Patient selection for surveillance colonoscopy following resection
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. 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. Harms related to intensive follow-up and salvage therapy were not well reported.
Overview of evidence (non-systematic literature review)[edit source]
No systematic reviews were undertaken for this topic. Practice points were based on selected evidence (see Guideline development process).
Risk factors for local recurrence following resection for colorectal cancer[edit source]
Recent studies suggest that follow-up after CRC resection could perhaps be customised according to a patient’s individual risk. Importantly for colonoscopic surveillance, a number of studies have determined features of a primary CRC, which increase the risk of local recurrence at the surgical anastomosis. 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. Local recurrence 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.
Risk factors for metachronous neoplasia following resection for colorectal cancer[edit source]
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. Some authors have reported that the presence of synchronous polyps or cancers at preoperative colonoscopy is a risk factor for metachronous CRC and for metachronous adenomatous polyps. 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.
Metachronous and synchronous tumours are features of Lynch syndrome, previously called hereditary non-polyposis colorectal cancer (HNPCC). 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.
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.
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.
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.
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