Rationale for follow-up

From Cancer Guidelines Wiki

The primary aim for surveillance is to promote long-term survival with improved quality of life through the early detection of local and distant recurrent disease.

Surveillance is also useful for detecting metachronous colorectal cancers, reassuring patients, and maximising quality of life, and for enabling collection of data for research purposes.

Overview of evidence (non-systematic literature review)

No systematic reviews were undertaken for this topic. Practice points were based on selected evidence and consensus. See Guidelines development process.

Early detection of recurrence

About one in three patients who have curative surgery for colorectal cancer will die as a result of recurrent disease.[1] Follow-up is performed to improve on this outcome by detecting recurrence at an earlier and potentially curable stage. In general, this will mean detecting recurrence in an asymptomatic person. Ideally such recurrence would be early and resectable local or distant disease, for which further treatment is potentially curative and may prolong survival. Proponents of intensive follow-up argue that this approach could lead to earlier detection of recurrent and/or metachronous disease and, by improving resectability rates, may improve survival time.

Chemotherapy and surgical resection for metastatic or recurrent disease have been shown to improve survival. Patients who have complete resection of liver metastases have a 5-year survival rate of approximately 40%.[2] Similar results have been reported for lung metastases.[3] Additionally, advances in pelvic exenteration for locally recurrent rectal cancer have shown improved complete oncological resection rates (R0) and achieved 5-year disease-free survival rates of up to 43%.[4]

Comparably complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer related peritoneal carcinomatosis is, in highly selected patients, beneficial, resulting in 40-50% five-year survival and 16% ten-year survival.[5][6]

Detection of secondary primary tumours

Following curative surgery for colorectal cancer, patients have an increased incidence of metachronous primary colorectal cancers and adenomatous polyps.[7] In one series, the rates of development of new primary cancers and adenomas at 4 years were 7.7% and 62%, respectively.[8]

Colonoscopic surveillance and the removal of any adenomas might reduce the incidence of subsequent primary bowel cancer.

Data collection and audit

Follow-up provides information on clinical outcomes for clinicians to evaluate their practice against professional standards.[9] It is essential for participation in clinical trials.[10] Follow-up is also required in order to produce national outcomes data to assess the impact of new guidelines and the introduction of alternative therapies.


Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

As there are no reliable indicators of an individual’s risk of synchronous or metachronous lesions, nor of treatable recurrence, all patients who have undergone curative surgery should be offered follow-up if they are fit for further intervention should disease be detected.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Patients who are unfit for further surgery or who have advanced disease require appropriate follow-up directed at psychological support and symptom relief.

Next section: optimal surveillance protocol

References

  1. Kievit J, Bruinvels DJ. Detection of recurrence after surgery for colorectal cancer. Eur J Cancer 1995 Jul;31A(7-8):1222-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7577026.
  2. Kanas GPA medical professional who treats acute and chronic illnesses and provides preventive care and health education to a wide range of patients., Taylor A, Primrose JN, Langeberg WJ, Kelsh MA, Mowat FS, et al. Survival after liver resection in metastatic colorectal cancer: review and meta-analysis of prognostic factors. Clin Epidemiol 2012;4:283-301 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23152705.
  3. Gonzalez M, Poncet A, Combescure C, Robert J, Ris HB, Gervaz P. Risk factors for survival after lung metastasectomy in colorectal cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 2013 Feb;20(2):572-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23104709.
  4. Milne T, Solomon MJ, Lee P, Young JM, Stalley P, Harrison JD. Assessing the impact of a sacral resection on morbidity and survival after extended radical surgery for locally recurrent rectal cancer. Ann Surg 2013 Dec;258(6):1007-13 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23364701.
  5. Elias D, Lefevre JH, Chevalier J, Brouquet A, Marchal F, Classe JM, et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol 2009 Feb 10;27(5):681-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19103728.
  6. Quenet F, Goéré D, Mehta SS, Roca L, Dumont F, Hessissen M, et al. Results of two bi-institutional prospective studies using intraperitoneal oxaliplatin with or without irinotecan during HIPEC after cytoreductive surgery for colorectal carcinomatosis. Ann Surg 2011 Aug;254(2):294-301 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21772129.
  7. Nava HR, Pagana TJ. Postoperative surveillance of colorectal carcinoma. Cancer 1982 Mar 1;49(5):1043-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7059921.
  8. Beck DE, Opelka FG, Hicks TC, Timmcke AE, Khoury DA, Gathright JB Jr. Colonoscopic follow-up of adenomas and colorectal cancer. South Med J 1995 May;88(5):567-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7732448.
  9. The Royal College of Surgeons of England: Association of coloproctology of Great Britain and Ireland. Guidelines for the Management of Colorectal Cancer.; 1996.
  10. Beart RW Jr, O'Connell MJ. Postoperative follow-up of patients with carcinoma of the colon. Mayo Clin Proc 1983 Jun;58(6):361-3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6855273.
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