Five-year follow-up after radical surgery for colorectal cancer. Results of a prospective randomized trial

Intensive surveillance following curative treatment of colorectal cancer allows effective treatment of recurrence even if limited to 4 years

BACKGROUND

Current evidence suggests a survival benefit to post-operative surveillance following curative colorectal cancer resection; however, there is still no consensus on the optimal duration and form.

OBJECTIVES

The objective is to prospectively audit outcomes of an intensive colorectal cancer follow-up scheme for time to recurrence and survival.

METHODS

We used a surveillance protocol designed to incorporate regular clinical, biochemical, radiological and endoscopic measures at pre-defined intervals.

SETTING

The setting was a Department of Colorectal Surgery in a Tertiary Academic Centre. Follow-up was led by specially trained colorectal nurses in conjunction with surgeons.

PATIENTS

Consecutive patients who had undergone curative treatment for colorectal cancer were included in this study.

MAIN OUTCOMES

Outcomes were measured in terms of overall survival and disease recurrence.

RESULTS

There were 436 patients entered into follow-up, all treated with curative intent. Mean age 65.9 years (SD 12.9 years) and 240 male (55.0 %). Ninety-four patients (21.5 %) with stage I disease, 119 (27.3 %) stage IIa, 30 (6.9 %) stage IIb, 18 (4.1 %) stage IIIa, 78 (17.9 %) stage IIIb, 45 (10.4 %) stage IIIc and 52 (11.9 %) stage IV. Overall median survival was 37.5 months for all patients, (range 0.0-207.8 months). Ninety-two (21.1 %) cancer-related deaths were recorded during the course of the study. The overall 5-year actuarial cancer-related survival was 81.7 %. There was a 40.3 % 5-year actuarial survival was recorded in patients with 39 a recurrence, 57.7 % in patients treated with further curative 40 intent and 27.7 % in patients who received palliative treatment 41 (P < 0.001). Ninety-seven percent of recurrences were detected within 4 years of curative treatment.

CONCLUSIONS

This follow-up protocol confers an 81 % overall 5-year actuarial survival. Our study suggests that surveillance after curative resection can be limited to 4 years, which would lead to detection of over 97 % of all recurrences.

Colorectal cancer screening and surveillance in the elderly: updates and controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.

Colonoscopic surveillance after colorectal cancer resection: who needs more intensive follow-up?

BACKGROUND/AIMS

Although there are guidelines for colonoscopic surveillance after colorectal cancer (CRC) surgery, the data evaluating the effectiveness of these guidelines are limited. We determined the risk factors for metachronous neoplasia (MN) by performing annual colonoscopy examinations after curative resection.

METHODS

We performed annual colonoscopic surveillance on stage I-III CRC patients after curative resection. We stratified the patients based on the advanced neoplasia risk during the surveillance.

RESULTS

Advanced MN detected was in 59 (13.1%) of 451 patients. Overall, the cumulative incidence of advanced MN was 17.3% at 5 years. By the multivariate analysis, the risk factors for advanced MN were male gender, age >65, left-sided index cancer and being in the high-risk group. The cumulative incidence of advanced MN was 38.9% at 5 years in the high-risk group. Among the patients who had advanced MN, secondary advanced MN was detected in 13 patients (22.0%) with a subsequent colonoscopy. The 2-year cumulative incidence of secondary advanced MN was 16.9%. Four (0.88%) patients had metachronous CRC during the surveillance and the interval from the index CRC was a median of 58.5 months.

CONCLUSIONS

Although the current follow-up guidelines for colonoscopic surveillance after CRC are well established, the high-risk group calls for more meticulous follow-up, which should be continued for a sufficient time.

Surveillance for asymptomatic recurrence in resected stage III colon cancer: does it result in a more favorable outcome?

BACKGROUND

Evidence from dated and moderate quality trials supports a modest survival benefit for intensive surveillance in resected colon cancer (CC). This study evaluates surveillance in a modern population-based cohort of stage III CC patients (pts).

METHODS

Records of pts who initiated oxaliplatin-based adjuvant chemotherapy (AC) for stage III CC between 2006-2011 at the British Columbia Cancer Agency (BCCA) were reviewed. Kaplan-Meier and log rank test were generated to investigate whether diagnosis of recurrence based on symptoms was associated with worse overall survival (OS). OS1 and OS2 were measured from date of recurrence or date of initial surgery, respectively.

RESULTS

Of 635 pts who received AC for stage III CC, 175 pts (27.5%) recurred and 118 (18.6%) died at a median follow-up of 67.7 months. Recurrences were detected by surveillance in 149 pts (41% by CEA elevation and 44% by abnormal imaging), and symptoms in 26 pts (15%). Patients with surveillance-detected recurrences had a shorter median relapse-free survival (RFS) (18.5 vs. 25.3 months, HR 1.82, P<0.001), and longer median OS1 (28.5 vs. 6.5 months, HR 0.37, P<0.001). However, median OS2 was not significantly different (50.9 vs. 39.1 months, HR 0.66, P=0.091). Pts with surveillance-detected recurrence received more potentially curative metastasectomy (39% vs. 7%, P=0.002) and chemotherapy (70% vs. 50%, P=0.03).

CONCLUSIONS

In this modern population-based cohort study, the OS impact of detecting asymptomatic recurrences in stage III CC is unclear. However, pts with asymptomatic recurrences were more likely to receive potentially curative metastasectomy and chemotherapy.

Choosing Wisely Canada Cancer List: Ten Low-Value or Harmful Practices That Should Be Avoided In Cancer Care

Using knowledge translation and exchange efforts, this list should empower patients with cancer and physicians to participate in a targeted conversation about the appropriateness and quality of individual patient care.

Addressing the needs of colorectal cancer survivors: current strategies and future directions

Colorectal cancer (CRC) is one of the three topmost common cancers in men and the second most common cancer in women worldwide. With current advances in the medical and surgical treatment of CRC, care has slowly transformed to curative treatment. With these advances, CRC survivors are increasing in numbers and these patients have a unique range of medical, physical and psychological needs that require regular follow-up. In 2006, the Institute of Medicine recommended that cancer survivors who are completing primary treatment receive a survivorship care plan. There are many different programs of different complexity that are implemented for CRC survivors. This review outlines the needs of CRC survivors, the current surveillance techniques used in the continuing care of patients with CRC after curative treatment and the evidence behind these strategies.

Long-term follow-up for melanoma patients: is there any evidence of a benefit?

As the incidence of melanoma and the number of melanoma survivors continues to rise, optimal surveillance strategies are needed that balance the risks and benefits of screening in the context of contemporary resource use. Detection of recurrences has important implications for clinical management. Most current surveillance recommendations for melanoma survivors are based on low-level evidence with wide variations in practice patterns and an unknown clinical impact for the melanoma survivor.

Intensive follow-up strategies improve outcomes in nonmetastatic colorectal cancer patients after curative surgery: a systematic review and meta-analysis

BACKGROUND

A wide variety of follow-up strategies are used for patients with colorectal cancer (CRC) after curative surgery. The aim of this study is to review the evidence of the impact of different follow-up strategies in patients with nonmetastatic CRC after curative surgery, in relation to overall survival and other outcomes.

PATIENTS AND METHODS

A systematic search of PubMed, EMBASE, SCOPUS and ISI Web of Knowledge up to June 2014 was carried out. Eligible studies were all randomized clinical trials comparing the effectiveness of different follow-up strategies after curative resection in nonmetastatic CRC.

RESULTS

Eleven studies with n = 4055 participants were included in a meta-analysis. A significant improvement in overall survival was observed in patients with more intensive follow-up strategies [hazard ratio = 0.75; 95% confidence interval (CI) 0.66-0.86]. A higher probability of detection of asymptomatic recurrences [relative risk (RR) = 2.59; 95% CI 1.66-4.06], curative surgery attempted at recurrences (RR = 1.98; 95% CI 1.51-2.60), survival after recurrences (RR = 2.13; 95% CI 1.24-3.69), and a shorter time in detecting recurrences (mean difference = -5.23 months; 95% CI -9.58 to -0.88) was observed in the intervention group. There were no significant differences in the total tumor recurrences, nor in the mortality related to disease.

CONCLUSION

Intensive follow-up strategies improve overall survival, increase the detection of asymptomatic recurrences and curative surgery attempted at recurrence, and are associated with a shorter time in detecting recurrences. This more intensive follow-up could not be associated with an improvement in cancer-specific survival nor with an increased detection of total tumor recurrences. Follow-up with serum carcinoembryonic antigen and colonoscopies are related to an increase in overall survival.

Post-Resection Surveillance in GI Cancers

Recurrence after curative resection of gastrointestinal (GI) cancers is common. Early detection of resectable recurrences may result in a curative resection. In un-resectable recurrences, early detection may improve the quality of life by palliation or with the use of newer chemotherapeutic drugs. The guidelines regarding follow-up of patients after curative resection of GI cancers are from the West which is very different from the Indian population in terms of a disease pattern and social milieu. The guidelines which are commonly used are also not strictly followed. We have proposed in this article the protocols which we follow at our centre after curative resection of GI cancer and how these are different from the guidelines proposed by the West.

Surveillance patterns after curative-intent colorectal cancer surgery in Ontario

BACKGROUND

Postoperative surveillance following curative-intent resection of colorectal cancer (CRC) is variably performed due to existing guideline differences and to the limited data supporting different strategies.

OBJECTIVES

To examine population-based rates of surveillance imaging and endoscopy in patients in Ontario following curative-intent resection of CRC with no evidence of recurrence, as well as patient or disease factors that may predispose certain groups to more frequent versus less frequent surveillance; to provide insight to the care patients receive in the presence of conflicting guidelines, in efforts to help improve care of CRC survivors by identifying any potential underuse or overuse of particular surveillance modalities, or inequalities in access to surveillance.

METHOD

A retrospective cohort study was conducted using data from the Ontario Cancer Registry and several linked databases. Ontario patients undergoing curative-intent CRC resection from 2003 to 2007 were identified, excluding patients with probable disease relapse. In the five-year period following surgery, the number of imaging and endoscopic examinations was determined.

RESULTS

There were 4960 patients included in the study. Over the five-year postoperative period, the highest proportion of patients who underwent postoperative surveillance received the following number of tests for each modality examined: one to three abdominopelvic computed tomography (CT) scans (n=2073 [41.8%]); one to three abdominal ultrasounds (n=2443 [49.3%]); no chest CTs, one to three chest x-rays (n=2385 [48.1%]); and two endoscopies (n=1845 [37.2%]). Odds of not receiving any abdominopelvic imaging (CT or abdominal ultrasound) were higher in those who did not receive adjuvant chemotherapy (OR 6.99 [95% CI 5.26 to 9.35]) or those living in certain geographical areas, but were independent of age, sex and income. Nearly all patients (n=4473 [90.2%]) underwent ≥1 endoscopy at some point during the follow-up period.

CONCLUSION

In contrast to findings from similar studies in other jurisdictions, most Ontario CRC survivors receive postoperative surveillance with imaging and endoscopy, and care is equitable across sociodemographic groups, although unexplained geographical variation in practice exists and warrants further investigation.

Colorectal cancer of the elderly

OPINION STATEMENT

Colorectal cancer (CRC) disproportionately affects the elderly. Older age is a strong risk factor for both the development of precancerous adenomas and CRC, thus raising the issue of screening and surveillance in older patients. However, screening and surveillance decisions in the elderly can be complex and challenging. Elderly patients are a diverse and heterogeneous group and special considerations such as co-morbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance. Such considerations also play a role in factors related to screening modalities, such as colonoscopy, as well as CRC treatment options and regimens. This review addresses many of the unique factors associated with CRC of the elderly and critically examines many of the controversies and challenges surrounding CRC in older patients.

Incidence and risk factors of metachronous colorectal neoplasm after curative resection of colorectal cancer in Korean patients

OBJECTIVE

Early detection and endoscopic removal of metachronous neoplasms are important preventive strategies for patients with colorectal cancer (CRC) after curative tumor resection. We aimed to determine the incidence of and the risk factors for metachronous colorectal neoplasms after curative resection for CRC.

METHODS

We retrospectively reviewed clinical data of patients who underwent curative resection for CRC at the National Cancer Center, Korea, from July 2004 to July 2007 and were followed up for a mean duration of 40.7 months. The incidence of and the risk factors for developing metachronous neoplasms were analyzed.

RESULTS

A total of 1049 patients were included in this study. A follow-up colonoscopy showed that 454 (43.3%) patients developed metachronous neoplasms, including 46 (4.4%) with advanced adenoma or cancer. Univariate analyses revealed that age ≥ 60 years, male gender, diabetes mellitus, hypertension, synchronous adenoma, synchronous multiple adenoma and synchronous advanced adenoma were associated with the development of metachronous neoplasms. Baseline risk factors associated with metachronous advanced neoplasm were age ≥ 60 years, synchronous multiple adenoma and synchronous advanced adenoma. Multivariate analysis showed that age ≥ 60 years, synchronous adenoma and diabetes mellitus were risk factors for the development of metachronous neoplasms. The cumulative incidence of metachronous neoplasms was higher in patients with these risk factors than in those without.

CONCLUSIONS

Elder age, synchronous adenoma and diabetes mellitus are risk factors for developing metachronous neoplasia. Therefore, careful surveillance colonoscopy are necessary for these patients.

Early detection of colorectal cancer recurrence in patients undergoing surgery with curative intent: current status and challenges

Despite advances in neoadjuvant and adjuvant therapy, attention to proper surgical technique, and improved pathological staging for both the primary and metastatic lesions, almost half of all colorectal cancer patients will develop recurrent disease. More concerning, this includes ~25% of patients with theoretically curable node-negative, non-metastatic Stage I and II disease. Given the annual incidence of colorectal cancer, approximately 150,000 new patients are candidates each year for follow-up surveillance. When combined with the greater population already enrolled in a surveillance protocol, this translates to a tremendous number of patients at risk for recurrence. It is therefore imperative that strategies aim for detection of recurrence as early as possible to allow initiation of treatment that may still result in cure. Yet, controversy exists regarding the optimal surveillance strategy (high-intensity vs. traditional), ideal testing regimen, and overall effectiveness. While benefits may involve earlier detection of recurrence, psychological welfare improvement, and greater overall survival, this must be weighed against the potential disadvantages including more invasive tests, higher rates of reoperation, and increased costs. In this review, we will examine the current options available and challenges surrounding colorectal cancer surveillance and early detection of recurrence.

Colorectal cancer surveillance: what's new and what's next

The accumulated evidence from two decades of randomized controlled trials has not yet resolved the question of how best to monitor colorectal cancer (CRC) survivors for early detection of recurrent and metachronous disease or even whether doing so has its intended effect. A new wave of trial data in the coming years and an evolving knowledge of relevant biomarkers may bring us closer to understanding what surveillance strategies are most effective for a given subset of patients. To best apply these insights, a number of important research questions need to be addressed, and new decision making tools must be developed. In this review, we summarize available randomized controlled trial evidence comparing alternative surveillance testing strategies, describe ongoing trials in the area, and compare professional society recommendations for surveillance. In addition, we discuss innovations relevant to CRC surveillance and outline a research agenda which will inform a more risk-stratified and personalized approach to follow-up.

Natural history and long-term outcomes of patients treated for early stage colorectal cancer

BACKGROUND

The long-term natural history of early stage colon cancer and the outcome of long-term colonoscopic surveillance in routine specialist clinical practice after removal of the incident cancers have not been fully defined. In the present long-term evaluation up to 25 years, metachronous neoplasia, including both advanced adenomas and carcinomas, was defined.

METHODS

All early stage colorectal cancer patients evaluated consecutively from a single clinical practice underwent follow-up colonoscopic evaluations after removal of the incident cancer and clearing of neoplastic disease. Colonoscopic surveillance was planned for two phases - initially on an annual basis for five years, followed by continued surveillance every three years up to 25 years with removal of any metachronous neoplastic lesion.

RESULTS

A total of 128 patients (66 men and 62 women) with 129 incident early stage colorectal cancers were evaluated. Virtually all patients were symptomatic, usually with clinical evidence of blood loss. Incident early cancers were located throughout the colon, especially in the rectosigmoid, and showed no pathological evidence of nodal or other metastases. All patients evaluated during the first five years did not experience recurrent disease or have metachronous cancer detected. After five years, a total of 94 patients were evaluated up to 25 years; six of these patients were found to have seven metachronous colon cancers. All developed cancer more than seven years after removal of the incident colorectal cancer, including six asymptomatic adenocarcinomas, of which only one had evidence of single node involvement. Another patient in this cohort developed a poorly differentiated neuroendocrine carcinoma of the colon. In addition, 45% of patients had a total of 217 adenomas removed, including 11% of patients with 33 advanced adenomas. Among 14 patients with advanced adenomas, seven (50%) developed ≥1 late metachronous cancers.

CONCLUSIONS

Following removal of an incident symptomatic early stage colorectal cancer, the risk of later metachronous neoplasia persists for an extended period more than five years after removal of the incident colorectal cancer. Moreover, risk for late metachronous cancer appears to be predicted by the presence of multiple adenomas or advanced adenomas; most metachronous cancers in this cohort were detected using colonoscopy before onset of symptoms and at an early stage.

Anastomotic Recurrence of Sigmoid Colon Cancer over Five Years after Surgery

The incidence of anastomotic recurrence after curative resection of colorectal cancer is relatively low compared to that of other types of recurrence, such as hepatic, lung and local recurrence. However, almost all cases of anastomotic recurrence of colorectal cancer occur within 3 years after surgery. We experienced a rare case of anastomotic recurrence in whom colonoscopy revealed no signs of recurrence 3 years after surgery; however, anastomotic recurrence was detected over 5 years after surgery. A 60-year-old female with a history of surgery for cancer of the cecum in her forties underwent sigmoidectomy and right colectomy with D3 lymph node dissection for both stage IIA sigmoid colon cancer and stage IIA transverse colon cancer. Computed tomography and colonoscopy revealed no signs of recurrence 3 years after surgery; however, 5 years and 4 months after surgery, colonoscopy demonstrated surrounding flaring and swelling in the anastomotic area of the sigmoid colon, and a biopsy revealed an adenocarcinoma. Under the diagnosis of anastomotic recurrence over 5 years after surgery, lower anterior resection was performed. The patient has exhibited no other signs of recurrence in the 2 years since the last operation.

Early stage colon cancer

Evidence has now accumulated that colonoscopy and removal of polyps, especially during screening and surveillance programs, is effective in overall risk reduction for colon cancer. After resection of malignant pedunculated colon polyps or early stage colon cancers, long-term repeated surveillance programs can also lead to detection and removal of asymptomatic high risk advanced adenomas and new early stage metachronous cancers. Early stage colon cancer can be defined as disease that appears to have been completely resected with no subsequent evidence of involvement of adjacent organs, lymph nodes or distant sites. This differs from the clinical setting of an apparent “curative” resection later pathologically upstaged following detection of malignant cells extending into adjacent organs, peritoneum, lymph nodes or other distant sites, including liver. This highly selected early stage colon cancer group remains at high risk for subsequent colon polyps and metachronous colon cancer. Precise staging is important, not only for assessing the need for adjuvant chemotherapy, but also for patient selection for continued surveillance. With advanced stages of colon cancer and a more guarded outlook, repeated surveillance should be limited. In future, novel imaging technologies (e.g., confocal endomicroscopy), coupled with increased pathological recognition of high risk markers for lymph node involvement (e.g., “tumor budding”) should lead to improved staging and clinical care.

Follow-up after curative resection of colorectal cancer

Of the 13.7 million cancer survivors living in the United States as of January 2012, 1.2 million, or 9 %, were colorectal cancer (CRC) survivors. Determining an optimal surveillance for CRC survivors is necessary because of the significant burden follow-up poses to patients, physicians, and the health care system. Currently, there is no consensus regarding optimal follow-up in CRC patients. Current literature and published guidelines related to CRC follow-up were reviewed to examine the evidence for the surveillance strategies and specific tools demonstrated to improve outcome after curative CRC resection. An intensive surveillance strategy results in increased identification of recurrences amenable to curative resection but does not result in reduced overall or CRC-specific mortality. Patients most likely to benefit from surveillance include younger patients, those with earlier tumors, locoregional recurrences, longer time to recurrence, lower carcinoembryonic antigen (CEA) levels before reoperation, and those with isolated recurrence. Complete resection of recurrence is the only factor consistently associated with improved survival. CEA, colonoscopy, and liver-focused imaging surveillance appear to have the greatest impact on mortality after curative CRC resection. A CRC surveillance strategy is recommended that includes tumor risk stratification, that provides a focus on identifying recurrences amenable to complete resection, and that utilizes those modalities demonstrated to be most effective at improving outcome after CRC resection.

Changing patterns of recurrent disease in colorectal cancer

BACKGROUND

Due to changes in staging, (neo)-adjuvant treatment and surgical techniques for colorectal cancer (CRC), it is expected that the recurrence pattern will change as well. This study aims to report the current incidence of, and time to recurrent disease (RD), further the localization(s) and the eligibility for successive curative treatment.

METHODS

A consecutive cohort of CRC patients, whom were routinely staged with CT and underwent curative treatment according to the national guidelines, was analyzed (n = 526).

RESULTS

After a mean and median FU of 39 months, 20% of all patients and 16% of all AJCC stage 0-III patients had developed RD. The annual incidences were the highest in the first two years but tend to retain in the succeeding years for stage 0-III patients. The majority of RD was confined to one organ (58%) and 28% of these patients were again treated with curative intent.

CONCLUSIONS

In follow-up nowadays, less recurrences are found than reported in historical studies but these can more often be treated with curative intent. A main cause for the decreased incidence of RD, next to improvements in treatment, is probably stage shift elicited by pre-operative staging. The outcomes support continuation of follow-up in colorectal cancer.

Current and emerging surveillance strategies to expand the window of opportunity for curative treatment after surgery in colorectal cancer

Colorectal cancer is the third most common cancer globally. At diagnosis, more than 70% of patients have nonmetastatic disease. Cure rates for early-stage colorectal cancer have improved with primary screening, improvements in surgical techniques and advances in adjuvant chemotherapy. Despite optimal primary treatment, 30-50% of these patients will still relapse. While death will result from widespread metastatic disease, patients with small volume oligometastatic disease are still considered curable with aggressive multimodality therapy. Hence, early detection of relapsed cancer when it is still amenable to resection expands the window of opportunity for cure. Here, the authors review the modalities currently employed in clinical practice and the evidence supporting intensive surveillance strategies. The authors also discuss ongoing clinical trials examining specific surveillance programs and emerging modalities that may be deployed in the future for early detection of metastatic disease.

Changing trends in the presentation of colorectal liver metastases in a single hepatobiliary tertiary referral centre over fourteen years

AIM

National Institute for Clinical Excellence guidelines suggest that patients who have undergone potentially curative treatment for colorectal cancer (CRC) should be followed up for 3 years. The aim of this study was to investigate whether the time to presentation with colorectal liver metastases (CRLM) has changed over time. This information, which is currently unknown, may inform future decisions regarding follow-up.

METHODS

Patients presenting with metachronous isolated liver metastases between 1997 and 2011 were included. Timings of presentation with CRLM, rates of liver resection, survival data and factors associated with delayed presentation were investigated.

RESULTS

269 patients were included in the study. Those having their primary CRC resection between 1997 and 2007 presented earlier with liver metastases over time (r = -0.33, 95% CI -0.45 to -0.20). However, 26% of patients who developed CRLM did so beyond 3 years. There was no significant difference in rates of liver resections for those presenting within, or beyond, 3 years (p = 0.21). There was no significant difference in survival for those presenting with resectable CRLM within, or beyond, 3 years (Exp(b) = 0.60, 95% CI 0.28-1.28). No factors associated with late presentation were identified.

CONCLUSIONS

These results suggest that CRC follow-up should be extended to 5 years. Follow-up interventions should be more frequent in the early stages reflecting the trend towards earlier presentation with CRLM. The economic implications of extending follow-up compare favourably to other NHS funded initiatives.

Long-term outcomes after surgical resection for gastric cancer liver metastasis: an analysis of 64 macroscopically complete resections

PURPOSE

The indication for hepatectomy in cases of gastric cancer liver metastases (GLM) remains unclear and it remains controversial whether surgical resection is beneficial for GLM. The objective of this retrospective study was to clarify the indications for and benefit of hepatectomy for GLM.

METHODS

Seventy-three patients underwent hepatectomies for GLM from January 1993 to January 2011. Macroscopically complete (R0 or R1) resection was achieved in 64 patients. Among them, 32 patients underwent synchronous hepatectomy with gastrectomy and the remaining 32 patients underwent metachronous hepatectomy. Repeat hepatectomy was done in 14 patients for resectable intrahepatic recurrences. Clinicopathological factors were evaluated by univariate and multivariate analyses among patients who received macroscopically complete resection for those affecting survival.

RESULTS

The overall 1-, 3-, and 5-year survival rates after macroscopically complete (R0 or R1) liver resection (n = 64) for GLM were 84, 50, and 37 %, respectively, with a median survival of 34 months. Univariate analysis identified serosal invasion of the primary gastric cancer and blood transfusions during surgery as poor prognosis indicators. By multivariate analysis, serosal invasion of the primary gastric cancer and larger hepatic tumor (>5 cm in diameter) were found to be independent indicators of poor prognosis.

CONCLUSIONS

GLM patients with the maximum diameter of hepatic tumors of <5 cm and without serosal invasion of the primary gastric cancer are the best candidate for hepatectomy.

Surgical treatment of colorectal cancer in patients aged over 80 years

PURPOSE

The aim of this study was to identify the clinical factors and tumour characteristics that predict the outcome in patients older than 80 years with colorectal cancer.

PATIENTS AND METHODS

One hundred and four patients with colorectal cancer aged over 80 years were identified from a computer database, and their clinical variables were analysed by both univariate and multivariate analyses.

RESULTS

All 104 patients underwent resective surgery, 87% radical and 13% palliative resection. Postoperative mortality was 5%, being associated with a number of coexisting diseases and the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 33%, the median survival was 31 months and the cancer-specific 5-year survival was 36%. The recurrence rate after radical surgery was 30%, being 13%, 25%, 44% and 100% in the Union for International Cancer Control stages I, II, III and IV. Kaplan-Meier estimates indicated that age, number of underlying diseases, radicality of operation, Dukes' staging, size of tumour, number of lymph node metastasis, metastasised disease, venous invasion and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion was an independent prognostic factor of survival.

CONCLUSIONS

Low mortality and acceptable survival can be achieved even in very elderly patients with colorectal cancer. Venous invasion is an independent predictor of survival.

Population-based longitudinal study of follow-up care for patients with colorectal cancer in Nova Scotia

PURPOSE

The purpose of this study was to examine colorectal cancer (CRC) follow-up care in Nova Scotia, Canada. More specifically, the objectives were to describe adherence to two elements of follow-up guidelines (colonoscopies and physician visits) and to identify factors associated with receiving at least guideline-recommended care.

METHODS

All patients with stage II or III CRC undergoing curative-intent surgery in Nova Scotia, Canada, were identified through the provincial cancer registry and anonymously linked to additional administrative health databases. For a 3-year follow-up period, beginning 1 year after the diagnosis date, descriptive statistics were calculated for physician visits and colonoscopies. Factors associated with receiving at least guideline-recommended care were identified using logistic regression.

RESULTS

Most patients received follow-up care from multiple physician specialties. In year 3, 58.1% of patients received oncologist follow-up care. Guideline adherence for colonoscopies was 52.4%, whereas guideline adherence for physician visits decreased from 41.9% to 25.4%. Receipt of at least guideline-recommended care was inversely associated with age and comorbidity for colonoscopy and inversely associated with age for physician visits.

CONCLUSION

Receipt of follow-up care from oncologists and primary care physicians, prolonged oncologist care, and receipt of care inconsistent with guideline recommendations suggest there may be potential issues with inefficient use of cancer system resources and integration of guidelines into follow-up care practices in Nova Scotia. Transitioning routine follow-up to primary care could potentially increase guideline adherence by improving access to and continuity of care. CRC may be well suited to targeted knowledge translation strategies to improve guideline adherence.

Intensive screening for resected stage II and III colorectal cancer

SUMMARY Disease recurrence continues to be a major cause of death in patients with resected stage II and III colorectal cancer. Distant and local relapses, unless successfully treated surgically, result in patient demise within 5 years in approximately 90% of patients. By contrast, patients who undergo curative-intent surgery and enter surgical remission experience 40–50% 5-year survival. Effective surveillance strategies are needed to improve the rate of colorectal cancer recurrence detection and maximize the chances of curative resections. In this article, we review the strength and shortfalls of the supportive data for intensive surveillance and reflect on the recommendations of various medical associations.

Clinicopathological features of colorectal cancer in patients over 70 years of age

OBJECTIVE

The aim was to identify the clinical factors and tumor characteristics that predict mortality and survival in patients older than 70 years with colorectal adenocarcinoma.

MATERIAL AND METHODS

One hundred and ninety-four patients with colorectal cancer aged over 70 years were identified from a computer database and their clinical variables were analyzed by both univariate and multivariate analyses.

RESULTS

All patients underwent resective surgery, 79% radical and 21% palliative resection, and postoperative mortality was 6% being associated with the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 38%, the median survival 35 months, and the cancer-specific 5-year survival 48% and this did not differ significantly between the age groups. The recurrence rate after radical surgery was 30%, being 12, 22, 56, and 100% in Dukes classes A, B, C, and D. Kaplan-Meier estimates indicated that gender, Dukes staging, grade of tumor, number of lymph node metastasis, venous invasion, and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion and recurrent disease were independent prognostic factors of survival.

CONCLUSIONS

Low mortality and acceptable survival can be achieved in elderly patients with colorectal cancer. Venous invasion and recurrent cancer are independent predictors of survival.

Surveillance after colorectal cancer resection: a systematic review

BACKGROUND

Surveillance programs are widely accepted as an integral part of the treatment plan provided to patients after surgical treatment of colorectal cancer. Despite an enormous amount of research performed regarding these programs, there is still uncertainty regarding what is appropriate surveillance.

OBJECTIVE

We sought to systematically review recent literature regarding outcomes achieved with different types of surveillance programs for patients with surgically treated colorectal cancer.

DATA SOURCES

A search of the PubMed database was performed to identify studies published in the English language between January 2000 and January 2010.

STUDY SELECTION

We included 2 types of studies in our systematic review: first, comparative studies where 2 or more surveillance strategies were applied and outcomes compared; second, single-cohort studies where the outcomes of a single surveillance strategy were reported.

MAIN OUTCOME MEASURES

Cancer-related outcomes included survival, recurrence detection rate, and the ability of a recurrence to be resected with curative intent.

RESULTS

Our review found 15 studies meeting our inclusion criteria. Of these, 9 were comparative (4 randomized trials) and 6 were single-cohort studies. One study reported a better survival rate among patients who received more intensive follow-up. The vast majority of recurrences occurred within 3 years.

LIMITATIONS

Our review found that the recent literature regarding the efficacy of surveillance is inconclusive, largely because of the small sample sizes and the heterogeneity in the surveillance programs and outcomes reported.

CONCLUSIONS

Future randomized trials need to focus on larger sample sizes, and experimental designs should isolate specific elements of surveillance to better understand how each element contributes to improvements in patient outcomes. Risk stratification and duration of surveillance are key elements of surveillance strategies that also deserve focused investigation.

Surveillance after curative resection of colorectal cancer

Surgical resection is the primary treatment modality for patients with localized colorectal cancer, but unfortunately one-third to one-half of these patients will develop a recurrence. If detected early, recurrent disease may be amenable to surgical resection and this provides the rationale for a follow-up strategy in patients with resected colorectal cancer. Despite eight published randomized controlled trials and six published systematic reviews evaluating different follow-up strategies, there is still no consensus as to the appropriateness of follow-up in colorectal cancer patients. In the present article the authors explore the reasons behind the controversy and the arguments used to support each side. They outline the current published guidelines and the data to support these recommendations, including the use of carcinoembryonic antigen (CEA) levels, liver imaging, and colonoscopy. Finally, they speculate on the future developments that may impact on this debate.

Colorectal cancer screening and surveillance in the elderly patient

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Older age is associated with a rise in colorectal cancer and adenomas, necessitating the need for CRC screening in older patients. However, decisions about CRC screening and surveillance in older adults are often difficult and challenging. The decision requires an individualized assessment that incorporates factors unique to performing colonoscopy in older adults in order to weigh the risks and benefits for each patient according to their overall health and preferences. This review addresses the factors unique to colorectal cancer and performing colonoscopy in older adults that are relevant in weighing the risks and benefits of screening and surveillance in this population.

Initial experience with transanal endoscopic microsurgery: the need for understanding the limitations

INTRODUCTION

Transanal endoscopic microsurgery is an alternative to transanal excision or radical surgery for benign and carefully selected malignant rectal tumors. Advantages over transanal excision include better visualization, access to more proximal lesions, higher likelihood of negative margins, and lower recurrence rates. Compared to radical resection, patients experience lower rates of morbidity and mortality but may have higher rates of local recurrence.

METHODS

A review of a prospectively maintained database of patients scheduled for transanal endoscopic microsurgery was performed.

RESULTS

Ninety-three patients underwent 96 procedures for 13 carcinoid tumors, 1 submucosal mass, 46 adenomas, 12 in situ adenocarcinomas, and 21 invasive adenocarcinomas. Of these cases, 81.2% was successfully completed. There were nine complications (11.5%). Final pathology demonstrated 33 in situ and invasive adenocarcinomas. The mean follow-up was 25.9 months. The four recurrences (12.1%) occurred in: one tubulovillous adenoma, two in situ carcinomas, and one T2 lesion.

CONCLUSIONS

Transanal endoscopic microsurgery is appropriate for benign lesions such as carcinoid tumors and adenomas and can also be curative in carefully selected patients with early-stage invasive rectal cancer. In cases of invasive adenocarcinoma, it should be reserved for low-risk cancers in patients who accept the possible increased risk of recurrence.

The Role of High Frequency Dynamic Threshold (HiDT) Serum Carcinoembryonic Antigen (CEA) Measurements in Colorectal Cancer Surveillance: A (Revisited) Hypothesis Paper

Following curative treatment for colorectal cancer (CRC), 30% to 50% of patients will develop recurrent disease. For CRC there are several lines of evidence supporting the hypothesis that early detection of metachronous disease offers a second opportunity for cure. This paper revisits the potential role of serum carcinoembryonic antigen (CEA) in follow-up. A comprehensive review of the literature (1978–2008) demonstrates that the initial promise of serum CEA as an effective surveillance tool has been tarnished through perpetuation of poorly designed studies. Specific limitations included: testing CEA as only an ‘add-on’ diagnostic tool; lack of standardization of threshold values; use of static thresholds; too low measurement frequency. Major changes in localizing imaging techniques and treatment of metastatic CRC further cause a decrease of clinical applicability of past trial outcomes. In 1982, Staab hypothesized that the optimal benefit of serum CEA as a surveillance tool is through high-frequency triage using a dynamic threshold (HiDT). Evidence supporting this hypothesis was found in the biochemical characteristics of serum CEA and retrospective studies showing the superior predictive value of a dynamic threshold. A multi-centred randomized phase III study optimizing the usage of HiDT against resectability of recurrent disease is commencing recruitment in the Netherlands.

The follow-up after radical surgery of colorectal cancer: is it time for a "tailored" strategy?

The problem of the surveillance for colorectal cancer after radical surgery is a widely debated argument. Like for other solid tumors, the issue is divided in 2 main routes: the early diagnosis of recurrence and the early diagnosis of a second primary cancer. Genetic and molecular features have been recognized as useful tools to measure these risks, however, the instruments are still insufficient to design a personalized strategy for the patient. In an era of "tailored therapies" in oncology, even the follow-up of the surgically treated patient for colorectal cancer should enter "a tailor's shop in which several competent tailors" should be available to manage a complex problem.

Follow-up routines in gynecological cancer - time for a change?

OBJECTIVE

To determine current practice of follow-up of Norwegian gynecological cancer patients, and to review available randomized controlled trials (RCTs) in gynecologic, breast and colorectal cancer patients in order to discuss whether such studies are feasible in gynecological cancer patients.

DESIGN

A combined questionnaire study and a systematic review of RCTs in follow-up of gynecological, breast, and colorectal cancers.

POPULATION

Gynecological, breast, and colorectal cancer patients.

METHODS

A questionnaire regarding follow-up routines was mailed to 31 gynecological departments in Norway. A systematic search on MEDLINE, EMBASE, and the Cochrane Library databases was conducted to identify RCTs in follow-up of breast, colorectal, and gynecological cancers.

RESULTS

The questionnaire study showed that the number of controls varied from eight to 16 during the first five years' post-treatment. Routine investigations such as chest X-ray and cytology were frequently used in endometrial and cervical cancer. All departments used CA-125 in follow-up of ovarian cancer patients. Reviewing the literature, 19 RCTs of varying methodological quality were identified for colorectal and breast cancers, and none for gynecologic cancer. Different follow-up models were compared, and most studies concluded that there were no significant differences in the detection of recurrence, overall survival, and quality of life between the studied groups.

CONCLUSIONS

Follow-up routines after gynecological cancer vary in Norway. The optimal approach is unknown and RCTs comparing follow-up protocols are missing. Studies of breast and colorectal cancer patients show that studies on follow-up strategies are feasible but sufficient sample size and observation time are important.

Scan? Cure? Sure!

Presentation of The Case

A 61-year-old man undergoes a sigmoid colectomy for a T3N1 (two of 18 nodes) adenocarcinoma of the sigmoid colon. He recovers well and receives 6 months of adjuvant FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) uneventfully. At his first follow-up visit, the oncologist recommended every 3 month visits for a physical, liver function tests, and carcinoembryonic antigen (CEA) measurement; every 6 month chest, abdomen, and pelvic computed tomography (CT) scans for 3 years; and aspirin, vitamin D supplementation, and exercise. Is CT scanning appropriate in the follow-up of colon cancer patients? (This case was presented at Massachusetts General Hospital Cancer Center.)

Colorectal cancer follow-up: patient satisfaction and amenability to telephone after care

PURPOSE

To explore patient satisfaction on different aspects of follow-up service provision following treatment for colorectal cancer and amenability to an alternative strategy for follow-up care.

METHODS AND SAMPLE

A postal survey was administered to 297 eligible patients who had been treated for colorectal cancer at a large hospital in the North West of England. Patients were asked to indicate responses to questions comprising likert scales, including views on organisation of care, information and advice, personal experience of care, satisfaction with information and care, views on specialist nursing services and amenability to telephone follow-up.

KEY RESULTS

One hundred and eighty-seven completed surveys were returned (62.97% response rate). Analysis of scale data indicated high levels of satisfaction on all outcome measures but sub-optimal rates of satisfaction on some items. Respondents indicated high levels of satisfaction with information related to disease and treatment but lower levels of satisfaction for items related to genetic risk, sexual attractiveness and self care. Colorectal nurse specialists were highly rated, especially in terms of information provision and personal experience of care. Patients were generally amenable to telephone follow-up, although male patients indicated higher levels of willingness to accept this approach than females.

CONCLUSIONS

Satisfaction with traditional medical based follow-up is generally high in this patient cohort but there is room for improvement in terms of service delivery. High levels of satisfaction with the care delivered by colorectal nurse specialists and patient acceptance of telephone follow-up suggests nurse-led telephone follow-up is a viable alternative to traditional hospital based follow-up.

Characteristics of recurrence after curative resection for T1 colorectal cancer: Japanese multicenter study

BACKGROUND

Because the rate of recurrence after curative resection for T1 colorectal cancer is low, the characteristics of recurrence remain obscure. This multicenter study attempted to clarify the characteristics of recurrence after curative resection for T1 colorectal cancer.

METHODS

We analyzed the associations between recurrence and various clinicopathological features in 798 patients who had undergone curative resection alone for T1 colorectal cancer at 14 hospitals between 1991 and 1996.

RESULTS

The rate of lymph node metastasis (LNM) in patients with T1 colorectal cancer was 10.5% (84/798), and 18 (2.3%) of the 798 patients developed recurrence during the median follow-up of 7.8 years. The recurrence rates in patients with colon cancer with and without LNM were 3.6 and 1.3%, respectively (p = 0.19). These rates in patients with cancer of the rectum were 25.0 and 1.1% (p < 0.0001). Among various parameters, histological grade (p < 0.0001), location (p = 0.025), LNM (p < 0.0001), and venous invasion (p = 0.0013) were risk factors for recurrence. Among them, LNM (p = 0.0008) and histological grade (p = 0.041) were independent risk factors for recurrence after curative resection for T1 colorectal cancer. Time to recurrence was more likely to be shorter for patients with, than without nodal involvement. In patients with an unfavorable histological grade, all recurrences developed within 1 year.

CONCLUSIONS

The recurrence rate after curative resection for node-negative T1 colorectal cancer was very low. The effectiveness of surveillance to detect recurrence after curative resection for T1 colorectal cancer should be validated in further studies.

Post-treatment surveillance in colorectal cancer

BACKGROUND

Though the post treatment surveillance of patients with colorectal cancer (CRC) treated with curative intent is common practice, its value is controversial. In the absence of conclusive clinical data, various modalities for the routine follow-up of patients with CRC have been proposed. In practice, the guidelines across countries and regions differ and are influenced by different health care policies, resource availability and doubts about effectiveness of follow-up.

CONCLUSIONS

The results of metaanalyses of available clinical trials demonstrated a survival benefit of intensified monitoring, but the questions regarding the optimal frequency of visits and the examinations to be performed remain unanswered. Furthermore, intensive monitoring of CRC survivors may be difficult to be administrated, causes discomfort and morbidity to the patient and can have serious cost-implications to the healthcare system. However, as it seems from available data, a comprehensive surveillance program does not affect the quality of patients' life. Ongoing large prospective multi-institutional randomised trials might elucidate some of the crucial questions and existing dilemmas to establish adequate surveillance strategy for CRC patients.

Advanced synchronous adenoma but not simple adenoma predicts the future development of metachronous neoplasia in patients with resected colorectal cancer

BACKGROUND

Patients with resected colorectal cancer remain at a high risk for developing metachronous neoplasia in the remnant colorectum. The aim of this study was to identify baseline clinical and colonoscopic features predictive of metachronous neoplasia after curative resection of colorectal cancer.

METHODS

The baseline clinical and colonoscopic data and follow-up details of 503 patients who had colonoscopic surveillance after curative colorectal resection between January 2000 and October 2005 in a single tertiary institution were analyzed. Univariate and multivariate analyses were done to identify risk factors for metachronous adenoma.

RESULTS

Metachronous adenomas were diagnosed in 176 patients (35.0%) and advanced adenomas in 39 (7.8%) during the follow-up period (35.7+/-20.9 mo). Among the clinical and colonoscopic factors at baseline, advanced age (> or = 60 y) (odds ratio (OR)=3.64; 95% confidence intervals (CI), 1.55-8.52), the presence of advanced synchronous adenoma (OR=4.38; 95% CI, 1.77-10.85), and longer total follow-up period (OR=1.03; 95% CI, 1.01-1.04) were independently correlated with developing advanced metachronous adenoma. Patients who had synchronous tubular adenoma without advanced features at baseline were not found to have an increased risk for future development of advanced metachronous adenoma compared with those in the synchronous adenoma-free group (OR=1.75; 95% CI, 0.69-4.43, P=0.650).

CONCLUSIONS

Our data showed that patients with advanced synchronous adenoma at baseline were identified to have an increased risk of advanced metachronous neoplasia during a longer follow-up period but those with tubular adenoma without advanced features at baseline were not.

Clinicopathological features of colorectal cancer in patients under 40 years of age

OBJECTIVE

The aim was to identify the clinical factors and tumour characteristics that predict survival in patients younger than 40 years with colorectal adenocarcinoma.

MATERIAL AND METHODS

Fifty-nine patients with colorectal cancer aged under 40 years were identified from a computer database, and their clinical variables were analysed. The factors predicting long-term survival were compared by both univariate and multivariate analysis.

RESULTS

The prevalence of positive family history of cancer was 27%, and predisposing factors were present in 31% of the patients. All patients underwent resective surgery, 76% radical and 24% palliative resection, and their 5-year survival was 59% and mean survival +/-75 months. The recurrence rate after radical resection was 38% being 14%, 30%, 78% and 100% in Dukes classes A, B, C and D. The cumulative 5-year survival of men, 45%, was significantly worse than that of women, 73%, and this phenomenon was closely related to more distended lymphatic and venous invasion of cancer in men. Kaplan-Meier estimates showed that gender, Dukes staging, grade of tumour, lymphatic invasion, the number of lymph nodes with metastases, venous invasion and size of tumour were significant predictors of survival, but in Cox regression model, only venous invasion was the independent prognostic factor of survival.

CONCLUSIONS

Young men with colorectal cancer in Northern Finland have poorer prognosis than women. Venous invasion is an independent predictor of survival.

The role of postoperative surveillance in colorectal cancer

Postoperative surveillance for recurrent and/or metachronous disease is an important component of the treatment of patients with colorectal cancer. The optimal schedule of follow-up investigations remains controversial. Several randomized trials have suggested a moderate improvement in 5-year survival and earlier detection of cancer recurrence with the implementation of intensive surveillance protocols. Whether these protocols are cost-effective has yet to be determined. Current guidelines from the American Society of Colon and Rectal Surgeons recommend periodic patient follow-up with office visits, carcinoembryonic antigen (CEA) measurement, and endoscopy following potentially curative resection of colorectal cancer.