Outcome evaluation

The goal of monitoring is to evaluate whether the patient is receiving any benefit from the management of the disease, to detect recurrence, and to minimize the adverse effects of treatment. During treatment for active disease, patients should undergo monitoring for measurable tumor response, progression, or new metastases; these tests may include chest CT scans or x-rays, abdominal or pelvic CT scans or x-rays, depending on the site of disease being evaluated for response, and carcinoembryonic antigen (CEA) measurements every 3 months if the CEA is or was previously elevated.52 A PET scan can be considered to identify localized sites of meta-static disease in situations where a rising CEA level suggests metastatic disease but CT scans and other imaging studies are negative. Symptoms of recurrence such as pain, changes in bowel habits, rectal bleeding, pelvic masses, anorexia, and weight loss develop in fewer than 50% of patients. Patients who undergo curative surgical resection, with or without adjuvant therapy, require close follow-up because early detection and treatment of recurrence could still result in patient cures. In addition, early treatment for asymptomatic metastatic colorectal cancer appears superior to delayed therapy. Colorectal cancer surveillance guidelines published by the American Society of Clinical Oncology recommend against routinely monitoring liver function tests, CBC, FOBT, CT scans,

annual chest x-rays, or pelvic imaging in asymptomatic patients.

In addition, a complete blood count should be obtained prior to each course of chemotherapy administration to ensure that hematologic values are adequate. In particular, white blood counts and absolute neutrophil counts can be decreased in patients receiving chemotherapy such as irinotecan and 5-fluorouracil. Baseline liver function tests and an assessment of renal function should be evaluated prior to and periodically during therapy. Other selected laboratory tests include checking for the presence of protein in the urine in patients receiving bevacizumab and monitoring of magnesium, calcium, and potassium in patients receiving cetuximab or panitumumab.

Patients should be evaluated during every treatment visit for the presence of anticipated side effects from their treatment, and health care practitioners should anticipate these adverse reactions and aggressively treat and prevent them from occurring. These generally include loose stools or diarrhea from irinotecan, 5-fluorouracil, and capecitabine; hand-foot syndrome from 5-fluorouracil and capecitabine; nausea or vomiting from irinotecan, 5-fluorouracil, and oxaliplatin; mouth sores from 5-fluorouracil; neuropathies from oxaliplatin; bleeding and hypertension from bevacizumab; and skin rash associated cetuximab and panitumumab.

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