Colorectal Cancer ____________________________________________________________________________
PRACTICE RECOMMENDATIONS FOR RESECTED STAGE II/III COLON CANCER SURVEILLANCE Parameter Organization ASCO NCCN ESMO/JSMO History and physical exam Every 3 to 6 months for 3 years, then every 6 months until 5 years Every 3 to 6 months for 2 years, then every 6 months until 5 years Every 3 to 6 months for 3 years, then every 6 to 12 months in years 4 and 5
Every 3 months for 3 years a
Every 3 to 6 months for 2 years, then every 6 months until 5 years
Every 3 to 6 months for 3 years, then every 6 to 12 months in years 4 and 5 Every 6 to 12 months for first 3 years At 1 year after surgery, then every 3 to 5 years thereafter
Carcinoembryonic antigen (CEA)
Chest CT a
Annually for 3 years
Annually for 5 years
Colonoscopy b
At 1 year, then every 5 years, based on previous colonoscopy findings
At 1, 3, and 5 years if negative
Abdominal CT a
Annually for 3 years
Annually for 5 years, including pelvic scan
Every 6 to 12 months for first 3 years
a For patients at high risk for recurrence (e.g., lymphatic/venous invasion, poorly differentiated tumor) b Colonoscopy is indicated 3 to 6 months postoperatively if preoperative colonoscopy was not performed due to obstructing lesion. Otherwise, colonoscopy should be done after 1 year. If abnormal, repeat in 1 year; if no advanced adenoma (e.g., villous polyp, polyp >1 cm, high-grade dysplasia), repeat in 3 years, then every 5 years. Source: [349; 352] Table 12
Post-Resection Colon Cancer Outcomes from several large clinical trials were pooled and ana- lyzed and demonstrated that following resection of the primary tumor, 85% of colon cancer recurrences occur within three years and 95% occur within five years. These results under- scored the importance of regular surveillance for a minimum of five years following the resection of stage II and III colon cancer [349]. Accordingly, several professional organizations have published updated practice recommendations for surveil- lance of patients with resected stage II and III colon cancer. The recommendations by the ASCO, the NCCN, and the joint European Society of Medical Oncology and Japanese Society of Medical Oncology (ESMO/JSMO) are broadly similar but differ on some parameters ( Table 12 ) [349; 352]. Post-Resection Rectal Cancer Guidelines for surveillance of patients following resection of stage II/III colon and rectal cancer have been produced by Cancer Care Ontario and endorsed by the ASCO. Many recommendations for patients with stage II/III rectal cancer are the same as those described for patients with colon can- cer [353]. A medical history, physical examination, and CEA testing should be performed every six months for five years. In addition to abdominal and chest CT imaging, pelvic CT should be performed every 6 to 12 months for two to three years, then annually until five years from surgery.
Rectosigmoidoscopy should be performed every six months for two to five years in patients who did not receive pelvic radiation [353]. In the absence of complete pre-diagnosis colonoscopy, a colonoscopy should be done as soon as is reasonable after completing adjuvant therapy and within six months of com- pleting primary treatment. New and persistent or worsening symptoms, such as pelvic pain, sciatica, and difficulty urinating or defecating, may indicate rectal cancer recurrence. Carcinoembryonic Antigen Measurement of the serum glycoprotein CEA as a tumor marker for colorectal cancer has been used to help guide patient management and follow-up. Serum CEA testing is not valuable in screening for colorectal cancer because of its low sensitivity and specificity [354]. Use of postoperative CEA testing is usually limited to patients who may benefit from further intervention, including [353]: • Patients with stage II or III colorectal cancer • Patients who would be candidates for resection of liver metastases
Patient Support after Apparently Curative Resection
The NICE recommends offering follow-up for the first three years to all patients with primary colorectal cancer undergoing treatment with curative intent [251]. Follow-up should begin at an outpatient clinic visit four to six weeks after potentially
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