Colorectal oncology

As with other high-incidence cancers, the EOC model of care in treating the colorectal cancer patient is the Specialty Oncology Centers (COS), the most modern and effective response to cancer disease.

The Oncology Center

Centers of expertise structured by organ, EOCs organize and optimize the care of the patient with cancer disease in a multidisciplinary and interprofessional care network. The model involves the cross-disciplinary and coordinated involvement of professionals with complementary specialties, the centralization of highly specialized services, and an accompanying service to treatment and recovery in all EOC hospitals.

Thanks to this model of care, EOC offers all Ticino patients up-to-date treatment protocols on the highest international standards and access to the best diagnostic, therapeutic and care pathway.

• Tumors of the intestine (small intestine, colon, rectum, anus, or appendix).
• Various types include adenocarcinoma (the most common), squamous cell carcinoma, gastrointestinal stromal tumor (GIST), or neuroendocrine tumor (NET).
• Large polyps of the colorectum.
• Colorectal cancers arising from predisposing familial conditions, e.g., familial adenomatous polyposis (FAP), Gardner syndrome, and others.

Diagnosis

Diagnosis of colorectal neoplasm is generally made by colonoscopy. In some situations it is discovered by CT scan of the abdomen, particularly in patients who present urgently with bowel obstruction due to the tumor.

• Colonoscopy is an examination that is performed under sedation, after cleansing the bowel by purging. It does not require hospitalization. Most importantly, it allows identification and at the same time immediate removal of small to medium-sized polyps. For more voluminous polyps or suspected malignancy, biopsies can be performed to make a precise diagnosis and plan definitive treatment.
• If the polyp is too voluminous to be removed immediately, biopsies are performed to analyze it under a microscope.
• If a malignant lesion is suspected or confirmed, the patient undergoes radiological examinations to find out whether or not there are signs of disease spread to other organs besides the intestine (generally liver, lymph nodes, lung). These investigations include CT (computed tomography), MRI (magnetic resonance imaging), endosonography, or PET (positron emission tomography).

Additional investigations include the following pathological examinations:

• Endoscopic biopsy: from relatively small tissue samples, a wealth of information can be obtained such as the presence or absence of tumor tissue and the definition of tumor type. Useful information on molecular biology can also be obtained for possible tumor therapy.
• After surgical or endoscopic removal of the lesion, the resected tissue is analyzed and reported according to national and international guidelines. All prognostic factors necessary for optimal patient care (extent of neoplasm, status of regional lymph nodes, status of resection margins) are provided to the oncologist.

Treatments

Cancer of the colorectal tract does not create specific symptoms other than occasional alterations in bowel transit or subtle bleeding. In the early stage, a polyp can be easily removed by colonoscopy, while a tumor of the intestine generally requires surgery sometimes associated, depending on stage and location, with additional therapies such as chemotherapy, immunotherapy or radiation therapy.

• Surgery still represents the central part of colorectal cancer treatment. According to the stage, location but also the patient's context, the most suitable type of surgery is chosen. In EOC, minimally invasive surgery (laparoscopy or with the Da Vinci ® robot) is the standard; laparotomy (large cut in abdomen) is reserved for special cases.
  • Colon resection (colectomy): removal of a segment of the colon and reconnection of the remaining parts.
  • Rectum resection: specialized surgery, performed by minimally invasive technique, often combining laparoscopy, robotics, or trans-anal surgery, with special care to avoid the need for packing an ostomy ("pouch").
  • Trans-analresection: for superficial tumors, surgical instruments are passed through the anus to remove the tumor while sparing the organ.
  • Resection and other treatments for liver metastases: performed in laparoscopic, robotic or open surgery, or with radiological interventions, allows a significant number of patients to recover even in advanced disease.

Patients undergoing colorectal resections are taken care of in a multi-disciplinary manner with the "ERAS per-operative care protocol," which helps minimize the risk of complications, length of hospital stay, and ensure accelerated recovery.

• Radiation therapy , possibly combined with chemotherapy and hyperthermia, uses high-energy ionizing radiation to "destroy" cancer cells while trying to safeguard surrounding healthy tissues and organs. It is an outpatient treatment and does not involve invasive procedures. It can have several purposes:
  • Preoperative (neoadjuvant) intent: it is performed prior to surgery to resect the rectum associated or not with chemotherapy to reduce the size and extent of the tumor by reducing the risk of local recurrence;
  • Curative intent: is performed associated or not with chemotherapy in order to radically eliminate all cancer cells in the rectum and/or pelvic lymph nodes;
  • Postoperative (adjuvant) intent: is performed after surgery if there is a risk of local recurrence;
  • Palliative intent: is performed in patients in whom the disease has spread to other organs. Palliative treatment can also be performed on the rectum when the disease is locally extensive and may condition local symptoms from rectal occlusion, compression/infiltration of neighboring organs.

• Medical treatment is used to treat colorectal cancer at different stages of the disease. There are multiple drugs that can be used individually or, much more often, combined: chemotherapy, immunotherapy, and molecularly targeted drugs. Antitumor drugs in colorectal cancer are used in different situations:
  • In the absence of metastasis to other organs: in colon cancers, as adjunctive therapy after surgery to reduce the risk of tumor recurrence if histologic analysis (under a microscope) of resected tissue demonstrates risk factors (e.g., cancer cells in lymph nodes). In rectal cancers, chemotherapy is used before surgery along with radiation therapy, enhancing its therapeutic effect, to reduce the tumor mass to sometimes its complete disappearance. This reduces the risk of local recurrence and sometimes, if it disappears completely, avoids surgery altogether.
  • In metastatic disease confined to the liver: if at the time of diagnosis the tumor is already spread to the liver (the most common site of metastasis), chemotherapy, possibly combined with new targeted-action drugs, is often given before other treatments, with the aim of regressing or stabilizing the lesions in the liver, until surgical removal is possible.
  • In metastatic disease, with spread to multiple organs: in this case, the aim of treatment is to try to slow the growth of the disease. The choice of new molecularly targeted drugs, which have a very targeted action, to establish efficacy is based on molecular investigations of the tumor tissue.

Professionals in Palliative and Supportive Care are an integral part of the team and fit into the surgical, oncologic, and radiation treatment plan in response to emerging needs.

Certifications

Certified Colorectal Cancer Centre
The Colorectal Cancer Centre of Italian Switzerland EOC has been awarded the "Certified Colorectal Cancer Centre" certificate, issued by European Cancer Centres (ECC). The Certificate is awarded based on adherence to requirements set by international guidelines, and confirms that the therapeutic offering corresponds to the quality, practices and methodologies defined by international experts.

Information and awareness

Colorectal oncology also has a role in providing information, clarification, and explanation regarding patients' problems related to colorectal cancer, as well as in raising awareness and informing the public about the issue.

Today, state-of-the-art therapies and multidisciplinary collaboration are offered with the goal of providing the patient with the highest possibility of treatment, reducing discomfort and the risk of loss of function.

Quality and safety of care

Multidisciplinary meetings
Multidisciplinary meetings or multi-disciplinary meetings (MDMs) are a tool developed to further ensure the quality and safety of care provided. Multidisciplinary meetings also aim to ensure that patients have access to the best treatment decisions through the involvement of multiple specialists in the definition and management of pre- and post-operative care.

In addition, Lugano Regional Hospital is counted among the few centers in Switzerland with a mandate of Highly Specialized Medicine (MAS) for low rectal surgery.
Last but not least, ERAS protocols for peroperative care for patients operated on for colorectal cancer have been applied at several EOC sites since 2013, care that promotes and accelerates the postoperative recovery process and limits any complications.

Cancer League Ticino

In the area of colorectal tract oncology, the collaboration with Cancer League Ticino, provides patients with specialized counseling in social and intensive oncology rehabilitation, offering patients and family members advice and support in administrative, financial and other areas.
Through its regional offices (Bellinzona, Locarno, Lugano, Mendrisio), the League is available to all patients and family members for counseling in the social, psychological and rehabilitation fields.

More information is available on the website or by calling 091 820 64 20.
Also available is the Cancer Info Line on 0800 11 88 11 where a nurse specializing in the area of oncology answers questions from patients and family members in the three national languages.

The League also supports cancer research, offers prevention information campaigns and cooperates with self-help associations.

Clinical manager

Doctors on the surgical core team