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Abstract
Surgery remains the mainstay of treatment for colon and rectal cancers. Colon cancer outcomes have improved with laparoscopic techniques, enhanced recovery pathways, and adjuvant chemotherapy. Adjuvant 5-fluorouracil with or without oxaliplatin in stage III and possibly high-risk stage II colon cancer is associated with improved survival. Multimodality management of rectal cancer continues to evolve; total mesorectal excision is the cornerstone. Oncologic results do not support the use of laparoscopic resection in rectal cancer. Preoperative short- or long-course radiation for stage II or III rectal cancer is the standard of care. Long course chemoradiation is recommended for bulky tumors.
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Affiliation(s)
- Atif Iqbal
- Department of Surgery, University of Florida, 1600 Southwest Archer Road, PO Box 100106, Gainesville, FL 32610-0019, USA
| | - Thomas J George
- Department of Medicine, University of Florida, 1600 Southwest Archer Road, PO Box 100278, Gainesville, FL 32610-0278, USA.
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Verberne CJ, Zhan Z, van den Heuvel ER, Oppers F, de Jong AM, Grossmann I, Klaase JM, de Bock GH, Wiggers T. Survival analysis of the CEAwatch multicentre clustered randomized trial. Br J Surg 2017; 104:1069-1077. [PMID: 28376235 DOI: 10.1002/bjs.10535] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/30/2016] [Accepted: 02/08/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND The CEAwatch randomized trial showed that follow-up with intensive carcinoembryonic antigen (CEA) monitoring (CEAwatch protocol) was better than care as usual (CAU) for early postoperative detection of colorectal cancer recurrence. The aim of this study was to calculate overall survival (OS) and disease-specific survival (DSS). METHODS For all patients with recurrence, OS and DSS were compared between patients detected by the CEAwatch protocol versus CAU, and by the method of detection of recurrence, using Cox regression models. RESULTS Some 238 patients with recurrence were analysed (7·5 per cent); a total of 108 recurrences were detected by CEA blood test, 64 (55·2 per cent) within the CEAwatch protocol and 44 (41·9 per cent) in the CAU group (P = 0·007). Only 16 recurrences (13·8 per cent) were detected by patient self-report in the CEAwatch group, compared with 33 (31·4 per cent) in the CAU group. There was no significant improvement in either OS or DSS with the CEAwatch protocol compared with CAU: hazard ratio 0·73 (95 per cent 0·46 to 1·17) and 0·78 (0·48 to 1·28) respectively. There were no differences in survival when recurrence was detected by CT versus CEA measurement, but both of these methods yielded better survival outcomes than detection by patient self-report. CONCLUSION There was no direct survival benefit in favour of the intensive programme, but the CEAwatch protocol led to a higher proportion of recurrences being detected by CEA-based blood test and reduced the number detected by patient self-report. This is important because detection of recurrence by blood test was associated with significantly better survival than patient self-report, indirectly supporting use of the CEAwatch protocol.
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Affiliation(s)
- C J Verberne
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Z Zhan
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - E R van den Heuvel
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - F Oppers
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - A M de Jong
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - I Grossmann
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Department of Gastrointestinal Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - J M Klaase
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - G H de Bock
- Departments of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - T Wiggers
- Departments of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Brandenbarg D, Roorda C, Stadlander M, de Bock GH, Berger MY, Berendsen AJ. Patients' views on general practitioners' role during treatment and follow-up of colorectal cancer: a qualitative study. Fam Pract 2017; 34:234-238. [PMID: 27920118 DOI: 10.1093/fampra/cmw124] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To clarify experiences and preferences of patients regarding the current and future role of GPs during treatment and follow-up care of colorectal cancer (CRC). METHODS Qualitative semi-structured, audio-recorded, face-to-face interviews in patients' homes in the north of the Netherlands were performed. Patients were sampled purposively on age, gender, time since diagnoses and primary health care use. Data were transcribed verbatim and analysed thematically by two independent researchers until saturation was reached. RESULTS Twenty-two patients were interviewed. GPs played a significant and highly valued role directly after surgery by proactively contacting their patients and offered support in clarification of medical issues, lifestyle advice and care for treatment-related side effects. During follow-up, GPs provided psychosocial support for patients and family members, besides routine health care. Concerning the organization of future follow-up care, most patients expressed a preference for specialist-led services; some said that primary care-led care would be more accessible and less expensive. CONCLUSION Although at present patients perceived their GP is involved in CRC care, they would prefer their follow-up care in a hospital setting. If, in line with recent insights, future follow-up care might become more relying on testing for markers instead of imaging, there may be scope for incorporating this care in current GP routines.
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Affiliation(s)
- Daan Brandenbarg
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carriene Roorda
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michelle Stadlander
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annette J Berendsen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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54
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van der Sluis FJ, Zhan Z, Verberne CJ, Muller Kobold AC, Wiggers T, de Bock GH. Predictive performance of TPA testing for recurrent disease during follow-up after curative intent surgery for colorectal carcinoma. Clin Chem Lab Med 2017; 55:269-274. [PMID: 27522097 DOI: 10.1515/cclm-2016-0207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 07/14/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of the present study was to investigate the predictive performance of serial tissue polypeptide antigen (TPA) testing after curative intent resection for detection of recurrence of colorectal malignancy. METHODS Serum samples were obtained in 572 patients from three different hospitals during follow-up after surgery. Test characteristics of serial TPA testing were assessed using a cut-off value of 75 U/L. The relation with American Joint Committee on Cancer stage and the potential additive value of tissue polypeptide antigen testing upon standard carcinoembryonic antigen (CEA) testing were investigated. RESULTS The area under the receiver operating characteristic curve of TPA for recurrent disease was 0.70, indicating marginal usefulness as a predictive test. Forty percent of cases that were detected by CEA testing would have been missed by TPA testing alone, whilst most cases missed by CEA were also not detected by TPA testing. In the subpopulation of patients with stage III disease predictive performance was good (area under the curve 0.92 within 30 days of diagnosing recurrent disease). In this group of patients, 86% of cases that were detected by CEA were also detected by TPA. CONCLUSIONS Overall, TPA is a relatively poor predictor for recurrent disease during follow-up. When looking at the specific subpopulation of patients with stage III disease predictive performance of TPA was good. However, TPA testing was not found to be superior to CEA testing in this specific subpopulation.
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55
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Zhan Z, de Bock GH, van den Heuvel ER. Statistical methods for unidirectional switch designs: Past, present, and future. Stat Methods Med Res 2017; 27:2872-2882. [PMID: 28125927 DOI: 10.1177/0962280216689280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical trials may apply or use a sequential introduction of a new treatment to determine its efficacy or effectiveness with respect to a control treatment. The reasons for choosing a particular switch design have different origins. For instance, they may be implemented for ethical or logistic reasons or for studying disease-modifying effects. Large-scale pragmatic trials with complex interventions often use stepped wedge designs (SWDs), where all participants start at the control group, and during the trial, the control treatment is switched to the new intervention at different moments. They typically use cross-sectional data and cluster randomization. On the other hand, new drugs for inhibition of cognitive decline in Alzheimer's or Parkinson's disease typically use delayed start designs (DSDs). Here, participants start in a parallel group design and at a certain moment in the trial, (part of) the control group switches to the new treatment. The studies are longitudinal in nature, and individuals are being randomized. Statistical methods for these unidirectional switch designs (USD) are quite complex and incomparable, and they have been developed by various authors under different terminologies, model specifications, and assumptions. This imposes unnecessary barriers for researchers to compare results or choose the most appropriate method for their own needs. This paper provides an overview of past and current statistical developments for the USDs (SWD and DSD). All designs are formulated in a unified framework of treatment patterns to make comparisons between switch designs easier. The focus is primarily on statistical models, methods of estimation, sample size calculation, and optimal designs for estimation of the treatment effect. Other relevant open issues are being discussed as well to provide suggestions for future research in USDs.
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Affiliation(s)
- Zhuozhao Zhan
- 1 Department of Epidemiology, University Medical Center Groningen, the Netherlands
| | - Geertruida H de Bock
- 1 Department of Epidemiology, University Medical Center Groningen, the Netherlands
| | - Edwin R van den Heuvel
- 2 Department of Mathematics and Computer Science, Technology University Eindhoven, the Netherlands
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56
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van der Stok EP, Spaander MCW, Grünhagen DJ, Verhoef C, Kuipers EJ. Surveillance after curative treatment for colorectal cancer. Nat Rev Clin Oncol 2016; 14:297-315. [DOI: 10.1038/nrclinonc.2016.199] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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57
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Jeffery M, Hickey BE, Hider PN, See AM. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2016; 11:CD002200. [PMID: 27884041 PMCID: PMC6464536 DOI: 10.1002/14651858.cd002200.pub3] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND It is common clinical practice to follow patients with colorectal cancer (CRC) for several years following their curative surgery or adjuvant therapy, or both. Despite this widespread practice, there is considerable controversy about how often patients should be seen, what tests should be performed, and whether these varying strategies have any significant impact on patient outcomes. This is the second update of a Cochrane Review first published in 2002 and first updated in 2007. OBJECTIVES To assess the effects of intensive follow-up for patients with non-metastatic colorectal cancer treated with curative intent. SEARCH METHODS For this update, we searched CENTRAL (2016, Issue 3), MEDLINE (1950 to May 20th, 2016), Embase (1974 to May 20th, 2016), CINAHL (1981 to May 20th, 2016), and Science Citation Index (1900 to May 20th, 2016). We also searched reference lists of articles, and handsearched the Proceedings of the American Society for Radiation Oncology (2011 to 2014). In addition, we searched the following trials registries (May 20th, 2016): ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We further contacted study authors. No language or publication restrictions were applied to the search strategies. SELECTION CRITERIA We included only randomised controlled trials comparing different follow-up strategies for participants with non-metastatic CRC treated with curative intent. DATA COLLECTION AND ANALYSIS Two authors independently determined trial eligibility, performed data extraction, and assessed methodological quality. MAIN RESULTS We studied 5403 participants enrolled in 15 studies. (We included two new studies in this second update.) Although the studies varied in setting (general practitioner (GP)-led, nurse-led, or surgeon-led) and "intensity" of follow-up, there was very little inconsistency in the results.Overall survival: we found no evidence of a statistical effect with intensive follow-up (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.78 to 1.02; I² = 4%; P = 0.41; high-quality evidence). There were 1098 deaths among 4786 participants enrolled in 12 studies.Colorectal cancer-specific survival: this did not differ with intensive follow-up (HR 0.93, 95% CI 0.78 to 1.12; I² = 0%; P = 0.45; moderate-quality evidence). There were 432 colorectal cancer deaths among 3769 participants enrolled in seven studies.Relapse-free survival: we found no statistical evidence of effect with intensive follow-up (HR 1.03, 95% CI 0.90 to 1.18; I² = 5%; P = 0.39; moderate-quality evidence). There were 1416 relapses among 5253 participants enrolled in 14 studies.Salvage surgery with curative intent: this was more frequent with intensive follow-up (risk ratio (RR) 1.98, 95% CI 1.53 to 2.56; I² = 31%; P = 0.14; high-quality evidence). There were 457 episodes of salvage surgery in 5157 participants enrolled in 13 studies.Interval (symptomatic) recurrences: these were less frequent with intensive follow-up (RR 0.59, 95% CI 0.41 to 0.86; I² = 66%; P = 0.007; moderate-quality evidence). Three hundred and seventy-six interval recurrences were reported in 3933 participants enrolled in seven studies.Intensive follow-up did not appear to affect quality of life, anxiety, nor depression (reported in three studies).Harms from colonoscopies did not differ with intensive follow-up (RR 2.08, 95% CI 0.11 to 40.17; moderate-quality evidence). In two studies, there were seven colonoscopic complications in 2112 colonoscopies. AUTHORS' CONCLUSIONS The results of our review suggest that there is no overall survival benefit for intensifying the follow-up of patients after curative surgery for colorectal cancer. Although more participants were treated with salvage surgery with curative intent in the intensive follow-up group, this was not associated with improved survival. Harms related to intensive follow-up and salvage therapy were not well reported.
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Affiliation(s)
- Mark Jeffery
- Christchurch HospitalCanterbury Regional Cancer and Haematology ServicePrivate Bag 4710ChristchurchNew Zealand8140
| | | | - Phil N Hider
- University of Otago, ChristchurchDepartment of Population HealthPO Box 4345ChristchurchNew Zealand8140
| | - Adrienne M See
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneAustralia4101
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58
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Loree JM, Cheung WY. Optimizing adjuvant therapy and survivorship care of stage III colon cancer. Future Oncol 2016; 12:2021-35. [DOI: 10.2217/fon-2016-0109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The MOSAIC trial demonstrated nearly a decade ago that the addition of oxaliplatin to 5-fluorouracil improves outcomes in the adjuvant treatment of colon cancer, but no new agents have been shown to be superior to standard FOLFOX therapy. Oncologists have refined the use of oxaliplatin containing regimens to optimize outcomes, improved patient selection for multi-agent chemotherapy and expanded survivorship care to meet the needs of the growing number of survivors. In this article, we review the historical contexts of current therapy, appropriate staging investigations, the importance of timely initiation of therapy and key survivorship issues. We also discuss exciting opportunities for change, including reduced duration of adjuvant chemotherapy and the use of circulating tumor cells and DNA in surveillance.
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Affiliation(s)
- Jonathan M Loree
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia, V5Z 4E6, Canada
| | - Winson Y Cheung
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia, V5Z 4E6, Canada
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59
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Mokhles S, Macbeth F, Farewell V, Fiorentino F, Williams NR, Younes RN, Takkenberg JJM, Treasure T. Meta-analysis of colorectal cancer follow-up after potentially curative resection. Br J Surg 2016; 103:1259-68. [PMID: 27488593 PMCID: PMC5031212 DOI: 10.1002/bjs.10233] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/15/2016] [Accepted: 05/17/2016] [Indexed: 12/24/2022]
Abstract
Background After potentially curative resection of primary colorectal cancer, patients may be monitored by measurement of carcinoembryonic antigen and/or CT to detect asymptomatic metastatic disease earlier. Methods A systematic review and meta-analysis was conducted to find evidence for the clinical effectiveness of monitoring in advancing the diagnosis of recurrence and its effect on survival. MEDLINE (Ovid), Embase, the Cochrane Library, Web of Science and other databases were searched for randomized comparisons of increased intensity monitoring compared with a contemporary standard policy after resection of primary colorectal cancer. Results There were 16 randomized comparisons, 11 with published survival data. More intensive monitoring advanced the diagnosis of recurrence by a median of 10 (i.q.r. 5–24) months. In ten of 11 studies the authors reported no demonstrable difference in overall survival. Seven RCTs, published from 1995 to 2016, randomly assigned 3325 patients to a monitoring protocol made more intensive by introducing new methods or increasing the frequency of existing follow-up protocols versus less invasive monitoring. No detectable difference in overall survival was associated with more intensive monitoring protocols (hazard ratio 0·98, 95 per cent c.i. 0·87 to 1·11). Conclusion Based on pooled data from randomized trials published from 1995 to 2016, the anticipated survival benefit from surgical treatment resulting from earlier detection of metastases has not been achieved.
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Affiliation(s)
- S Mokhles
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - F Macbeth
- Wales Cancer Trials Unit, Cardiff University, Cardiff, UK
| | - V Farewell
- Medical Research Council Biostatistics Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - F Fiorentino
- Division of Surgery and Cancer, and Imperial College Trials Unit, Imperial College London, London, UK
| | - N R Williams
- Surgical and Interventional Trials Unit, Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - R N Younes
- Oncology Centre, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - J J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - T Treasure
- Clinical Operational Research Unit, University College London, London, UK
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60
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Zhan Z, de Bock GH, Wiggers T, van den Heuvel E. The analysis of terminal endpoint events in stepped wedge designs. Stat Med 2016; 35:4413-4426. [PMID: 27311403 DOI: 10.1002/sim.7004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 12/25/2022]
Abstract
The stepped wedge design is a unique clinical trial design that allows for a sequential introduction of an intervention. However, the statistical analysis is unclear when this design is applied in survival data. The time-dependent introduction of the intervention in combination with terminal endpoints and interval censoring makes the analysis more complicated. In this paper, a time-on-study scale discrete survival model was constructed. Simulations were conducted primarily to study the performance of our model for different settings of the stepped wedge design. Secondary, we compared our approach to continuous Cox proportional hazard model. The results show that the discrete survival model estimates the intervention effects unbiasedly. If the length of the censoring interval is increased, the precision of the estimates is decreased. Without left truncation and late entry, the number of steps improves the precision of the estimates, whereas in combination of left truncation and late entry, the number of steps decreases the precision. Given the same number of participants and clusters, a parallel group design has higher precision than a stepped wedge design. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Zhuozhao Zhan
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Theo Wiggers
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Edwin van den Heuvel
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands. .,Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, The Netherlands.
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Present and future role of surgery in metastatic gastrointestinal malignancies. Curr Opin Oncol 2016; 28:348-52. [PMID: 27136137 DOI: 10.1097/cco.0000000000000297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Metastases from gastrointestinal malignancies are systemic or abdominal disseminations of cancer cells. From a biological perspective surgical resections are questionable but case series show that for some tumour types, surgery influences survival outcome. This review focuses on management and indications for surgery in recent literature of these metastatic gastrointestinal malignancies. RECENT FINDINGS A few gastrointestinal malignancies have emerged to be candidates for surgery in case of metastatic disease. Surgery can be considered in selected cases with liver metastases or abdominal dissemination of colorectal cancer, metastases from gastrointestinal stromal tumours or neuroendocrine tumours. On the contrary, recent publications do not support surgery for metastatic disease of any other gastrointestinal origin. The literature has ample examples of small series and anecdotal cases of successful surgical interventions for most tumour types but no new evidence has been presented to support broader indications for surgery. SUMMARY The evidence base for surgery of different metastatic gastrointestinal malignancies is unchanged. There are some clarifications when to perform surgery and the timing of surgery in regard to combined treatments. No new tumour types are added to potential candidates for surgery.
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Verberne CJ, Wiggers T, Grossmann I, de Bock GH, Vermeulen KM. Cost-effectiveness of a carcinoembryonic antigen (CEA) based follow-up programme for colorectal cancer (the CEA Watch trial). Colorectal Dis 2016; 18:O91-6. [PMID: 26757353 DOI: 10.1111/codi.13273] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/18/2015] [Indexed: 02/08/2023]
Abstract
AIM The study CEA Watch (Netherlands Trial Register 2182) has shown that an intensified follow-up schedule with more frequent carcinoembryonic antigen (CEA) measurements but fewer outpatient visits detects more curable recurrences compared with the usual follow-up protocol in colorectal cancer (CRC) patients. The aim of the study was to compare the cost and cost-effectiveness between various follow-up programmes. METHOD In total, 3223 patients with stage I-III CRC were followed between October 2010 and October 2012. Direct medical costs were calculated per patient adding the costs for all visits, CEA measurements and imaging. Productivity losses and travel expenses were calculated using answers from questionnaires. The cost-effectiveness displayed the additional costs per additional patient with recurrent disease and used an incremental cost-effectiveness ratio (ICER) to compare them. RESULTS The mean yearly cost per patient was €548 in the intensified protocol and €497 in the control protocol. The ICER was €94 (95% CI €76-€157) per cent; to detect one additional patient with a recurrence in the intervention protocol compared with the control protocol would require an additional €9400. For curable recurrences, the ICER was €607 (95% CI €5695-€5728). Annual patient-reported costs were €509 per year in the intervention protocol and €488 in the control protocol. CONCLUSION The current study demonstrates that the direct medical and patient-reported cost of a newly introduced, safe and effective way of CRC follow-up was comparable to that of standard care. The ICER per curable recurrence was considered acceptably low.
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Affiliation(s)
- C J Verberne
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - T Wiggers
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - I Grossmann
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - G H de Bock
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - K M Vermeulen
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Treasure T, Macbeth F. Is there a survival benefit from increased intensity of CEA monitoring after primary resection of colorectal cancer? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:312-3. [PMID: 26560023 DOI: 10.1016/j.ejso.2015.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 10/05/2015] [Indexed: 10/22/2022]
Affiliation(s)
- T Treasure
- Clinical Operational Research Unit, University College London, London, UK; Clinical Trials Group, University College London, London, UK.
| | - F Macbeth
- Wales Cancer Trials Unit, Cardiff University, Cardiff, UK
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Nicholson BD, Shinkins B, Pathiraja I, Roberts NW, James TJ, Mallett S, Perera R, Primrose JN, Mant D. Blood CEA levels for detecting recurrent colorectal cancer. Cochrane Database Syst Rev 2015; 2015:CD011134. [PMID: 26661580 PMCID: PMC7092609 DOI: 10.1002/14651858.cd011134.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Testing for carcino-embryonic antigen (CEA) in the blood is a recommended part of follow-up to detect recurrence of colorectal cancer following primary curative treatment. There is substantial clinical variation in the cut-off level applied to trigger further investigation. OBJECTIVES To determine the diagnostic performance of different blood CEA levels in identifying people with colorectal cancer recurrence in order to inform clinical practice. SEARCH METHODS We conducted all searches to January 29 2014. We applied no language limits to the searches, and translated non-English manuscripts. We searched for relevant reviews in the MEDLINE, EMBASE, MEDION and DARE databases. We searched for primary studies (including conference abstracts) in the Cochrane Central Register of Controlled Trials (CENTRAL), in MEDLINE, EMBASE, and the Science Citation Index & Conference Proceedings Citation Index - Science. We identified ongoing studies by searching WHO ICTRP and the ASCO meeting library. SELECTION CRITERIA We included cross-sectional diagnostic test accuracy studies, cohort studies, and randomised controlled trials (RCTs) of post-resection colorectal cancer follow-up that compared CEA to a reference standard. We included studies only if we could extract 2 x 2 accuracy data. We excluded case-control studies, as the ratio of cases to controls is determined by the study design, making the data unsuitable for assessing test accuracy. DATA COLLECTION AND ANALYSIS Two review authors (BDN, IP) assessed the quality of all articles independently, discussing any disagreements. Where we could not reach consensus, a third author (BS) acted as moderator. We assessed methodological quality against QUADAS-2 criteria. We extracted binary diagnostic accuracy data from all included studies as 2 x 2 tables. We conducted a bivariate meta-analysis. We used the xtmelogit command in Stata to produce the pooled estimates of sensitivity and specificity and we also produced hierarchical summary ROC plots. MAIN RESULTS In the 52 included studies, sensitivity ranged from 41% to 97% and specificity from 52% to 100%. In the seven studies reporting the impact of applying a threshold of 2.5 µg/L, pooled sensitivity was 82% (95% confidence interval (CI) 78% to 86%) and pooled specificity 80% (95% CI 59% to 92%). In the 23 studies reporting the impact of applying a threshold of 5 µg/L, pooled sensitivity was 71% (95% CI 64% to 76%) and pooled specificity 88% (95% CI 84% to 92%). In the seven studies reporting the impact of applying a threshold of 10 µg/L, pooled sensitivity was 68% (95% CI 53% to 79%) and pooled specificity 97% (95% CI 90% to 99%). AUTHORS' CONCLUSIONS CEA is insufficiently sensitive to be used alone, even with a low threshold. It is therefore essential to augment CEA monitoring with another diagnostic modality in order to avoid missed cases. Trying to improve sensitivity by adopting a low threshold is a poor strategy because of the high numbers of false alarms generated. We therefore recommend monitoring for colorectal cancer recurrence with more than one diagnostic modality but applying the highest CEA cut-off assessed (10 µg/L).
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Affiliation(s)
- Brian D Nicholson
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Bethany Shinkins
- University of LeedsAcademic Unit of Health Economics101 Clarendon RoadLeedsUKLS29LJ
| | - Indika Pathiraja
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Tim J James
- Oxford University Hospitals NHS TrustClinical BiochemistryHeadingtonOxfordUK
| | - Susan Mallett
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - John N Primrose
- University of SouthamptonDepartment of SurgerySouthampton General HospitalTremona RoadSouthamptonUKS0322AB
| | - David Mant
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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