Colorectal Cancer and Polyps:

You Should Be Concerned

How to Choose a Doctor and Hospital for Your Treatment

Hospitals and doctors are not all alike_ they vary in quality due to differences in their training, experience and services. These differences in quality become greater and matter more when you need sophisticated medical care for a complex condition.

For example, a surgeon who performs a complex procedure often, has better results with it than a surgeon who does the same procedure only occasionally. The complication rate, death rate and effectiveness of the same procedure may vary considerably from one hospital to another.

Clearly, the doctor and hospital that you choose have a direct impact on how well you do _ especially when you need treatment for conditions as serious and complex as colon and rectal cancer.

Cancer of the colon and rectum (also called colorectal or large bowel cancer) affects nearly 150,000 Americans each year and causes more than 50,000 deaths annually.

The full picture, however, is far more positive. Colorectal cancer can be prevented through regular examinations to detect polyps, benign growths of the intestine lining that may develop into cancer. If polyps are found, they can be removed without surgery so they will never develop into cancer. And if colorectal cancer is diagnosed in its early stages, the latest medical and surgical treatments offer a good chance for a cure.

You may be reading this brochure because your risk of colorectal cancer is high and you would like to be examined, or because you have already been diagnosed with a polyp or cancer.

Selecting a doctor and hospital to assess your risk, to provide comprehensive screenings, or to treat colorectal cancer effectively involves making some difficult and critical decisions. No one has more at stake than you; it is one of the most important decisions of your life.

This guide discusses colorectal cancer and its diagnosis and treatment in general terms to help you choose a medical center if you or a loved one need cancer care. The questions we suggest and the comparisons we talk about in this guide are intended to help you make your decision.

How Do You Judge Quality?

Most of us do more research when we buy a car or a television set than when we choose a doctor and hospital. That may be because we do not know what questions to ask or on what to base our evaluation.

Quality of care may be measured in many different ways, and no universal agreement exists on which should be used. At the Cleveland Clinic, however, we believe that you can use the following six points, or quality indicators, to compare health care providers:

· Credentials

· Experience

· Range of services

· Participation in research and education

· Patient satisfaction

· Outcome

Choosing a doctor or hospital is often influenced by values. You may want a hospital with a specific religious affiliation. But when you need specialized medical care for colorectal cancer, considering factors such as a doctor's qualifications, the cancer care team's credentials and the hospital's experience is very important in making your decision. These quality indicators will help you make those evaluations should you require treatment for colorectal cancer.

Sidebar

A Step-by-Step Guide

This brochure deals with colorectal cancer and helps you choose a doctor and hospital by:

· explaining colorectal cancer

· describing how colorectal cancer is detected and diagnosed

· explaining who may be at risk

· explaining the procedures available for the prevention and treatment of colorectal cancer, which may include colonoscopy and polyp removal; endoscopic ultra-sound to determine the extent of the cancer; surgical techniques such as local excision, partial colectomy and laparoscopic surgery; medical treatments such as chemotherapy and radiation therapy; and treatments such as biological therapy that are available for advanced cancer

· explaining six points that indicate quality

· providing questions and answers from the Cleveland Clinic that you can use to compare doctors and hospitals.

Polyps & Colorectal Cancer

Colorectal cancer is the third most common form of cancer in both men and women in the United States. Almost all colorectal cancers begin as polyps, benign (noncancerous) growths of the tissue lining the colon and rectum. It is the colon and rectum that together make up the large intestine or bowel.

As many as 40 percent of people over age 60 have polyps, 98 percent of which never develop into cancer. But 2 percent of polyps will grow, will invade surrounding tissue and will become cancerous. Colorectal cancer can be prevented by removing these polyps before they start to grow.

How are polyps detected?

In their early stages polyps usually do not cause any symptoms. A screening examination performed as part of a regular health evaluation is the best way to detect polyps in their early stages.

The most thorough, accurate means of examining the colon and rectum for polyps is by endoscopy, which involves looking inside the gastrointestinal tract using a lighted scope. The different types of endoscopy and what each examines are as follows:

· Proctoscopy examines the rectum;

· Flexible sigmoidoscopy examines the rectum and lower part of the colon;

· Colonoscopy examines the entire colon. This is the most accurate way for the physician to examine the entire colon and rectum for polyps.

Because a physician cannot determine which polyps will become cancerous by simply looking at them, all polyps should be removed. Almost all precancerous polyps can be removed through a colonoscope, a lighted scope through which the physician can perform the removal without open abdominal surgery. This procedure is called a polypectomy.

How is colorectal cancer detected or diagnosed?

Polyps that are found and removed are sent to the laboratory for analysis. By microscopic examination and various laboratory tests, a pathologist determines if the polyps are cancerous. Colorectal cancer found in this early stage, before symptoms develop, is the most curable.

In later stages, colorectal cancer can cause symptoms such as blood in the stool, changes in normal bowel habits, narrowing of the stool, abdominal pain, weight loss or constant fatigue. When a patient with symptoms comes in for an examination, the doctor may perform X-rays of the colon and rectum (a barium enema) or a colonoscopy to look for tumors. The physician will take tissue samples of any growths that are found, and these samples are examined in the laboratory to determine if they are cancerous.

How is it treated?

Treatment for colorectal cancer depends on the extent to which it has spread, a person's general health and where the cancer is located. Treatment may include surgery, chemotherapy, radiation therapy or a combination of these.

Surgery. The goal of surgical treatment is to remove the cancer and all lymph nodes in the surrounding area as completely as possible. Most patients will have a partial colectomy, which means the surgical removal of the part of the colon or rectum that contains the cancer. As much as possible of the surrounding tissue and lymph nodes are also removed.

After removing the cancerous portion, the surgeon reconnects the healthy sections of the colon and rectum. Surgeons try to cut (resect) and reconnect the bowel in a way that maintains normal bowel function as much as possible.

A pathologist examines the cancer and lymph nodes under a microscope to determine the extent to which the cancer has spread.

Colostomy. A colostomy is a surgical procedure which involves creating an opening in the abdominal wall through which the colon passes. A bag is fitted to the opening to collect stool. A small number of patients require a temporary colostomy after surgery. The number of patients who need a permanent one is very low, and the newest surgical techniques have reduced this number to the minimum.

Radiation therapy. High energy X-rays can be used to kill cancer cells and shrink tumors. External radiation is delivered by a machine outside the body. Internal radiation is delivered by putting materials that produce radiation (radioisotopes) through thin plastic tubes into the area where the cancer cells are found.

Chemotherapy. Special drugs can be used to kill cancer cells. The drugs may be taken orally or injected into a vein. Chemotherapy is usually a systemic treatment, meaning the drugs enter the bloodstream, travel through the body and kill cancer cells throughout the body.

Why does it sometimes recur?

Recurrence refers to a cancer coming back after it has been treated. In colorectal cancer, the chance of recurrence depends largely on the surgeon's skill in removing the cancer and the lymph nodes involved. The greater the surgeon's skill, the more complete the removal is likely to be. In general, the more complete the removal, the lower the risk of recurrence. Some cancers, however, are more aggressive than others. In these cases, in spite of the best surgery by the most skilled surgeon, the cancer has a greater probability of recurring.

Recent Advances

Several newly developed procedures are available at some medical centers as part of the treatment plan for some patients who have colorectal cancer.

Laparoscopy. Laparoscopic surgery, an alternative to a large surgical incision, is performed through several tiny incisions in the abdomen which can reduce pain and blood loss, speed recovery and result in less scarring.

Laser endoscopy. A laser inserted through an endoscope can be used to reduce the size of large rectal tumors that cannot be treated in any other way.

Intrarectal radiation. Internal radiation is used in patients with small, low rectal cancers to cure the cancer and to avoid surgery.

Polyp prevention. Rather than waiting for polyps to form and then removing them, much attention is being focused on ways to prevent them from growing at all. In the forefront of today's polyp prevention methods is chemoprevention, a concept which suggests that drugs, vitamins and minerals might work to protect healthy cells from becoming polyps that could eventually become cancerous.

Studies are also currently evaluating whether aspirin, in addition to vitamins and folic acid, can prevent the recurrence of precancerous colon polyps in people who have had precancerous colon polyps removed. This could potentially reduce the risk of colon cancer in people who are at high risk.

Sidebars

Are You at Risk?

Risk factors are the things about a person that are scientifically proven to be associated with a high rate of a certain disease. The main risk factors for colorectal cancer are: being more than 50 years of age; having a family history of polyps or colorectal cancer; or having a chronic inflammatory disease of the colon, such as ulcerative colitis.

Family history is an important risk factor. People with one or two immediate family members (father, mother, a brother, a sister) with the disease have a two- to three-times greater than normal risk. People with three immediate family members with colorectal cancer have a 10-times greater than normal risk.

This increased risk occurs because people with a family history of the disease can carry certain abnormal genes that are passed on through the generations. These abnormal genes allow uncontrolled growth of the cells lining the colon and rectum. A person with one or two abnormal genes may develop benign polyps; if more abnormal genes are present, polyps may progress to cancer.

Screenings Recommended for Colorectal Cancer

Your chance of developing colorectal cancer is determined by which risk factors you have. Physicians rate risk on a scale from very low to very high. Which screenings are appropriate for you depend on where you fall in that range.

The American Cancer Society recommends the following for people of average risk:

· An annual digital rectal examination (examination of the lower part of the rectum) for everyone beginning at age 40.

· An annual test for blood in the stool for everyone beginning at age 50.

· A flexible sigmoidoscopy every three to five years beginning at age 50. Those of any age at high risk need a more extensive evaluation and should have a colonoscopy. This includes people with prior colorectal cancer or a strong family history of the disease.

Specialized blood tests are now being used at some medical centers to detect the abnormal gene responsible for very rare family patterns of disease.

Where Do You Begin?

Measuring quality in ways that are useful to consumers is a new idea in health care. Because of that, it may not be possible to get complete information for each of these quality indicators. But when providers are willing to give you as much information as possible, it is a good sign. It shows that they are dedicated to maintaining and improving their quality, responsive to patients, and confident of their capability.

If you are at risk for or have been diagnosed with colorectal cancer, ask your doctor about seeing a specialist in gastroenterology or colorectal surgery. This specialist should have experience in the diagnosis and full range of treatments for colorectal cancer. Ask for a referral to a hospital with a multidisciplinary cancer center that offers a team approach to cancer treatment.

Get the names of several doctors and hospitals that offer screenings and follow-up visits for people who have a high risk of developing colorectal cancer. Look for those doctors and hospitals that offer the newest, most effective treatments for people diagnosed with the disease. Look for centers where research is being conducted. Those that participate in clinical trials that compare the latest drugs with experimental drugs may provide even better results.

Ask the questions that we suggest on the following pages. Make comparisons. Then make your decision. Be an informed consumer for yourself and your family.

Sidebar

Second Opinions

When you have cancer, getting the right treatment the first time is extremely important because you may not get a second chance for a cure.

If you have been diagnosed with colorectal cancer, you may want to seek a second opinion to confirm the diagnosis and treatment plan. You will want to make sure that the diagnosis is based on expert pathology at an institution experienced in identifying different types of cancers and disease stages.

If a colostomy is part of the recommended treatment plan, you may also want to get a second opinion. You should be aware that most people do not require a permanent colostomy to remove their bowel. At institutions using the latest surgical techniques, less than 1 percent of all patients with colon cancer and less than 10 percent of patients with rectal cancer require a permanent colostomy.

How to Use

Quality Indicators

How can you use these indicators to judge if one doctor or hospital is better for you than another? By combining information from more than one quality indicator, according to the report "The Quality of Medical Care: Information for Consumers" produced by the U.S. Congress, Office of Technology Assessment.

According to the report, patients about to have surgery can be confident if the hospital performs a high number of surgeries, if it has a low mortality (death) rate, and if the surgeon has extensive training and experience in the procedure.

On the other hand, the report states: "_if a hospital has a high mortality rate and a low volume of procedures, the patient might wish to question the surgeon about that hospital and about alternatives, even if other hospitals require longer travel."

1. Credentials

Do the doctor and hospital measure up?

Credentials have been set by nationally recognized medical professional organizations to verify that doctors and hospitals meet certain standards in the delivery of health care.

Doctors:

Board certification, or the international equivalent, is a sign that doctors are highly trained in their field. Doctors who specialize, such as gastroenterologists, colorectal surgeons and medical oncologists, should be board certified in the specialty in which they are practicing. Each specialty has a national board that is responsible for setting standards doctors must meet in order to be certified. Doctors who are board certified in their specialty have completed the amount of training that the specialty board requires, have practiced for a specified number of years in that specialty, and have passed a difficult examination in their specialty area. Some excellent doctors are not board certified. Board certification, however, is generally a good indication of competence and experience.

Hospitals:

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the nationwide authority that surveys hospitals. The JCAHO decides whether a hospital gets, keeps or loses accreditation based on its meeting certain criteria for staffing, equipment and facility safety requirements. Although accreditation is voluntary, most hospitals go through the process. If the hospital that you are considering is not accredited, it is important to know why.

Some of the best hospitals are often in the public spotlight for their medical advances and the quality of their care. Information about a hospital's reputation is widely available through the mass media, listings, the government, consumer groups, books and magazines such as U.S. News & World Report.

Sidebar

For information about a hospital's status, call the Joint Commission on Accreditation of Healthcare Organizations at 708/916-5800.

One of America's Best

The Cleveland Clinic is often named among the top medical centers in the country:

· For the past six years, U.S. News & World Report has recognized the Cleveland Clinic as one of the best gastroenterology centers in America.

· U.S. News has named the Clinic as one of "America's Ten Best Hospitals" for the past six years.

· In 1993, 1994 and 1995, U.S. News ranked the Cleveland Clinic Cancer Center as the best in cancer care in Ohio.

· The April 1993 issue of American Health named the Clinic among the top medical centers in the country and cited its expertise in gastroenterology.

· Cleveland Clinic physicians and surgeons frequently serve as officers in national medical organizations related to their specialty, such as the American College of Gastroenterology and the American Society of Colon and Rectal Surgeons.

· Four members of the departments of Colorectal Surgery and Gastroenterology, including both chairmen, are listed in the 1994-95 edition of The Best Doctors in America. In all, 56 Cleveland Clinic physicians were selected by their peers nationally for inclusion in this book.

Q&A

Is the gastroenterologist board certified in gastroenterology?

All Cleveland Clinic gastroenterologists are board certified in gastroenterology.*

Is the surgeon board certified in colorectal surgery?

All Cleveland Clinic colorectal surgeons are board certified in colorectal surgery by the American Board of Colon and Rectal Surgeons.*

Is the pathologist board certified?

The Cleveland Clinic's staff surgical pathologists are board certified by the American Board of Pathology and have many years of experience, in gastrointestinal pathology.

Are the hematologists and medical oncologists board certified in their subspecialty?

All Cleveland Clinic staff hematologists and medical oncologists have subspecialty board certification in hematology or medical oncology and board certification in the specialty of internal medicine.

Are the radiation oncologists board certified in radiation oncology?

All Cleveland Clinic staff radiation oncologists are board certified in radiation oncology.

Is the hospital accredited by the JCAHO?

Yes.

Has the hospital been positively and consistently recognized for medical excellence and leadership?

Yes. The Cleveland Clinic is often named among the top medical centers in the country. Some of the publications that have recognized the Clinic for excellence are listed in the box at the left.

*Board certification or its international equivalent became a requirement at the Cleveland Clinic in 1989 for doctors who are being appointed to the medical full staff.

2. Experience

Does practice make perfect?

In the case of complex, specialized medical and surgical care for colorectal cancer, the more experience the doctor and hospital have with the necessary procedures, the better the results usually will be.

Experience in treating colorectal cancer is important because the problems can be so complex. Colorectal cancer may spread to the liver or lungs, and the surgeon does not always know the extent of the cancer until the time of surgery. It could require a simple operation that takes only an hour, or it could result in a complicated, lengthy procedure. Experience with complex cases means the surgeon will be prepared for difficult problems or complications that may arise during surgery. Because the best chance for a cure is the first chance, it is important for the surgeon to perform the most appropriate procedure correctly the first time.

Q&A

How many people with colorectal cancer are treated at the hospital each year?

In 1994, Cleveland Clinic physicians treated more than 825 outpatients and managed more than 325 hospital admissions for patients with colorectal cancer.

How many endoscopies are performed each year?

In 1994, Cleveland Clinic gastroenterologists and colorectal surgeons performed more than 18,000 endoscopic procedures to detect colorectal cancer and other digestive diseases.

How many polypectomies are performed each year?

In 1994, Cleveland Clinic gastroenterologists and colorectal surgeons performed more than 2,000 polypectomies.

How many bowel resections for colorectal cancer are performed each year?

Cleveland Clinic colorectal surgeons perform approximately 800 bowel resections each year for a wide range of problems, including 300 for colorectal cancer.

How many laparoscopic bowel procedures are done?

Clinic colorectal surgeons have performed more than 150 laparoscopic bowel procedures, giving them one of the country's largest experiences with this new technique.

How long has the hospital been treating people with colorectal cancer?

The Cleveland Clinic's Department of Gastroenterology was formed in 1936 and the Department of Colorectal Surgery was formed in 1954.

3. Range of Services

What services are available?

Hospitals with a broad range of services can treat more complex medical conditions and better handle complications that may occur. If complications arise, you want the best medical care available, and you want it immediately.

Range of specialty departments:

Patients with colorectal cancer may have related medical problems such as heart disease, lung disease, diabetes or chronic inflammation of the small intestine. There is also an association between colorectal cancer and longstanding inflammatory bowel disease, such as ulcerative colitis. Therefore, immediate access to a full range of specialty departments within a facility is critical.

Range of diagnostic and treatment options:

The diagnosis and treatment of colorectal cancer involves health care professionals from many disciplines working as a team. These professionals include gastroenterologists, colorectal surgeons, pathologists, radiation and medical oncologists and enterostomal therapists.

Several different surgical options are available to treat colorectal cancer. For these reasons, it is important to choose a facility that can diagnose and treat colorectal cancer in a variety of ways. That way you will get the most beneficial, cost-effective treatment available, and the one most appropriate for you.

Sidebar

Registries: Linking Past and Future

The David G. Jagelman Center for Inherited Colorectal Cancer has one purpose: to prevent needless deaths from colon cancer. Because heredity plays such a major role in colorectal cancer and polyps, keeping track of patients and their family members through a registry can save lives.

The Center's five registries, the largest in the country, identify and track at-risk individuals and guide them into appropriate screenings and early treatment.

216/444-6470

(in Cleveland)

800/223-2273, Ext. 46470 (toll-free outside Cleveland)

The Colon Polyp Registry tracks more than 8,000 patients with a history of colon polyps who need continued surveillance. People who have had polyps are reminded of regular screenings and follow-up visits. Registry data is also used in ongoing research into risk factors for polyps.

216/444-5113

(in Cleveland)

800/223-2273, Ext. 45113 (toll-free outside Cleveland)

Q&A

Is help available from a full range of specialty departments?

The Cleveland Clinic's 600 physicians _ all on staff full time _ provide care in 100 specialties and subspecialties including colorectal surgery, gastroenterology, medical oncology, pathology and radiation oncology. All of these specialties, as well as the Cleveland Clinic Children's Hospital, are present in one facility so that prompt multidisciplinary consultation, diagnosis and treatment are readily available.

Does the hospital offer a variety of options for diagnosing and treating colorectal cancer?

The Cleveland Clinic offers a comprehensive range of options for prevention, diagnosis and treatment of colorectal cancer. In addition to standard tests such as digital rectal examinations, blood and urine tests and laboratory pathology, the Clinic also offers specialized expertise in the following:

Flexible sigmoidoscopy, colonoscopy and polypectomy

Strip biopsy

Upper and lower GI series (barium X-rays)

Computerized tomography scanning

Magnetic resonance imaging

Positron emission tomography

Abdominal, endoscopic and transrectal endo-sonography for rectal cancer

CEA assay (carcino-embryonic antigen blood test)

Flow cytometry

Molecular genetics for detecting inherited genes related to an increased risk of colorectal cancer

Bowel resection, partial colectomy and proctocolectomy

Colostomy

Surgical techniques to preserve anal sphincter function

Laparoscopic bowel surgery

Laser treatment

Turnbull "no-touch" technique for preventing the spread of cancer during colon cancer surgery

Noninvasive Neoprobe examination to detect extremely small tumors

Transanal techniques

Intrarectal radiation

Radiation therapy

Chemotherapy

Biological therapy

Enterostomal therapy

4. Participation in Research and Education

What type of hospital is it?

There are many advantages to selecting a hospital that combines patient care with research and patient education.

Physicians who engage in clinical research compare and study the results of different treatments in thousands of patients. They apply what they learn from the large clinical trials to future treatment decisions. In this way, all the patients at a hospital which engages in clinical trials benefit from research, even if they have not personally participated in the trials.

Clinical trials are also an important aspect of medical education. Physicians who are responsible for teaching residents and medical students must stay up-to-date on the newest treatments and technology so that they can effectively instruct their students. At a teaching hospital, clinical trials allow physicians to examine the effectiveness of the latest investigative treatment strategies. And patients who choose to participate in clinical trials can receive promising new therapies before they are available in the general community.

There may be other advantages to choosing a teaching hospital. Private, not-for-profit teaching hospitals had lower mortality rates than other types of hospitals, a study in a December 1989 issue of the New England Journal of Medicine suggested.

Sidebar

Enterostomal Therapy

The Cleveland Clinic's Rupert B. Turnbull, Jr., M.D. School of Enterostomal Therapy Nursing, the first school of its kind in the world, has graduated nearly 750 of the approximately 2,000 nurse specialists practicing in this field throughout the world. Enterostomal nurses provide pre- and postoperative teaching and counseling for people who have a temporary or permanent colostomy.

The Cleveland Clinic's 12 enterostomal therapists who help patients cope with the emotional and physical aspects of a colostomy are valuable additions to the medical and surgical team.

Q&A

Is the hospital associated with a teaching program?

Yes. Incorporated in 1935, The Cleveland Clinic Educational Foundation sponsors one of the nation's largest physician postgraduate training programs and is affiliated with The Ohio State University College of Medicine.

Does the hospital have fully accredited residency training programs in gastroenterology and colorectal surgery?

The Accreditation Council on Graduate Medical Education has accredited the Cleveland Clinic's residency training programs in gastroenterology and colorectal surgery, which help teach innovative procedures to doctors in training.

Does the hospital conduct research or clinical trials related to colorectal cancer?

The Clinic maintains basic and clinical research programs in colorectal cancer and offers many investigational therapies not widely available. Current efforts include:

· Studies of the safety and effectiveness of laparoscopic techniques for bowel cancer

· Experimental use of specialized blood tests to detect abnormal genes responsible for rare, inherited forms of colon cancer

· A National Cancer Institute (NCI) study of a new drug which may shrink existing polyps and prevent growth of new polyps in patients with familial polyposis

· Clinical trials of autofluorescence spectroscopy for early cancer detection

· Two NCI studies investigating whether calcium, aspirin or the vitamin folic acid might prevent polyp recurrence

· Participation as one of only five U.S. centers in an NCI-sponsored study of a new drug to treat colorectal cancer that has spread

· A Cleveland Clinic study of guided imagery (a relaxation technique) as an adjunct to various forms of colorectal surgery to determine its effectiveness in decreasing anxiety associated with surgery.

5. Patient Satisfaction

Is everybody happy?

If you ask one person about his or her experience with a doctor or hospital, you get one person's point of view. Patient satisfaction surveys allow you to judge quality based on the experience of many previous patients. This provides you with a more objective measure to use.

Most hospitals routinely use surveys to learn if patients are satisfied with their medical experiences. The hospital can use these results to improve its services.

Patient satisfaction often reflects the personal side of care. Surveys ask questions such as, How willing are the doctors and nurses to listen? Do they answer questions and explain treatments? How much time does the doctor spend with the patient? Is the hospital clean? Is the food good?

Patient satisfaction information can predict what your experience in a particular hospital is likely to be.

Q&A

How do hospitalized patients rate the quality of care they receive at this facility?

94% of patients who were hospitalized at the Cleveland Clinic for digestive diseases such as colorectal cancer rated the quality of their care as good to excellent.

93% said they would return to the Cleveland Clinic for their care.

Would patients treated at this hospital recommend it to their families and friends?

98% of patients with digestive diseases such as colorectal cancer said they would recommend the Cleveland Clinic to others.

How satisfied are outpatients with their experience at this facility?

97% of outpatients who visited the departments of Colorectal Surgery and Gastroenterology said they were either very satisfied or satisfied with their experience.

98% said they would return if they needed care in the future.

Is there a program to help patients and their families with difficulties that may arise during a hospital stay?

Cleveland Clinic patients may call an ombudsman _ another name for patient-relations representative _ if they have concerns about their care.

Patients in the Cleveland Clinic hospital may dial a 24-hour Helpline from their room if they have any problems, questions, suggestions, or concerns related to service.

6. Outcome Indicators

What is the prognosis?

Cancer is a very complicated group of diseases, and many different factors influence an individual's prognosis, or prospects for recovery. No one can give you an exact prognosis. Some cancers have a 100 percent cure rate if caught early and treated with the newest, most effective therapies. Others may not respond to even the latest therapies given by the most experienced physicians to patients most determined to survive. What you can do for yourself is discuss with your doctor several different outcome indicators and the hospital's rates for each. We suggest asking about the following two specific measures.

On the following pages we have provided Cleveland Clinic outcome data. To give you an idea of what expected rates might be, wherever possible we have included references to other studies that match ours as closely as possible.

Five-Year Survival Rate

Hospitals collect cancer survival statistics as 5-year survival rates, based on treatment and survival data for a span of 5 years. Rates published in 1995 reflect data from patients diagnosed and treated between 1984 and 1990. Because of this time lag between collecting and reporting data, even the most recently published rates may not reflect the impact on survival of the latest advances in treatment. These rates are not adjusted by a person's age or overall health status.

Five-year survival rates do not mean that a person can expect to live only 5 years after treatment or that there are no cures for cancer. Cancer survival statistics are averages based on large numbers of patients. They cannot be used to predict what will happen to one person.

Recurrence Rate

Recurrence rate indicates that the cancer has come back (recurred) after it has been treated. Recurrence can be affected by two factors: the skill of the surgeon and the aggressiveness of the cancer. Several studies of large numbers of patients have shown that the local recurrence rate varies from surgeon to surgeon. These studies suggest that local recurrence is affected by a surgeon's skill, specialty and experience, and that local recurrence is lower if surgery for colorectal cancer is performed by a colorectal surgeon. This is because colorectal surgeons are more likely to be skilled in different types of operations and to remove more of the colon and neighboring organs to which cancer may have spread.

Sidebar

Staging of Colon and Rectal Cancer

The stage of cancer refers to the extent to which it has spread. The stage of the disease at the time it is diagnosed is an important factor in determining the outcome.

Cancer stages range from I to IV. A person with Stage I cancer generally has a better outcome than the person with Stage IV cancer.

· Stage I cancer has spread into the tissue underneath the innermost lining of the colon, but not yet through the muscle wall.

· Stage II cancer has spread through the muscular wall of the colon, but it has not reached the lymph nodes.

· Stage III cancer has spread to the nearby lymph nodes, but not to other parts of the body.

· Stage IV cancer has spread to distant areas of the body.

Q&A

What are the hospital's 5-year survival rates for people with colorectal cancer?

In the most recent study of 650 Cleveland Clinic patients with colon cancer and 607 Cleveland Clinic patients with rectal cancer, the following 5-year survival rates were found:

Colon Cancer CCF* Other**

Stage I 85% 74%

Stage II 83% 63%

Stage III 58% 46%

Rectal Cancer CCF* Other**

Stage I 85% 72%

Stage II 74% 54%

Stage III 59% 39%

*Unpublished Cleveland Clinic data submitted to the Journal of the American College of Surgeons, November 1995.

** Journal of the American College of Surgeons, September 1995. An analysis of reports from 943 hospitals.

What is the hospital's local recurrence rate for people with rectal cancer?

According to a recent study, the local recurrence rate of all Cleveland Clinic colorectal surgeons ranged from 1% for Stage I to 7% for Stage III.

According to a study reported in the British Journal of Surgery (1989), surgeons' local recurrence rates ranged from less than 5% to greater than 20%.

What percentage of patients treated for colorectal cancer at this hospital require a permanent colostomy?

By using the latest medical and surgical techniques, Cleveland Clinic surgeons usually can treat colorectal cancer successfully without requiring a permanent colostomy. Currently, less than 1% of all patients treated for colon cancer and fewer than 10% of all rectal cancer patients treated at the Cleveland Clinic require a permanent colostomy.

What is the hospital's surgical mortality rate for procedures used to treat colorectal cancer?

In 1994, the most recent year for which national comparable data is available, mortality for Cleveland Clinic patients undergoing complicated abdominal surgery was 5.4%.(This data is based on 242 patients under- going large and small bowel procedures, 30% of which were for colorectal cancer.)*

In the Greater Cleveland area during the same period, mortality was 8.9% (1,412 patients). Nationally, mortality was 7.2% (15,229 patients).*

Pioneering Work in Colorectal Cancer

The Cleveland Clinic Foundation is recognized worldwide for its comprehensive commitment to understanding, diagnosing and treating colorectal cancer. Doctors and scientists here are leaders in the field of gastroenterology and colorectal surgery and have been responsible for a number of major advances.

· Development of the Turnbull "no-touch" surgical technique by Cleveland Clinic colorectal surgeon, Rupert B. Turnbull Jr., M.D., which is used by surgeons around the world to prevent the spread of cancer cells during colon resections.

· Development of the concept of enterostomal therapy in the 1950s by Clinic physician Rupert B. Turnbull Jr., M.D., who introduced the world's first training program for enterostomal therapists.

· Pioneering laparoscopic techniques for removing colon cancer and creating colostomies.

· One of the country's oldest and largest Inherited Colorectal Cancer Registries, The David G. Jagelman Center for Inherited Colorectal Cancer.

· One of the country's largest Polyp Registries.

· Use of strip biopsy, a new technique that allows the non-surgical removal of large, flat polyps.

Sidebar

For An Appointment or Information

If you would like to make an appointment with a Cleveland Clinic physician who specializes in the care of colorectal cancer, please call:

Department of Colorectal Surgery

216/444-5404 (in Cleveland)

800/223-2273, Ext. 45404 (toll-free outside Cleveland)

Department of Gastroenterology

216/444-6536 (in Cleveland)

800/223-2273, Ext. 46536 (toll-free outside Cleveland)

If you would like to receive other guides in our "How to Choose a Doctor and Hospital for Your Treatment" series, please call one of the numbers below:

216/444-8919 (in Cleveland)

800/545-7718 (toll-free outside Cleveland)

Cleveland Clinic Florida

Through these activities, the Cleveland Clinic has built and maintains an international reputation for excellence and innovation in the diagnosis and treatment of colorectal cancer. Its affiliated Cleveland Clinic Florida has drawn upon this experience and expertise to establish corresponding programs for the diagnosis and treatment of colorectal cancers.

For more information or to make an appointment at Cleveland Clinic Florida, call 800/359-5101.

Reprinted with permission by: Med Help International

Copyright © The Cleveland Clinic Foundation. 1995 All rights reserved