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Colorectal Cancer
Rectal Cancer requires a multidisciplinay approach. Our workup includes Endorectal US, Pelvic MRI, CT scan with oral, intravenous and rectal contrast and endoscopy. Cases are then discussed in tumor board with radiation oncologists, surgeons, pathologists and oncologists.
MRI of Rectal Cancer
At KFSH-RC Jeddah we are using pelvic MRI to aid in determining the circumferential margin prior to resection. Knowing the CRM aids in planning for neoadjuvant therapy and surgery. Tumors that have positive CRM or less than 5mm will under go preoperative radiation followed by surgery. Please see the practice guidelines for further information.
Endorectal Ultrasound. Normal Tis T3
Total Mesorectal Excision (TME). Gross 1 (Anterior). 2 (Posterior: bilobed appearance). 3 (Defect in mesorectum posteriorly)
St Mark's retractors and deep pelvic retractors necessary for direct visualization during TME.
Standardized Method of Pathological Examination of Rectal Cancer Specimens. For compete discription please see practice guidelines.
Donught sectioning of specimen. 1 (complete donughts in total mesorectal excision) . 2 (incomplete donughts)
Microscopic Pictures of Circumferential Margin (CRM) in Rectal Cancers. CRM less than 1 mm is considered positive.
CRM1: Positive CRM. Tumor seen at inked margin. CRM2: Distance from tumor focus to inked margin. This focus is distant from the primary tumor.
CRM3: The shortest distance to CRM is taken.
Cancer Registries
Introduction
The oldest cancer registry in the world is in Denmark, the oldest registry in the States is in New Haven, Conecticut (1926) folowed by the central registries in Conecticut (1935). The National Cancer Registry in Riyadh has been active since January 1994. There are hospital-based registries, regional registries, state registries and national registries -- all developed for the OVERALL purpose of "Accurately reporting the burden of cancer in a defined population". The WHO developed the manual that all registrars use to assign the primary site code and the histology - so all around the world the codes are usually comparable.
Purposes
Education: Evaluate sucess of treatment of cancer patients.
Follow-Up: Sending automated reminders for follow-up for physical check up, blood tests or screening methods.
Research: Descriptive epidemiology of cancer is initiated using the accumulated data. This information can be used to aid in establishment of guidelines for screening, treatment and family counselling.
Referal: information can also be used by health policy makers to assess referral patterns of cancer patients. An epidmeic of cancer cases from a certain region can draw attention to an etiological agent. The central government is very interested in analyzing these data to fund research on cancer.
Types
Hospital-based registries collects information about all cancer patients seen at a particular institution. They are primarily used to support their own cancer program of oncology surgery, chemotherapy, radiation, therapy and over time, to evaluate the efficacy of treatment, folow-up and eventually aid in establishing guidelines. The Oncology data unit in KFSHRC in Riyadh has been collecting data since 1975. It produces its annaul report which is pubished by KFSH. Its sister hospital KFSHRC in Jeddah has established a cancer registry that is looking retrospectively at data since its inception in 1999.
Special purpose registry collects data on one type or aspect of cancer, such as leukemia, familial adenomatous polyposis or young colorectal cancer.
Population -based registries
SAMSO Cancer Program has been collecting cancer data since 1987. SAMSO was the first health organization to collect infromation on the incidence of cancer. The earliest reports are those of Taylor (1963), Gelpi (1970) and Perrine (1975). This registry is based on review and anlysis of medical records. SAMSO registry maintains a complete database of all cancer cases diagnosed and/or treated at Saudi Aramco Medical Services Organization. This database include 3,501 cases diagnosed from 1987 to December 31, 1999. Annualy, 300-400 new cases are added.
Limitations of Registries:
1. The denominator of all incidence reports is the population at risk. Population census and estimated number of individulas in each age group is important for calculation of age adjusted incidence rates. An innacurate population census will produce inaccurate incidence rates.
2. Death certificates inaccuracies.
4. Lack of Autoposy confirmation of suspected cancer deaths.
5. Reluctancyof the elderyl population to seek medical assistence.
6. Incomplete reporting by hospitals or health professionals.
All the above produce under ascertainment of cancer cases which is probably around 10-15%.
Personal View of a cancer registrant:
A huge strength of the cancer registry is that eventhough it's not an incredibly well-paying job (although it can be), the people who do this work are not in it for the money -- for the most part, they care deeply about the cost of cancer in human, personal terms. I've seen registrars go way above and beyond the call of duty just because they have been touched by this disease or a friend or family member has. These registrars often do "double-duty" and wear many hats in their position. Some are responsible for registering patients in protocols (SWOG, ECOG, NSABP) and various studies. They also support such events as "Daffodil Days," "I Can Cope" patient support groups, "Relay for Life," "Reach to Recovery" for breast cancer survivors, the "Black & White Ball" to raise money and awareness, etc.
Cancer registrars working in cancer registries of any kind are really dedicated people who have the overall wellbeing of PEOPLE at the top of their list -- not just the dry data. However, most of the groups and organizations mentioned above depend on good quality data from cancer registries so it's so important to have enough staff and funding in all registries to support the data collection, abstraction, submission, etc. It's tough because, unlike other programs, cancer registries are not normally considered revenue generating and depend on the whims of the administation section to allocate the money. So I would think that one of the weaknesses is one that is shared by many others - lack of adequate funding to do the job, which then dovetails into sub-quality data, which then impacts the results of various reports. Probably the biggest weakness regarding cancer registration is the general lack of knowledge about what we, as cancer registrars, can do. Most people haven't a clue what a registrar is - in the beginning, registries were connected to the Medical Records Dept, when we now realize registries need to be part of the cancer program .
Brenda Lange, ex-registrar at NCR.
Cancer Registries in the GCC:
Dr Jamal Al Sayyad. Public Health Directorate. Ministry of Health
P.O.Box 12, Manama Bahrain. JSayyad@health.gov.bh
Dr Nasser Al-Hamdan.
KFSHRC Riyadh. P.O.Box 3354 (MBC 64), Riyadh 11211. KSA.
nhamdan@kfshrc.edu.sa
Dr Omar El Hattab, Kuwait Cancer Control Centre.
P.O.Box 42262. Shuwaikh 70653. Kuwait. ohattab@hotmail.com
Dr Jawad A Al-Lawati. Ministry of Health.
P.O.Box 393, Muscat 113, Oman. jallawat@omantel.net.om
Dr Ahmed Al Mulla
P.O.Box 3050, Doha. Qatar. dralmulla@hotmail.com
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