University of Melbourne and Department of Colorectal Medicine & Genetics, The Royal Melbourne Hospital, Victoria, Australia.
The opportunity to host as Guest-Editor this issue of Cancer Forum, has indeed been timely. The unannounced rescindment by the National Health and Medical Research Council’s Guideline of the Prevention, Early Detection and Management of Colorectal Cancer, as published on its website, met with ripples of discontent from the colorectal cancer clinical community.1 Such solid effort was invested in those 2005 guidelines which have served the community well. Many could see that the baby was being thrown out with the bathwater. Secondary, unintended consequences were articulated – that now there are no guidelines, anyone’s views prevail with a non-evidence based distortion of clinical practice that might follow.
Enter then the invitation to edit this issue of Cancer Forum. I have selected Australia’s most authoritative academics, clinicians and researchers to address the chapters in this issue. Furthermore, I have charged them with a focus to move from the 2005 (rescinded) guidelines to a position that could be the foundation of thinking and systematic address for a new and updated version of the National Health and Medical Research Council (NHMRC) guidelines, which we believe is now much needed. My colleagues have done a magnificent job meeting this challenge. Some have juxtaposed the 2005 guidelines with new and updated considerations which are sound and influential. Others have taken topics which have evolved since 2005, and initiated concepts into evidence-based recommendations which were nascent in 2005, but are now viably part of clinical practice.
So we have seen a refinement of the data behind primary prevention brought forward by our CSIRO colleagues who, recognising the major importance of colorectal cancer (CRC) to the health of many Australians, have themselves invested substantial resources in CRC prevention through their pHealth program.2 Drawing on recent reports from the World Cancer Research Fund, their recommendations are sound and comprehensive. Their assessment of aspirin in prevention of CRC is a ground-breaking message in terms of guidelines internationally, and one which I am keen to see advocated internationally from Australia. After all, the first signal pointing to the benefit of aspirin in CRC prevention came from the Melbourne Colorectal Cancer study, lead by Professor Gabriel Kune, who insightfully asked the question about aspirin in his case control study. The recently published randomised control trial of aspirin in Lynch Syndrome showing a 50% reduction in CRC and other Lynch Syndrome cancers, was also internationally supported from Australia.
Graeme Young is the foremost clinical academic worldwide in the field of screening for colorectal cancer, leading the World Endoscopy Organisation’s Colorectal Cancer Screening Committee over the last eight years to a position where its annual meetings are considered the most informative horizon scanning opportunities anywhere in the world on this topic. So his chapter on screening carries a wealth of understanding and foresight.3
The team from the University of Melbourne’s School of Population Health, who are at the forefront of epidemiology in CRC, especially familial CRC, through their leadership in the US National Cancer Institute Colon Cancer Family Register, have assembled evidence relating to familial risk and its individualisation.4 Aung Win’s academic work on this topic has been recognised by the unique Premier’s Award in 2013.
Nicholas Pachter, a rising star in clinical cancer genetics from Western Australia, paints the important picture of how the familial cancer clinics integrate in the matrix of CRC management.5 Genomics undoubtedly will continue to push its importance, some would say peripherally, others centrally, into CRC clinical management. My belief is that it is central and our young trainees across many disciplines would do well to invest their time in grappling with, and understanding, the genomics and genetics revolution of which we are in the midst. Already, cancer multi-disciplinary team meetings include clinical genetics or organ specialists with a dedicated interest in the field of familial predisposition.
Personally, I am very grateful to Karen Barclay, a young and energetic colorectal surgeon, who filled the gap from the 2011 NHMRC updated guideline on colonoscopic surveillance after adenoma and CRC removal, with an easily read wall chart which should adorn the walls of all colonoscopy suites. She has sounded my contribution with a reassuring grasp of the literature herself.6
Professor Robyn Ward, scientist and clinician, describes the challenge and experience of determining personalised approaches to colorectal cancer chemotherapy, in a grounded presentation.7 Robyn herself is a wonderful advocate for practical guidelines, developing the eviQ process supporting clinical oncological practice. Michael Michael and John Zalcberg use the sharp tools of medical oncology to systematically answer practical clinical questions around chemotherapy and radiotherapy for CRC, firmly founded on their tool of trade – the randomised control trial.8
Academic surgery is no better remonstrated than by Michael Solomon’s team at University of Sydney –Michael’s academic disciplinary approach was the backbone of the 2005 guidelines, so his approach to issues of surgery for CRC in this issue carries the same measured and calibrated approach to the evidence around surgery.9
A major interest and focus professionally is being placed on quality of colonoscopy, picked up also by the National Bowel Cancer Screening Program, which has funded the National Endoscopy Training Initiative to upskill the colonoscopy community. Complacently, we have thought our practices and training of surgeons and physicians alike has been adequate if not good. But the ‘Train the Trainer’ and audit programs in the UK have challenged this complacency. No colonoscopist in Australia can ignore the messages in the chapter from Mark Appleyard, who has brought Queensland endoscopy near singlehandedly, to new heights of competency.10
Survivorship and palliation – so different but so integral to the population’s journey from prevention to palliation, is presented through a unique consumer perspective. Mark Dunstan’s frank account of his journey is a moving wakeup story to what otherwise could be stylised in clinical dispassionateness.11 It is a refreshing work to bring us back to earth. Palliation, less recognised in 2005, is now a core discipline in cancer management. Brian Le’s contribution promises to be the foundation for a new chapter in national guidelines.12
Our authors’ efforts provide a firm basis for a much needed new version of the Australian guidelines. Lives are at stake through support of clinical decision-making, which otherwise may deviate unintentionally from contemporary best practice. Engaging the CRC community to bring such a process to fruition, including adequate impartial funding (who better than the National Health and Medical Research Council?), must be an Australian national priority given the 1 in 12 or more Australians who are diagnosed with CRC. All the more important given the NHMRC’s programmed decision to rescind the guidelines, when most, but not all, are sound, and still extant in clinical practice.
My hope is that this issue will either support contemporary decision making to enshrine good practice, or form the kernel for a comprehensive but costly NHMRC ‘bells and whistles’ approach to updated guideline development, or both! Necessarily, we must place a disclaimer around the recommendations presented. Sound as they are, they are the views of the individual authors, and have not been presented for endorsement by Cancer Council, the NHMRC or indeed the Guest-Editor of this issue of Cancer Forum. That would require a greater investment in process, consultation and promulgation – though I suspect the content and message would ultimately be the same.
Meantime, I hope, as do my authors, that the distinguished contributions here presented, can inform your practice to deliver best care.