Patient selection for surveillance colonoscopy following resection

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The Clinical practice guidelines for the prevention, early detection and management of colorectal cancer updated in 2017, proposed that intensive follow-up for colorectal cancer (CRC) should be considered for patients who have had potentially curable disease. The US Multi-Society Task Force on Colorectal Cancer recommended that all patients who have undergone curative resection of either colon or rectal cancer should undergo surveillance colonoscopy.[1] A Cochrane review updated in 2016 concluded that, although intensive follow-up can detect recurrences earlier, resulting in more salvage surgery with curative intent, this was not associated with improved survival.[2] Harms related to intensive follow-up and salvage therapy were not well reported.

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Overview of evidence (non-systematic literature review)

No systematic reviews were undertaken for this topic. Practice points were based on selected evidence (see Guideline development process).

Risk factors for local recurrenceThe reappearance of cancer at a site that was previously treated and responded to therapy. following resection for colorectal cancer

Recent studies suggest that follow-up after CRC resection could perhaps be customised according to a patient’s individual risk.[3][4][5][6][7][8][9][10][11][12] Importantly for colonoscopic surveillance, a number of studies have determined features of a primary CRC, which increase the risk of local recurrenceThe reappearance of cancer at a site that was previously treated and responded to therapy. at the surgical anastomosis.[3][4][5][13][14] Anastomotic recurrence occurs far more often in rectal cancer patients than in colon cancer patients, and additional proctoscopy follow-up has been recommended by some for this reason.[1][5][15] Local recurrenceThe reappearance of cancer at a site that was previously treated and responded to therapy. is also more likely to occur in patients undergoing local excision (including transanal endoscopic microsurgery) of their rectal primary cancers. Unfortunately, some of these recurrences are associated with extra-colonic disease or local spread and are not curable.[3][16][17][18][19]Back to top

Risk factors for metachronous neoplasia following resection for colorectal cancer

Having developed one CRC, patients are at risk for the development of metachronous polyps and cancers. Bouvier et al reported the incidence of metachronous cancer as being 1.8% at 5 years, 3.4% at 10 years, and 7.2% at 20 years with the greatest excess risk between 1 and 5 years post-operatively.[20] Some authors have reported that the presence of synchronous polyps or cancers at preoperative colonoscopy is a risk factor for metachronous CRC[21][22][23][24][25] and for metachronous adenomatous polyps.[21][26] However, in several other studies including a large cancer registry based population-based study have failed to identify any link between synchronous adenomas and the development of subsequent metachronous CRC.[20][23][27]

Metachronous and synchronous tumours are features of Lynch syndrome, previously called hereditary non-polyposis colorectal cancer (HNPCC).[28][29] A propensity for metachronous CRCs with a predilection for the proximal colon, and development of cancer at an early age, are well recognised characteristics of Lynch syndrome.[30]

Primary tumour location is a risk factor for the development of metachronous cancer. In a study of more than 500 CRC patients from a cancer registry database, patients whose first cancer was located proximal to splenic flexure were found to be at twice the risk for developing a metachronous cancer compared to those with a first cancer in the distal colon.[13]

Thus, reported studies have disagreed about whether patients who have undergone CRC resection can be stratified with regard to their risk of future development of metachronous polyps and cancers. Even in those studies where a positive predictive factor was identified, the strength of the association with the development of future colonic neoplasia was insufficiently strong to exclude patients without the factor from colonoscopic surveillance.

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Practice pointQuestion mark transparent.png

Patients with hereditary colorectal cancer syndromes should have surveillance colonoscopy performed post-operatively as per the Clinical practice guidelines for the prevention, early detection and management of colorectal cancer.

Practice pointQuestion mark transparent.png

Other clinically high-risk patients should be considered for more frequent surveillance colonoscopy after surgery than would otherwise be recommended (e.g. initial post-operative colonoscopy at 1 year and then 1–3 yearly depending on personalised estimate of risk). These include patients:

  • whose initial diagnosis was made younger than age 40 years
  • with suspected but un-identified hereditary colorectal cancer syndromes
  • with multiple synchronous cancers or advanced adenomas at initial diagnosis.
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  1. 1.01.1 Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, et al. Colonoscopy surveillance after colorectal cancer resection: recommendations of the US multi-society task force on colorectal cancer. Gastrointest Endosc 2016 Mar;83(3):489-98.e10 Abstract available at
  2. Jeffery M, Hickey BE, Hider PN, See AM. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2016 Nov 24;11:CD002200 Abstract available at
  3. Barillari P, Ramacciato G, Manetti G, Bovino A, Sammartino P, Stipa V. Surveillance of colorectal cancer: effectiveness of early detection of intraluminal recurrences on prognosis and survival of patients treated for cure. Dis Colon Rectum 1996 Apr;39(4):388-93 Abstract available at
  4. 4.04.1 Chan CL, Bokey EL, Chapuis PH, Renwick AA, Dent OF. Local recurrence after curative resection for rectal cancer is associated with anterior position of the tumour. Br J Surg 2006 Jan;93(1):105-12 Abstract available at
  5. Manfredi S, Bouvier AM, Lepage C, Hatem C, Dancourt V, Faivre J. Incidence and patterns of recurrence after resection for cure of colonic cancer in a well defined population. Br J Surg 2006 Sep;93(9):1115-22 Abstract available at
  6. Obrand DI, Gordon PH. Incidence and patterns of recurrence following curative resection for colorectal carcinoma. Dis Colon Rectum 1997 Jan;40(1):15-24 Abstract available at
  7. Renehan AG, Egger M, Saunders MP, O'Dwyer ST. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002 Apr 6;324(7341):813 Abstract available at
  8. Battersby NJ, Dattani M, Rao S, Cunningham D, Tait D, Adams R, et al. A rectal cancer feasibility study with an embedded phase III trial design assessing magnetic resonance tumour regression grade (mrTRG) as a novel biomarker to stratify management by good and poor response to chemoradiotherapy (TRIGGER): study protocol for a randomised controlled trial. Trials 2017 Aug 29;18(1):394 Abstract available at
  9. Borda A, Martínez-Peñuela JM, Borda F, Muñoz-Navas M, Jiménez FJ, Carretero C. Drawing up an individual risk index for development of metachronous neoplastic lesions in resected colorectal cancer. Rev Esp Enferm Dig 2012 Jun;104(6):291-7 Abstract available at
  10. Kawai K, Sunami E, Tsuno NH, Kitayama J, Watanabe T. Polyp surveillance after surgery for colorectal cancer. Int J Colorectal Dis 2012 Aug;27(8):1087-93 Abstract available at
  11. Lee SY, Kim BC, Han KS, Hong CW, Sohn DK, Park SC, et al. Incidence and risk factors of metachronous colorectal neoplasm after curative resection of colorectal cancer in Korean patients. J Dig Dis 2014 Jul;15(7):367-76 Abstract available at
  12. Mulder SA, Kranse R, Damhuis RA, Ouwendijk RJ, Kuipers EJ, van Leerdam ME. The incidence and risk factors of metachronous colorectal cancer: an indication for follow-up. Dis Colon Rectum 2012 May;55(5):522-31 Abstract available at
  13. 13.013.1 Gervaz P, Bucher P, Neyroud-Caspar I, Soravia C, Morel P. Proximal location of colon cancer is a risk factor for development of metachronous colorectal cancer: a population-based study. Dis Colon Rectum 2005 Feb;48(2):227-32 Abstract available at
  14. Kobayashi H, Mochizuki H, Sugihara K, Morita T, Kotake K, Teramoto T, et al. Characteristics of recurrence and surveillance tools after curative resection for colorectal cancer: a multicenter study. Surgery 2007 Jan;141(1):67-75 Abstract available at
  15. Cone MM, Beck DE, Hicks TE, Rea JD, Whitlow CB, Vargas HD, et al. Timing of colonoscopy after resection for colorectal cancer: are we looking too soon? Dis Colon Rectum 2013 Nov;56(11):1233-6 Abstract available at
  16. Barrier A, Houry S, Huguier M. The appropriate use of colonoscopy in the curative management of colorectal cancer. Int J Colorectal Dis 1998;13(2):93-8 Abstract available at
  17. Juhl G, Larson GM, Mullins R, Bond S, Polk HC Jr. Six-year results of annual colonoscopy after resection of colorectal cancer. World J Surg ;14(2):255-60; discussion 260-1 Abstract available at
  18. Khoury DA, Opelka FG, Beck DE, Hicks TC, Timmcke AE, Gathright JB Jr. Colon surveillance after colorectal cancer surgery. Dis Colon Rectum 1996 Mar;39(3):252-6 Abstract available at
  19. Renehan AG, O'Dwyer ST, Whynes DK. Cost effectiveness analysis of intensive versus conventional follow up after curative resection for colorectal cancer. BMJ 2004 Jan 10;328(7431):81 Abstract available at
  20. 20.020.1 Bouvier AM, Latournerie M, Jooste V, Lepage C, Cottet V, Faivre J. The lifelong risk of metachronous colorectal cancer justifies long-term colonoscopic follow-up. Eur J Cancer 2008 Mar;44(4):522-7 Abstract available at
  21. 21.021.1 Ballesté B, Bessa X, Piñol V, Castellví-Bel S, Castells A, Alenda C, et al. Detection of metachronous neoplasms in colorectal cancer patients: identification of risk factors. Dis Colon Rectum 2007 Jul;50(7):971-80 Abstract available at
  22. Carlsson G, Petrelli NJ, Nava H, Herrera L, Mittelman A. The value of colonoscopic surveillance after curative resection for colorectal cancer or synchronous adenomatous polyps. Arch Surg 1987 Nov;122(11):1261-3 Abstract available at
  23. 23.023.1 Brady PG, Straker RJ, Goldschmid S. Surveillance colonoscopy after resection for colon carcinoma. South Med J 1990 Jul;83(7):765-8 Abstract available at
  24. Togashi K, Konishi F, Ozawa A, Sato T, Shito K, Kashiwagi H, et al. Predictive factors for detecting colorectal carcinomas in surveillance colonoscopy after colorectal cancer surgery. Dis Colon Rectum 2000 Oct;43(10 Suppl):S47-53 Abstract available at
  25. Fajobi O, Yiu CY, Sen-Gupta SB, Boulos PB. Metachronous colorectal cancers. Br J Surg 1998 Jul;85(7):897-901 Abstract available at
  26. Hassan C, Gaglia P, Zullo A, Scaccianoce G, Piglionica D, Rossini FP, et al. Endoscopic follow-up after colorectal cancer resection: an Italian multicentre study. Dig Liver Dis 2006 Jan;38(1):45-50 Abstract available at
  27. Lan YT, Lin JK, Li AF, Lin TC, Chen WS, Jiang JK, et al. Metachronous colorectal cancer: necessity of post-operative colonoscopic surveillance. Int J Colorectal Dis 2005 Mar;20(2):121-5 Abstract available at
  28. Lynch HT, Smyrk TC, Watson P, Lanspa SJ, Lynch JF, Lynch PM, et al. Genetics, natural history, tumor spectrum, and pathology of hereditary nonpolyposis colorectal cancer: an updated review. Gastroenterology 1993 May;104(5):1535-49 Abstract available at
  29. Watson P, Lynch HT. Extracolonic cancer in hereditary nonpolyposis colorectal cancer. Cancer 1993 Feb 1;71(3):677-85 Abstract available at
  30. Fante R, Roncucci L, Di GregorioC, Tamassia MG, Losi L, Benatti P, et al. Frequency and clinical features of multiple tumors of the large bowel in the general population and in patients with hereditary colorectal carcinoma. Cancer 1996 May 15;77(10):2013-21 Abstract available at

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