Follow-Up in Patient’s After Curative Resection for Colon Cancer Surveillance for Colon Cancer

Pt Population

Intervention

Comparators

Outcomes studied

Pts after curative resection of colorectal cancer

Intensive follow up

Clinical followup

Early detection of recurrence, salvage rates, cost

Introduction

According to the American Cancer Society, 134,490 new cases of colon and rectal cancer will be diagnosed in 2016. The effect is nearly equal between men and women, with 70,820 diagnosed in men, and 63,670 diagnosed in women [1]. Colon and rectal cancer is the fourth most common cancer, however it is the second most common cause of cancer deaths [1]. At least, one third (25–49 % reported) of patients treated with stage II or stage III colon cancer will experience a recurrence, and this has remained fairly steady over the past 20 years [1–3].

The purpose of surveillance following potentially curative surgery for colorectal cancer, is the early identification of recurrent cancer in those patients who might potentially be cured by secondary surgical intervention. Secondly, surveillance also enables screening for metachronous primary cancers and polyps. The diagnosis of an asymptomatic recurrence is more likely to result in attempts at curative reoperation [4]. Even with an intensive investigative program, up to 50 % of asymptomatic recurrences may not be detected [4]. Several studies have also demonstrated that asymptomatic recurrences of colorectal cancer are more amenable to a surgical resection with negative margins (R0) [5].

Although there is extensive literature of evaluating the benefit of surveillance strategies for colorectal cancer, there remains ongoing debate. The cost of intensive follow-up is unclear but remains central to the discussion [5].

Search Strategy

An electronic search of the PubMed database was performed from 1996 to 2016. This search terms included “cancer follow-up”, “colon surgery” and “postoperative surveillance for colon cancer” with 444 matches. The National Comprehensive Cancer Network (NCCN) [6], along with society guidelines from the American Society of Colorectal Surgeons (ASCRS), American Cancer Society of Clinical Oncology (ASCO) were reviewed. In addition the search included the Cochrane database, Google search and the Ontario evidence based series 26–2 on follow-up care surveillance protocol and secondary measures for survivors of colorectal cancer.

Results

Guidelines

The vast majority of studies exploring the benefits of surveillance have been conducted on patients with resected stage II or stage III disease. Intensive postoperative surveillance programs have been justified in the hope that early detection of asymptomatic recurrences will increase the proportion of patients potentially eligible for curative therapy [7]. Although individual randomized trials have not demonstrate a survival benefit, meta-analyses suggest a modest but significant survival benefit from intensive surveillance after resection of colorectal cancer [8–13]. It does seem clear patients with a recurrence detected by more intense surveillance are more likely to undergo curative resection, whereas the actual reported survival advantage is more variable.

For a starting template, we began with the National Comprehensive Cancer Network guidelines version 2.2015(6) which reccommend;

1.

History and physical every 3–6 months for 2 years and then every 6 months for a total of 5 years
2.

CEA every 3–6 months for 2 years, then every 6 months for a total of 5 years
3.

CT scan of the chest, abdominal and pelvis annually up to 5 years, especially for patient’s at high risk for recurrence. High risk patients would include those with lymphatic, venous or perineural invasion, with poorly differentiated tumors, or patients presenting with obstruction or perforation.
4.

Colonoscopy at 1 year when the colon was cleared prior to or at the time of surgery – repeat in 3 years and then every 5 years.
5.

If colonoscopy not performed at the time of surgery, then colonoscopy in 3–6 months.
6.

PET CT scan is not routinely recommended

Most guidelines are based on the above recommendations. We will now review each of the recommendations.

History and physical examination – low quality evidence – strong recommendation
Recommendation – Office visit with history and physical every 3–6 months for 2 years and every 6 months for a total of 5 years

While the benefit of office visits has not been well established, up to one-half of symptomatic patients may not report their symptom(s) until it is time for the visit with her physician [14, 15]. In addition, this provides an opportunity to discuss the results of surveillance testing. The evidence is limited to suggest that the physician visits provide psychological support and reassurance for patients three, but is a good time to reinforce healthy behaviors such as physical activity.

CEA testing –moderate quality evidence – strong recommendation
Recommendation – CEA every 3–6 months for 2 years and then every 6 months for a total of 5 years- should correlate with the office visit

The use of CEA has been extensively studied. The rationale for postoperative CEA monitoring is to detect an asymptomatic recurrence. Its greatest use has been in patients that have an elevated CEA before surgery which returns to normal after surgery. The strongest argument in favor of CEA testing is that resection of limited metastases, particularly involving the liver, leads to long-term relapse free survival in as many as 40 % of patients that undergo an attempted resection [7].

An asymptomatic elevation of the CEA increases the likelihood of a complete resection and will be associated with better long-term outcomes. Of note, approximately 30 % of all colorectal cancer recurrences are not associated with a CEA elevation. A false-negative CEA result is more commonly observed in poorly differentiated tumors. Even in patients with a normal preoperative CEA, there may be an elevated CEA in over 40 % of recurrences.

When an elevated CEA is detected, it should be confirmed by retesting. False positive elevations are seen in up to 50 % of patients at some time during their surveillance and follow-up. Also the CEA level is elevated in cigarette smokers. However a progressively rising CEA confirmed on retesting is indicative of metastatic or recurrent disease. These patients need to undergo further evaluation and testing.