This article is more than 5 years old. Information may no longer be current.
Managing Long-term Follow-up Cured Colon Cancer
Q: What Do I Tell the Surgeons Who Insist on Annual Colonoscopies for Patients With Cured Colon Cancer, Even for Those 5 to 10 Years Past Therapy?
Click Here to Manage Email Alerts
A: Recommendations on the use of surveillance colonoscopy after resection of colorectal cancer were produced jointly by the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society (ACS). They constitute the updated recommendations of both organizations. These guidelines were endorsed by the Colorectal Cancer Advisory Committee of the ACS and by the governing boards of the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy and represent the evidence-based recommendations for the surveillance of patients with a history of colorectal cancer (Table 1 and Table 2).
In general, patients who undergo surgical resection of Stage I, II, or III colon and rectal cancers, or curative-intent resection of Stage IV cancers are candidates for surveillance colonoscopy. Patients who undergo curative endoscopic resection of Stage I colon cancers are also candidates for surveillance colonoscopy. Patients with Stage IV colon or rectal cancer that is unresectable for cure are generally not candidates for surveillance colonoscopy because their chance of survival from their primary cancer is low, and the risks of surveillance outweigh any potential benefit.
It is important to realize that historically there have been two primary goals for surveillance of patients with a history of resected colorectal cancer that have prompted clinicians to perform frequent surveillance procedures. The first is the detection of early recurrence of the primary tumor at a stage that will permit curative treatment. The second goal is to search for and identify metachronous colorectal cancers. In regard to detection of recurrences of the initial primary cancer, serial measurements of carcinoembryonic antigen are widely used. In addition, recent meta-analyses of randomized controlled trials suggest that annual chest x-rays and CT scans of the liver can improve survival from the original primary cancer by early detection of surgically curable recurrences.
The answer to the question posed is simply that neither individual randomized controlled trials of intensive surveillance with colonoscopy, nor meta-analyses of these trials, have demonstrated a survival benefit from the original primary tumor by performing colonoscopy at annual or shorter intervals. The rationale that yearly colonoscopy for patients with resected colorectal cancer will identify anastomotic or intraluminal recurrences that are amenable to curative therapy has simply not been borne out to be true. Several studies have shown that the low rate of these recurrences after resection do not merit surveillance colonoscopy and that even when such an unfortunate event occurs, the disease is usually already extended into the abdomen or pelvis and can rarely be resected for cure. Thus, the performance of annual colonoscopy for the purpose of detecting recurrent disease does not have an established survival benefit for patients with colorectal cancer. The more immediate goal of surveillance is to detect metachronous cancers.
An exception to the above occurs in the case of rectal cancer. In contrast to the anastomotic recurrence rate of 2% to 4% seen with colon cancer, the rate of anastomotic recurrence in rectal cancer may be 10 times higher. High recurrence rates of rectal cancer are partly a function of surgical technique and volume. Specifically, recurrence rates below 10% have been consistently reported when patients are operated on by a technique called total mesorectal excision. This technique involves sharp dissection of the rectum and its surrounding adventitia along the first plane outside the adventitia (the mesorectal fascia). Local recurrence rates of rectal cancer can be further reduced by administration of chemotherapy and radiation therapy, which have been most effectively administered in the neoadjuvant (preoperative) setting to patients with locally advanced disease. Therefore, knowledge of surgical technique and other therapies is important to ascertain when considering surveillance of patients with a history of rectal cancer. Because local recurrence rates for rectal cancer across the United States are generally higher than those achieved in series utilizing total mesorectal excision, there is a rationale for performing periodic examinations of the rectum by rigid or flexible proctoscopy or endoscopic ultrasound. Current recommendations include periodic examination of the rectum for the purpose of identifying local recurrence, usually performed at 3- to 6-month intervals for the first 2 or 3 years after low anterior resection of rectal cancer. These techniques have not been shown to improve survival, and the only rationale for their use is high rates of local recurrence.
Image: Cash BD
With regard to metachronous cancers, among 23 studies in which patients underwent perioperative clearing by colonoscopy, 157 colonoscopies were required per metachronous cancer detected, which compares favorably to the rate of prevalent cancers detected during screening colonoscopy of approximately 135. Among studies of postcancer resection surveillance colonoscopy, there were 57 metachronous cancers in the first 2 years after resection of the initial primary, with an incidence rate of 0.7% over this interval. Nearly two-thirds of these metachronous cancers were Dukes’ Stage A or B, slightly more than half were asymptomatic, and nearly 90% of patients in these studies underwent operations with curative intent. Taken together, these findings were considered sufficient to warrant a colonoscopy 1 year after resection or after the perioperative clearing colonoscopy for the purpose of identification of apparently metachronous colorectal neoplasms (Figure 1). The recommendation to perform a colonoscopy at 1 year does not diminish the need for high quality in the performance of the perioperative clearing examination for synchronous neoplasms. If the examination performed at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that colonoscopy is normal, then the interval before the next subsequent examination should be every 5 years. Shorter intervals should be reserved for patients whose age, family history, or tumor testing indicate definite or probable hereditary nonpolyposis colorectal cancer. This is what should be communicated to your colleagues who insist on annual surveillance examinations 3 to 5 years after curative resection of the primary colon cancer.
Excerpted from:
Cash BD, Farraye FA, eds. Curbside Consultation of the Colon: 49 Clinical Questions (pp 35-38) © 2009 SLACK Incorporated.
- References:
- Cali RL, et al. Dis Colon Rectum. 1993;36(4):388-393.
- Jeffery GM, et al. Cochrane Database Syst Rev. 2002;(1):CD002200.
- Kapiteijn E, et al. N Engl J Med. 2001;345(9):638-646.
- Pagana TJ, et al. Cancer. 1984;53(2):356-359.
- Renehan AG, et al. BMJ. 2002;324(7341):813.
- Rex DK, et al. CA Cancer J Clin. 2006;56(3):160-167.
- For more information on the Curbside Consultation in Gastroenterology Series:
- Please visit Healio.com/Books/Gastroenterology.