
There was a 15% reduction in the cumulative colorectal cancer mortality in the screening group compared with the control group, with a median follow-up of 7.8 years.
Odds Ratio, OR = 0.85 (95% CI 0.74 - 0.98).ⁱ
Colorectal cancer mortality, including deaths attributable to complications from the treatment, was significantly lower in the screening group than in controls.
OR =0.82 (95% CI 0.68 - 0.99).ⁱⁱ
(Health gain notation -2 "likely to be beneficial")

i. Hardcastle JD, Chamberlain JO, Robinson MH et al. Randomised Controlled trial of faecal-occult-blood screening for Colorectal Cancer. Lancet 1996; 348: 1472-1477
(Type II evidence - randomised controlled trial of 150251 individuals)
ii. Kronberg O, Fenger C, Olsen J, Jorgensen OD, Sondegaard O. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996; 348: 1467-1471
(Type II evidence - randomised controlled trial of 61933 individuals)
iii. Winawer SJ, Fletcher RH, Miller L et al. Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology 1997; 112: 594-642
(Type V evidence - consensus statement)

2.2.1b. High quality case-control studies of screening by flexible sigmoidoscopy suggest that this can reduce the future incidence of colorectal cancer by identifying and removing premalignant adenomas.^i, ^{ii, iii}
(Health gain notation - 2 "likely to be beneficial")
caveat: This is currently being evaluated in the UK in a multicentre (13) MRC / NHS R&D funded trial.^iv The aim is to discover whether offering a flexible sigmoidoscopy just once to everyone at age 55 -64 is a cost-effective means of preventing bowel cancer. The screening started in 1995 and the results should be available within 10 years.

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence- observational studies)
ii. Selby JV, Friedman GD, Quesenberry CP, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. New England Journal of Medicine 1992; 326(10): 653-657
(Type IV evidence- observational studies)
iii.Winawer SJ, Fletcher RH, Miller L et al. Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology 1997; 112: 594-642
(Type V evidence - consensus statement)
iv. ICRF/MRC ‘once only’ sigmoidoscopy screening trial: Family history sub study. National Research Register Project No. N0207039958, ends 01/06/2008
(Type II evidence –ongoing randomised controlled trial) http://www.update-software.com/National/

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2.2.2 Screening in high risk groups

2.2.2a. Genetic counselling should be offered to those with familial adenomatous polyposis (FAP) or hereditary non-polyposis colorectal cancer (HNPCC). ⁱ
(Health gain notation -3 " trade-off between beneficial and adverse effects")
caveat: However there are no studies which test the impact of counselling or the importance of using a trained counsellor.

2.2.2b. Those with, or who are at risk of carrying the FAP gene or HNPCC should be offered regular screening.^{i, ii}
Whilst the biological case for screening in HNPCC is clear, direct evidence of reduced morbidity or mortality is lacking. Based on observational studies, colonoscopy every 1 to 3 years starting at age 25 years is recommended for individuals known to have HNPCC -associated mutations.
Endometrial cancer screening is recommended for those with HNPCC, based on expert opinion.ⁱⁱ
People with a family history of FAP should be offered genetic testing to see if they are gene carriers. ^{i, iii} FAP gene carriers or indeterminate cases should be offered flexible sigmoidoscopy every 12 months from puberty. If polyposis is present, they should begin to consider colectomy.ⁱⁱⁱ
(Health gain notation -2 "likely to be beneficial" )
caveat: Prospective studies are needed to identify an optimal screening programme.

i. Cancer Guidance Sub -Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type V evidence - expert opinion)
ii. Burke W, Petersen G, Lynch P et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer. Journal of the American Medical Association 1997; 277 (11) :915-919
(Type V evidence -expert consensus statement)
iii. Winawer SJ, Fletcher RH, Miller L et al. Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology 1997; 112: 594-642
(Type V evidence - consensus statement)

2.3 DIAGNOSIS

2.3a. UK studies report delays of around 10 months between the onset of symptoms and treatment. However, there is no consistent evidence that delays (in patient presenting with symptoms, GP referring to specialists ) affect health outcomes in colorectal cancer.ⁱ
(Health gain notation - 5 "unlikely to be beneficial")

caveat: The public should be made more aware that persistent or recurrent bowel symptoms need to be investigated. There is the potential for community pharmacists to advise patients with symptoms.

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2.3b. The most common presenting symptoms of colorectal cancer are non-specific and occur relatively frequently in the adult population. The symptoms include change in bowel habit, rectal bleeding, abdominal pain, anaemia, tenesmus and weight loss. General Practitioners should take a careful history and carry out physical and rectal examination in any patient presenting with persistent or recurrent symptoms.Patients in whom any abnormality is found or in whom there is a suspicion of colorectal cancer should be referred to a specialist clinic for an urgent appointment.
Audit of this phase can measure the delay between the onset of symptoms and treatment, although there is no good evidence that diagnostic delay increases stage at presentation.ⁱ
(Health gain notation -1 "beneficial" )

2.3c. There is little difference between the two main methods of diagnosis of suspected colorectal cancer ie colonoscopy, or flexible sigmoidoscopy plus double contrast barium enema - depending on operator competence.ⁱ
(Health Gain Notation - 2 "likely to be beneficial")
caveat: In colonoscopy reliable results can only be obtained if the tip of the colonoscope reaches the caecum (‘completion’) Colonoscopy technique improves with practice. ( further training should be given when completion rates are below 85% and this needs to be audited on a regular basis.)
In flexible sigmoidoscopy less practice is required before competence is reached.ⁱⁱ
Further Research has been commissioned by the NHS Health Technology Assessment Programme on the use of nurses for endoscopy.ⁱⁱⁱ

i. Rex DK, Weddle RA, Lehman GA, et al. Flexible sigmoidoscopy plus air contrast barium enema versus colonoscopy for suspected lower gastrointestinal bleeding. Gastroenterology 1990; 98: 855-61
(Type II evidence - randomised controlled trial, 380 patients)
ii. Cancer Guidance Sub -Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type V evidence- expert opinion)
iii. NHS Executive. The Annual Report of the NHS Health Technology Assessment Programme 1997. London: Department of Health, 1998

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2.3d. Pre-operative staging is recommended to identify metastatic lesions unless the findings are unlikely to influence management. Ultrasound may be used as the first of a series of investigations but CT or MRI of the liver and or pelvis is more accurate. ^{i,
ii}
(Health gain notation - 2 "likely to be beneficial")

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type V evidence- expert opinion)
ii. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence -observational study. Described in Zerhouni EA, Rutter C, Hamilton SR, et al. CT and MR imaging in the staging of colorectal carcinoma: report of the Radiology Diagnostic Oncology Group II. Radiology 1996;200:443-51)

2.3e. A clinical assessment and histological examination of resected tumour are necessary in order to determine the clinico pathological staging and most appropriate treatment.ⁱ
Preoperative histological confirmation is mandatory in a rectal cancer which might result in a permanent stoma or when preoperative radiotherapy is being considered.ⁱⁱ
(Health gain notation - 2 "likely to be beneficial")

i. Scottish Intercollegiate Guidelines Network (SIGN). Colorectal Cancer: A National Clinical Guideline Recommended for Use in Scotland. Edinburgh: SIGN, 1997.
(Type V evidence -expert opinion)
http://www.sign.ac.uk
ii. Expert Advisory Group of the Royal College of Surgeons. Guidelines for the Management of Colorectal Cancer. London: The Royal College of Surgeons of England and Association of Coloproctology of Great Britain and Ireland, 1996
(Type V evidence -expert opinion)

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2.4 TREATMENT

2.4.1 Surgery

2.4.1a. There is a substantial variability in outcome between surgeons.ⁱThis study looked at patients presenting between 1974 and 1979, however similar variability was found when outcome data from a more recent series (1991-1994) was analysed. ⁱⁱ
caveat: Outcomes may vary considerably dependent on the extent of the cancer and the general condition of the patient at the time of surgery. Surgeons in the UK are strongly advised by the Royal College of Surgeons and Association of Coloproctology to audit their practice.

i. McArdle CS, Hole D. Impact of variability amongst surgeons on postoperative morbidity and mortality and ultimate survival. British Medical Journal 1991; 302: 1501-5
(Type IV evidence - well designed observational study of 645 patients)
ii. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence - observational studies)

2.4.1b. Total Mesorectal Excision (TME) should be considered for all patients with tumours in the lower two-thirds of the rectum. In tumours of the upper rectum the mesorectum should be divided no less than 5cm below the lower margin of the tumour.^{i, ii}
(Health gain notation -2 "likely to be beneficial" )

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence - observational studies)
ii. Expert Advisory Group of the Royal College of Surgeons. Guidelines for the Management of Colorectal Cancer. London: The Royal College of Surgeons of England and Association of Coloproctology of Great Britain and Ireland,1996
(Type II evidence - randomised controlled trials)

2.4.1c. A prospective study showed a reduction in local recurrence at 5years when the circumferential margin of tissue removed during surgery was clear of cancer cells compared with margin involvement (90% [95%CI:84%-96%] compared with 22% [95%CI:6%-38%]). Surgeons should monitor their performance by working closely with histopathologists. ⁱ
(Health gain notation -2 "likely to be beneficial" )
caveat: There have been no randomised trials directly comparing the effectiveness of different surgical approaches.

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence - observational study. Described in Quirke P. Limitations of existing systems of staging for rectal cancer:the forgotten margin. In Soreide, ed. Rectal Cancer Research: Springer-Verlag, 1997: 63-81)

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2.4.1d. Outcomes are worse after emergency surgery. The odds of death within 30 days of emergency admission were 3.5 times higher (95% CI: 1.9-6.6) compared with elective surgery for colon cancer and 13.3 times higher (95% CI: 3.5-50.1) than elective surgery for rectal cancer. In the absence of imminent or overt obstruction, surgery should be regarded as an urgent rather than an emergency procedure. ^{i, ii}
Many emergency patients can be held over and their condition stabilised medically until an experienced team can take responsibility for their management. A national audit of emergency colorectal cancer surgery is in progress.ⁱⁱⁱ
(Health gain notation 3 "trade off between beneficial and adverse effects")
caveat: It is not clear from the evidence how such emergencies can be avoided.

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type IV evidence- observational study. Described in Wessex Colorectal Cancer Audit. Progress Report. Winchester: Institute of Public Health Medicine,1996)
ii. Scottish Intercollegiate Guidelines Network (SIGN). Colorectal Cancer: A National Clinical Guideline Recommended for Use in Scotland. Edinburgh: SIGN, 1997
(Type IV evidence – observational studies)
http://www.sign.ac.uk
iii. Outcome Audit of Malignant Large Bowel Obstruction. London: Association of Coloproctology of Great Britain and Ireland
(Ongoing audit)

2.4.2 Radiotherapy

2.4.2a. There is good evidence from randomised trials that preoperative radiotherapy can moderately improve survival in rectal cancer when compared with the same treatment without radiotherapy. The benefit is greatest in those who went on to have curative resections.
The reduction in colorectal mortality is more pronounced for preoperative radiotherapy (14% (SD5, p=0.002) than for postoperative radiotherapy (7% (SD6, p=NS) as is the reduction in local recurrence (43%(SD7) for preoperative RT versus 32% (SD11) for postoperative RT.^{i, ii}
^{(Health gain notation - 2 "likely to be beneficial")}

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type I evidence -systematic review)
ii. Expert Advisory Group of the Royal College of Surgeons. Guidelines for the Management of Colorectal Cancer. London: The Royal College of Surgeons of England and Association of Coloproctology of Great Britain and Ireland, 1996
(Type II evidence - randomised controlled trials)

2.4.3 Chemotherapy

2.4.3a. The IMPACT Trial suggested that the use of prolonged chemotherapy with 5-fluorouracil / folinic acid (5-FU/FA) results in improved outcomes with a saving of up to 6 lives in every 100 treated for patients with Dukes’ Stage C colorectal cancer. There are inadequate data on the effect of chemotherapy in patients with Stage B cancer.^{i, ii} However there is an expert view that, on the basis of trial data already reported, there could be a 10% absolute survival improvement with both Dukes B and C tumours.ⁱⁱⁱ
(Health gain notation -2 "likely to be beneficial")
caveat: There is no consensus view regarding the optimum chemotherapy regime and route of administration. These factors are being addressed in prospective randomised trials, QUASAR^iv in UK and PETACC in Europe.^iv

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type V evidence - expert opinion)
ii. International Multicentre Pooled Analysis of Colon Cancer Trials (IMPACT) Investigators. Efficacy of adjuvant fluoracil and folinic acid in colon cancer. Lancet 1995; 345: 939-944
(Type II evidence -randomised controlled trial)
iii. Waters JS, Cunningham D. Colorectal cancer. Lancet 1999; 353: 1012
(Type V evidence – letter to the Lancet)
iv. Randomised trial of adjuvant chemotherapy following curative resection for colorectal cancer (QUASAR). CRC Trials Unit. National Research Register Project No. N0176009066, ends 31.12.2000
(Type II evidence –ongoing randomised controlled trial) http://www.update-software.com/National/
v. PETACC – Pan European trial of adjuvant colorectal cancer, PETACC-1, the value of Tomudex relative to standard Leucovorin modulated bolus 5-FU. National Research Register Project No. N0287023134, ends 11.03.2001
(Type II evidence –ongoing randomised controlled trial) http://www.update-software.com/National/

2.4.3b. A one week postoperative intraportal infusion of fluoracil may show a beneficial effect, but this conclusion is not statistically secure.ⁱ
(Health gain notation -4 "unknown" )
caveat: The national AXIS study is addressing this issue.ⁱⁱ

i. Liver Infusion Meta-analysis Group. Portal vein chemotherapy for colorectal cancer: a meta-analysis of 4,000 patients in 10 studies. Journal of the National Cancer Institute 1997; 89: 497-501
(Type I evidence -systematic review)
ii. Adjuvant X-ray and 5-Fluorouracil Infusion Study – AXIS. MRC Clinical Trials Unit.
(Type II evidence –ongoing randomised controlled trial)

2.4.3c. For the treatment of metastatic colorectal carcinoma confined to the liver, hepatic artery infusion chemotherapy confers a modest survival benefit over chemotherapy alone.^{i, ii}
(Health gain notation -4 "unknown" )
caveat: Further studies of combined systemic/arterial regimens are necessary.

i. Harmantas A, Rotstein LE, Langer B. Regional versus systemic chemotherapy in the treatment of colorectal carcinoma metastatic to the liver. Cancer 1996; 78(8): 1639-1645
(Type I evidence -systematic review)
ii. Kemeny NE. Regional chemotherapy of colorectal cancer. European Journal of Cancer 1995; 31A (7/8): 1271-1276
(Type II evidence -randomised controlled trials)

2.5 FOLLOW UP AND CONTINUING CARE.

2.5a. There is insufficient evidence to justify routine intensive follow up following completion of treatment.^{i, ii}
(Health gain notation - 5 "unlikely to be beneficial")

caveat: Standard follow up is necessary to audit outcome and to monitor those patients taking part in clinical trials.

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type II evidence -randomised controlled trial . Described in Lennon T, Houghton J, Northover J. What is the value of clinical follow-up for colorectal cancer patients? The experience of the CRC/NIH CEA second-look trial. In the proceedings of the Nottingham International Colorectal Cancer Symposium, Nottingham 1995)
ii. Bruinvels DJ. Stiggelbout AM, Kievet J et al. Follow up of patients with colorectal cancer: a meta analysis. Annals of Surgery 1994; 219(2): 174-82
(Type III evidence - meta analysis of data from non randomised studies)

2.5b. Patients with colostomies should have ready access to a stoma care nurse. Psychological support for patients is an integral part of the role of the stoma care nurse.^{i,
ii}
(Health gain notation - 2 "likely to be beneficial")

i Jeffries E, Joels J, Wood EJ et al. A service evaluation of stoma care nurses’ practice. Journal of Clinical Nursing 1995; 4: 234-242
(Type IV evidence - observational studies)
ii Expert Advisory Group of the Royal College of Surgeons. Guidelines for the Management of Colorectal Cancer. London: The Royal College of Surgeons of England and Association of Coloproctology of Great Britain and Ireland, 1996
(Type IV evidence- observational studies)

2.5c. Patients benefit from being offered full verbal and written information.ⁱ
(Health gain notation - 2 "likely to be beneficial")

2.5d. Radiotherapy is highly effective in palliative use to reduce symptoms in locally advanced rectal cancer in patients who have not previously had radiotherapy.ⁱ
(Health gain notation - 3 "trade-off between beneficial and adverse effects")

i. Cancer Guidance Sub-Group of the Clinical Outcomes Group. Guidance Improving Outcomes in Colorectal Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1997
(Type V evidence - expert opinion. Described in Swedish Council on Technology Assessment in Health Care. Acta Oncologica 1996; 35: 64-9)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk