Rational Follow-Up After Curative Cancer Resection

Abstract

Cancer recurrence after complete resection of the primary tumor is dreaded by patients and physicians alike. Intensive follow-up after curative resection is considered a marker of good practice and frequently perceived as an antidote against recurrence by patients and families. In the United States, there is abiding faith in frequent imaging and blood tests as the best tools for the job. Thoughtful practice, clinical guidelines, retrospective reviews of prospectively gathered data, and clinical trials of follow-up have focused on the number, frequency, and sequence of modalities. 1,2 A different perspective on which to predicate follow-up of patients with curatively treated cancer is to consider whether meaningful treatment options exist for recurrence. In cancers for which there are meaningful treatment options, it is reasonable to expect that moreintensive follow-up may improve survival. This commentary discusses this perspective in the context of the established literature in patients with colorectal and breast cancers, two cancers considered to have effective treatments for metastatic and recurrent disease as compared with non-small-cell lung cancer (NSCLC) and pancreatic cancer, which do not. Colorectal CancerEffective treatments for advanced colorectal cancer have evolved over the past 20 years. Life-prolonging therapies exist for metastatic disease. 3,4 Some, such as resection of isolated hepatic and lung metastases, have curative potential. [5][6][7] These data suggest that intensive follow-up of patients with curatively treated colorectal cancer could improve overall survival.However, the current literature is not definitive. In 2000, Berman et al 8 published a systematic review in Lancet on the use of many different tests for colorectal cancer surveillance. The review concluded that "after baseline colonoscopy to rule out synchronous and metachronous tumors, data support surveillance restricted to review of clinical symptoms and physical examination." 8(p398) This conclusion stimulated published objections that the analysis reflected older practices, less willingness to resect metastatic disease, and lesseffective chemotherapy. 9In 2002, Kievit et al 10 performed a meta-analysis addressing the impact of intensity of surveillance strategies for colorectal cancer. This study, including 267 published articles, calculated that 360 positive follow-up tests and 11 surgeries would be needed to provide one patient with colorectal cancer long-term survival. The authors concluded that cost-effective follow-up should be of limited intensity and duration, consisting of carcinoembryonic antigen testing and hepatic ultrasound.

Pancreatic Adenocarcinoma, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

“…Although data on the role of surveillance in patients with resected pancreatic adenocarcinoma are very limited, [171][172][173] recommendations are based on the consensus that earlier identification of disease may facilitate patient eligibility for investigational studies or other forms of treatment. The panel recommends a history and physical examination for symptom assessment every 3 to 6 months for 2 years, then every 6 to 12 months.…”

SEOM Clinical Guideline for the treatment of pancreatic cancer (2016)

“…The majority of recurrences occur within 2 years after resection and can be locoregional and/or to distant sites, including the liver, lung, or peritoneum [31]. Although computed tomography, positron emission tomography and the serum CA19-9 can detect preclinical recurrences, limited available information does not support the idea that early treatment of relapse improves survival [32]. Therefore, considering the poor prognosis of the disease upon diagnosis of a recurrence, there is no evidence that regular follow-up has any impact on the outcome.…”

Differences in Patterns of Recurrence in Early-Stage Versus Locally Advanced Non-Small Cell Lung Cancer

“…At present, there is no evidence that such an aggressive surveillance regimen would result in improved survival. As a result, many have argued against intensive surveillance, citing increased costs as well as unnecessary and ineffective interventions [19]. In theory, earlier detection of locoregional disease would allow for earlier curative intervention.…”