Follow-up of patients with curatively resected colorectal cancer: a practice guideline

Abstract

BackgroundA systematic review was conducted to evaluate the literature regarding the impact of follow-up on colorectal cancer patient survival and, in a second phase, recommendations were developed.MethodsThe MEDLINE, CANCERLIT, and Cochrane Library databases, and abstracts published in the 1997 to 2002 proceedings of the annual meeting of the American Society of Clinical Oncology were systematically searched for evidence. Study selection was limited to randomized trials and meta-analyses that examined different programs of follow-up after curative resection of colorectal cancer where five-year overall survival was reported. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee.ResultsSix randomized trials and two published meta-analyses of follow-up were obtained. Of six randomized trials comparing one follow-up program to a more intense program, only two individual trials detected a statistically significant survival benefit favouring the more intense follow-up program. Pooling of all six randomized trials demonstrated a significant improvement in survival favouring more intense follow-up (Relative Risk Ratio 0.80 (95%CI, 0.70 to 0.91; p = 0.0008). Although the rate of recurrence was similar in both of the follow-up groups compared, asymptomatic recurrences and re-operations for cure of recurrences were more common in patients with more intensive follow-up. Trials including CEA monitoring and liver imaging also had significant results, whereas trials not including these tests did not.ConclusionFollow-up programs for patients with curatively resected colorectal cancer do improve survival. These follow-up programs include frequent visits and performance of blood CEA, chest x-rays, liver imaging and colonoscopy, however, it is not clear which tests or frequency of visits is optimal. There is a suggestion that improved survival is due to diagnosis of recurrence at an earlier, asymptomatic stage which allows for more curative resection of recurrence.Based on this evidence and consideration of the biology of colorectal cancer and present practices, a guideline was developed.Patients should be made aware of the risk of disease recurrence or second bowel cancer, the potential benefits of follow-up and the uncertainties requiring further clinical trials. For patients at high-risk of recurrence (stages IIb and III) clinical assessment is recommended when symptoms occur or at least every 6 months the first 3 years and yearly for at least 5 years. At the time of those visits, patients may have blood CEA, chest x-ray and liver imaging. For patients at lower risk of recurrence (stages I and Ia) or those with co-morbidities impairing future surgery, only visits yearly or when symptoms occur. All patients should have a colonoscopy before or within 6 months of initial surgery, and repeated yearly if villous or tubular adenomas >1 cm are found; otherwise repeat every 3 to 5 years. All patients...

Early detection of recurrence by 18FDG-PET in the follow-up of patients with colorectal cancer

“…Recurrence of colon and rectal cancer may occur in asymptomatic patients, and this means that physical examinations, biological marker assays and imaging procedures must also be performed (Figueredo et al, 2003;Meyerhardt and Mayer, 2003). However, improvements in the survival of patients who have had curative therapy for colon or rectum cancer have been attributable to intense follow-up programmes including imaging procedures (Northover et al, 1994;Figueredo et al, 2003).…”

“…However, improvements in the survival of patients who have had curative therapy for colon or rectum cancer have been attributable to intense follow-up programmes including imaging procedures (Northover et al, 1994;Figueredo et al, 2003). Among these techniques, CT scans seem to be more sensitive than US for detecting liver metastases (Pietra et al, 1998;Schoemaker et al, 1998;Secco et al, 2002), and this procedure is now recommended ( Benoist et al, 2006), although 3 -15% of recurrences may still be missed (Holt et al, 2006).…”

Defining cancer survivor and cancer survivorship: The who, what, and when

“…In bladder cancer patients, for instance, the rate of recurrence, ranges from 15-61% within 1 year and from 31-78% within 5 years (40) . In one of the most common cancers (38) , colorectal cancer (CRC), recurrence ranges from 12% within 5 years for stage I patients (41) to 40% for stage II or III patients (42) . In 20% of female breast cancer cases, local, regional or distant recurrence occurs within 10 years after cancer diagnosis (42) .…”

“…In one of the most common cancers (38) , colorectal cancer (CRC), recurrence ranges from 12% within 5 years for stage I patients (41) to 40% for stage II or III patients (42) . In 20% of female breast cancer cases, local, regional or distant recurrence occurs within 10 years after cancer diagnosis (42) . For prostate cancer, an average of 15% of patients experience recurrence within 5 years of radical prostatectomy (44) .…”

Genomic era diagnosis and management of hereditary and sporadic colon cancer

“…These tools include serial history and physical examination by a physician, CEA testing, colonoscopy and in some cases CT scans of the chest, abdomen and pelvis [77] . The advantages of more intensive surveillance regimens for patients with stage Ⅱ and Ⅲ CRC have been shown [86][87][88] and current recommendations for patients with successfully treated stage Ⅰ-Ⅲ CRC include history and physical examination every 3-6 mo for 2 years, CEA testing every 3-6 mo for 2 years and colonoscopy 3-6 mo post-resection (if not performed preoperatively) [77] . Surveillance colonoscopy is repeated based on findings (3 years if normal and 1 year if concerning adenomatous polyp removed), with CEA, history and physical exam spaced to every 6 mo to complete the first 5 years of posttreatment surveillance [77] .…”