Colorectal cancer follow-up: perspectives for future studies

Follow-up strategies for patients treated for non-metastatic colorectal cancer

BACKGROUND

This is the fourth update of a Cochrane Review first published in 2002 and last updated in 2016.It is common clinical practice to follow patients with colorectal cancer 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.

OBJECTIVES

To assess the effect of follow-up programmes (follow-up versus no follow-up, follow-up strategies of varying intensity, and follow-up in different healthcare settings) on overall survival for patients with colorectal cancer treated with curative intent. Secondary objectives are to assess relapse-free survival, salvage surgery, interval recurrences, quality of life, and the harms and costs of surveillance and investigations.

SEARCH METHODS

For this update, on 5 April 2109 we searched CENTRAL, MEDLINE, Embase, CINAHL, and Science Citation Index. We also searched reference lists of articles, and handsearched the Proceedings of the American Society for Radiation Oncology. In addition, we searched the following trials registries: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We contacted study authors. We applied no language or publication restrictions to the search strategies.

SELECTION CRITERIA

We included only randomised controlled trials comparing different follow-up strategies for participants with non-metastatic colorectal cancer treated with curative intent.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently determined study eligibility, performed data extraction, and assessed risk of bias and methodological quality. We used GRADE to assess evidence quality.

MAIN RESULTS

We identified 19 studies, which enrolled 13,216 participants (we included four new studies in this second update). Sixteen out of the 19 studies were eligible for quantitative synthesis. 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 intensive follow-up made little or no difference (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.80 to 1.04: I² = 18%; high-quality evidence). There were 1453 deaths among 12,528 participants in 15 studies. In absolute terms, the average effect of intensive follow-up on overall survival was 24 fewer deaths per 1000 patients, but the true effect could lie between 60 fewer to 9 more per 1000 patients.Colorectal cancer-specific survival: we found intensive follow-up probably made little or no difference (HR 0.93, 95% CI 0.81 to 1.07: I² = 0%; moderate-quality evidence). There were 925 colorectal cancer deaths among 11,771 participants enrolled in 11 studies. In absolute terms, the average effect of intensive follow-up on colorectal cancer-specific survival was 15 fewer colorectal cancer-specific survival deaths per 1000 patients, but the true effect could lie between 47 fewer to 12 more per 1000 patients.Relapse-free survival: we found intensive follow-up made little or no difference (HR 1.05, 95% CI 0.92 to 1.21; I² = 41%; high-quality evidence). There were 2254 relapses among 8047 participants enrolled in 16 studies. The average effect of intensive follow-up on relapse-free survival was 17 more relapses per 1000 patients, but the true effect could lie between 30 fewer and 66 more per 1000 patients.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%; high-quality evidence). There were 457 episodes of salvage surgery in 5157 participants enrolled in 13 studies. In absolute terms, the effect of intensive follow-up on salvage surgery was 60 more episodes of salvage surgery per 1000 patients, but the true effect could lie between 33 to 96 more episodes per 1000 patients.Interval (symptomatic) recurrences: these were less frequent with intensive follow-up (RR 0.59, 95% CI 0.41 to 0.86; I² = 66%; moderate-quality evidence). There were 376 interval recurrences reported in 3933 participants enrolled in seven studies. Intensive follow-up was associated with fewer interval recurrences (52 fewer per 1000 patients); the true effect is between 18 and 75 fewer per 1000 patients.Intensive follow-up probably makes little or no difference to quality of life, anxiety, or depression (reported in 7 studies; moderate-quality evidence). The data were not available in a form that allowed analysis.Intensive follow-up may increase the complications (perforation or haemorrhage) from colonoscopies (OR 7.30, 95% CI 0.75 to 70.69; 1 study, 326 participants; very low-quality evidence). Two studies reported seven colonoscopic complications in 2292 colonoscopies, three perforations and four gastrointestinal haemorrhages requiring transfusion. We could not combine the data, as they were not reported by study arm in one study.The limited data on costs suggests that the cost of more intensive follow-up may be increased in comparison with less intense follow-up (low-quality evidence). The data were not available in a form that allowed analysis.

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 groups, this was not associated with improved survival. Harms related to intensive follow-up and salvage therapy were not well reported.

Patterns of cancer centre follow-up care for survivors of breast, colorectal, gynecologic, and prostate cancer

Background

Rising demand on cancer system resources, alongside mounting evidence that demonstrates the safety and acceptability of primary care-led follow-up care, has resulted in some cancer centres discharging patients back to primary care after treatment. At the same time, the ways in which routine cancer follow-up care is provided across Canada continue to vary widely. The objectives of the present study were to investigate patterns of routine follow-up care at a cancer centre for breast, colorectal, gynecologic, and prostate cancer survivors; factors associated with receipt of follow-up care at a cancer centre; and changes in follow-up care at a cancer centre over time.

Methods

We identified all people diagnosed in Nova Scotia with an invasive breast, colorectal, gynecologic, or prostate cancer between 1 January 2006 and 31 December 2013. We linked the resulting population-based dataset, at the patient level, to cancer centre or clinic data and to census data. We identified a nonmetastatic survivor cohort (n = 12,267) and developed decision rules to differentiate routine from non-routine visits during the follow-up care period (commencing 1 year after diagnosis). Descriptive statistics were computed to describe the patterns of routine follow-up care at a cancer centre. Negative binomial regression was used to examine factors associated with visits made and changes over time.

Results

Nearly half the survivors (48.4%) had at least 1 follow-up visit to the cancer centre, with variation by disease site (range: 30.2%-62.4%). Disease site and stage at diagnosis were associated with receipt of follow-up care at a cancer centre. For instance, compared with breast cancer survivors, survivors of gynecologic cancer had more visits [incidence rate ratio (irr): 1.48; 95% confidence interval (ci): 1.34 to 1.64], and survivors of colorectal cancer had fewer visits (irr: 0.45; 95% ci: 0.40 to 0.51). Year of diagnosis was associated with follow-up at a cancer centre, with each successive calendar year being associated with an 8% increase in visits made (irr: 1.08; 95% ci: 1.07 to 1.10).

Conclusions

Despite evidence that follow-up care can be effectively and safely delivered in primary care, and despite intensifying demands on oncology services, many survivors continue to receive routine follow-up care at a cancer centre.

Follow-up strategies for patients treated for non-metastatic colorectal cancer

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.

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.

Post-treatment surveillance of patients with colorectal cancer with surgically treated liver metastases

BACKGROUND

Little is known about current surveillance patterns after treatment of colorectal liver metastasis (CRLM) or whether the intensity of surveillance correlates with outcome. We sought to define current population-based patterns of surveillance and investigate whether intensity of surveillance impacted outcome.

METHODS

We queried the Surveillance, Epidemiology, and End Results-linked Medicare database for patients with CRLM diagnosed between 1991 and 2005 who underwent liver resection and/or tumor ablation. Frequency of post-treatment abdominal computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) was recorded for ≤ 5 years after treatment. The association between frequency of imaging with secondary interventions and long-term survival were analyzed.

RESULTS

We identified 1,739 patients with CRLM treated with surgery; median age was 73 years, and the majority were male (52.6%). CRLM treatment consisted of liver resection (61%), ablation (32%), or both simultaneously (6%). CT (97%) was utilized more often for post-treatment surveillance compared with MRI (7%) and PET (18%). A temporal trend was noted with more frequent surveillance imaging obtained in post-treatment year 1 (2.4 scans/year) versus year 5 (0.6 scans/year; P = .01); 66% of living patients had no imaging after 2 years. Frequency of surveillance imaging correlated with procedure type (total number of scans/5 years: resection, 5.0; ablation, 4.6; resection and ablation, 6.2; P = .01). Other factors associated with a greater frequency of surveillance included younger age at diagnosis, geographic location in the South, and CRLM directed surgery in 2000 through 2005 (all P < .05). Overall survival did not differ by intensity of surveillance imaging (3-4 scans/yr, 43 months vs 2 scans/yr, 57 months vs 1 scan/yr, 54 months; P = .08).

CONCLUSION

Marked heterogeneity exists in how often surveillance imaging is obtained after treatment of CRLM. Intensity of imaging does not affect time to second procedure or median survival duration. Surveillance guidelines for CRLM need to be refocused to provide the best value for healthcare resources.

Trends and patterns of utilization in post-treatment surveillance imaging among patients treated for hepatocellular carcinoma

BACKGROUND

Little is known about the patterns of utilization of surveillance imaging after treatment of hepatocellular carcinoma (HCC). We sought to define population-based patterns of surveillance and investigate if intensity of surveillance impacted outcome following HCC treatment.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients with HCC diagnosed between 1998 and 2007 who underwent resection, ablation, or intra-arterial therapy (IAT). The association between imaging frequency and long-term survival was analyzed.

RESULTS

Of the 1,467 patients, most underwent ablation only (41.5%), while fewer underwent liver resection only (29.6 %) or IAT only (18.3%). Most patients had at least one CT scan (92.7%) during follow-up, while fewer had an MRI (34.1%). A temporal trend was noted with more frequent surveillance imaging obtained in post-treatment year 1 (2.5 scans/year) vs. year 5 (0.9 scans/year; P = 0.01); 34.5% of alive patients had no imaging after 2 years. Frequency of surveillance imaging correlated with procedure type (total number of scans/5 years, resection, 4.7; ablation, 4.9; IAT, 3.7; P < 0.001). Frequency of surveillance imaging was not associated with a survival benefit (three to four scans/year, 49.5 months vs. two scans/year, 71.7 months vs. one scan/year, 67.6 months; P = 0.01) CONCLUSION: Marked heterogeneity exists in how often surveillance imaging is obtained following treatment of HCC. Higher intensity imaging does not confer a survival benefit.

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.

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.

Follow-up strategies for patients treated for non-metastatic colorectal cancer

BACKGROUND

It is common clinical practice to follow patients with colorectal cancer (CRC) for several years following their definitive surgery and/or adjuvant therapy. 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.

OBJECTIVES

To review the available evidence concerning the benefits of intensive follow up of colorectal cancer patients with respect to survival. Secondary endpoints include time to diagnosis of recurrence, quality of life and the harms and costs of surveillance and investigations.

SEARCH STRATEGY

Relevant trials were identified by electronic searches of MEDLINE, EMBASE, CINAHL, CANCERLIT, Cochrane Controlled Trials Register, Science Citation Index, conference proceedings, trial registers, reference lists and contact with experts in the field.

SELECTION CRITERIA

Only randomised controlled trials comparing different follow-up strategies for patients with non-metastatic CRC treated with curative intent were included.

DATA COLLECTION AND ANALYSIS

Trial eligibility and methodological quality were assessed independently by the three authors.

MAIN RESULTS

Eight studies were included in this update of the review. There was evidence that an overall survival benefit at five years exists for patients undergoing more intensive follow up OR was 0.73 (95% CI 0.59 to 0.91); and RD -0.06 (95% CI -0.11 to -0.02). The absolute number of recurrences was similar; OR was 0.91 (95% CI 0.75 to 1.10); and RD -0.02 (95% CI -0.06 to 0.02) and although the weighted mean difference for the time to recurrence was significantly reduced by -6.75 (95% CI -11.06 to -2.44) there was significant heterogeneity between the studies. Analyses demonstrated a mortality benefit for performing more tests versus fewer tests OR was 0.64 (95% CI 0.49 to 0.85), and RD -0.09 (95%CI -0.14 to -0.03) and liver imaging versus no liver imaging OR was 0.64 (95% CI 0.49 to 0.85), and RD -0.09 (95%CI -0.14 to -0.03). There were significantly more curative surgical procedures attempted in the intensively followed arm: OR 2.41(95% CI 1.63 to 3.54), RD 0.06 (95%CI 0.04 to 0.09). No useful data on quality of life, harms or cost-effectiveness were available for further analysis.

AUTHORS' CONCLUSIONS

The results of our review suggest that there is an overall survival benefit for intensifying the follow up of patients after curative surgery for colorectal cancer. Because of the wide variation in the follow-up programmes used in the included studies it is not possible to infer from the data the best combination and frequency of clinic (or family practice) visits, blood tests, endoscopic procedures and radiological investigations to maximise the outcomes for these patients. Nor is it possible to estimate the potential harms or costs of intensifying follow up for these patients in order to adopt a cost-effective approach in this clinical area. Large clinical trials underway or about to commence are likely to contribute valuable further information to clarify these areas of clinical uncertainty.

Colorectal cancer follow-up: Useful or useless?

Follow-up of surgically treated colorectal cancer patients is not supported by objectively certain data. Despite the thousands of investigations reported in the scientific literature, only six randomized prospective studies and two meta-analysis of randomized studies provide data suggesting clear conclusions. Our review of the literature revealed that intensive colorectal follow-up should be performed even if the long-term survival benefit is small. The timing and investigations conducted in follow-ups diverge. The inconsistency of follow-ups is revealed by the fact that the leading USA and European societies propose different guidelines. One datum that the literature agrees on is that pancolonoscopy performed at 3-5 year intervals in colorectal cancer surgery patients supports diagnosis of adenomatous polyps and metachronous cancers. Cost analysis have shown that intensive follow-up would certainly exceed the cut-off point level set for every additional year of good quality of life.

Plasma gelatinase activity does not reflect disease activity after operation for colorectal cancer

OBJECTIVE

To investigate if plasma matrix metalloproteinase (MMP)-2 or -9 are better markers for disease activity than carcinoembryonic antigen (CEA) in the postoperative follow-up of colorectal cancer patients.

METHODS

A prospective study was performed including 61 patients operated for primary colorectal cancer. The follow-up was for at least 2 years and postoperative blood samples were obtained periodically with 3-month intervals. Plasma gelatinase activity was measured with quantitative gelatin zymography and serum CEA with a specific immunoassay.

RESULTS

Zymographic analysis of plasma samples revealed the presence of the proforms, but not the active forms, of both MMP-2 and -9. Prior to the detection of recurrent disease or metastasis in potentially curatively operated colorectal cancer patients, the changes in proMMP-2, -9 and CEA blood levels were determined. ProMMP-2 and -9 plasma levels changed little in this period and changes between patients with and without disease relapse were not statistically significant. In contrast, patients with disease relapse showed a significant increase (p = 0.002) in CEA in the two consecutive serum samples prior to the detection of recurrent disease or metastasis. Similarly, prior to death due to colorectal cancer, proMMP-2 and -9 plasma levels showed no significant change, whereas CEA levels increased considerably and significantly (p < 0.001) when compared to changes found in survivors.

CONCLUSION

Plasma proMMP-2 and -9 activities show no potential value as prognostic markers in the follow-up of colorectal cancer.

Follow-up of patients with curatively resected colorectal cancer: a practice guideline

BACKGROUND

A systematic review was conducted to evaluate the literature regarding the impact of follow-up on colorectal cancer patient survival and, in a second phase, recommendations were developed.

METHODS

The MEDLINE, CANCERLIT, and Cochrane Library databases, and abstracts published in the 1997 to 2002 proceedings of the annual meeting of the American Society of Clinical Oncology were systematically searched for evidence. Study selection was limited to randomized trials and meta-analyses that examined different programs of follow-up after curative resection of colorectal cancer where five-year overall survival was reported. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee.

RESULTS

Six randomized trials and two published meta-analyses of follow-up were obtained. Of six randomized trials comparing one follow-up program to a more intense program, only two individual trials detected a statistically significant survival benefit favouring the more intense follow-up program. Pooling of all six randomized trials demonstrated a significant improvement in survival favouring more intense follow-up (Relative Risk Ratio 0.80 (95%CI, 0.70 to 0.91; p = 0.0008). Although the rate of recurrence was similar in both of the follow-up groups compared, asymptomatic recurrences and re-operations for cure of recurrences were more common in patients with more intensive follow-up. Trials including CEA monitoring and liver imaging also had significant results, whereas trials not including these tests did not.

CONCLUSION

Follow-up programs for patients with curatively resected colorectal cancer do improve survival. These follow-up programs include frequent visits and performance of blood CEA, chest x-rays, liver imaging and colonoscopy, however, it is not clear which tests or frequency of visits is optimal. There is a suggestion that improved survival is due to diagnosis of recurrence at an earlier, asymptomatic stage which allows for more curative resection of recurrence. Based on this evidence and consideration of the biology of colorectal cancer and present practices, a guideline was developed. Patients should be made aware of the risk of disease recurrence or second bowel cancer, the potential benefits of follow-up and the uncertainties requiring further clinical trials. For patients at high-risk of recurrence (stages IIb and III) clinical assessment is recommended when symptoms occur or at least every 6 months the first 3 years and yearly for at least 5 years. At the time of those visits, patients may have blood CEA, chest x-ray and liver imaging. For patients at lower risk of recurrence (stages I and Ia) or those with co-morbidities impairing future surgery, only visits yearly or when symptoms occur. All patients should have a colonoscopy before or within 6 months of initial surgery, and repeated yearly if villous or tubular adenomas >1 cm are found; otherwise repeat every 3 to 5 years. All patients having recurrences should be assessed by a multidisciplinary team in a cancer centre.

Phase II study of MGI-114 administered intravenously for 5 days every 28 days to patients with metastatic colorectal cancer

We examined the use of MGI-114 (6-hydroxymethyacylfulvene) for the treatment of patients with advanced colorectal carcinoma. Twenty-six patients were enrolled, with a median age of 60 years (range 41-75); 64% were male and all patients had a performance status of 0 or 1. We administered a dose of 11 mg/m2/d x 5 days every 4 weeks. With a median of two cycles (range 0-6) administered, no complete responses or partial responses were observed. Four patients had no change in disease (16%); 15 patients (57%) had progressive disease; seven patients were inevaluable (27%). Toxicity was evaluated in 25 of 26 patients. The main toxicities were hematologic, including granulocytopenia and thrombocytopenia. Neuropsychiatric adverse events included hallucination (7.7%), depression/anxiety (15.4%), and/or insomnia (19.2%). Given the lack of antitumor activity, further study of MGI-114 in colorectal cancer does not appear warranted.

Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial

AIMS

This paper aims to evaluate the diagnostic efficacy and costs of follow-up tailored according to risk of recurrence compared with minimal surveillance.

METHODS

A total of 358 patients treated by surgery alone for colorectal cancer were prospectively divided into two groups of 200 and 158 patients considered at high and low risk of recurrence respectively, according to prognostic factors. They were further randomized into two subgroups: group 1, 192 patients undergoing risk-adapted follow-up, intensive and low-intensity; group 2, 145 patients undergoing minimal surveillance. Twenty-one cases dropped out. Median follow-up was 61.5 months and 42 months for cases at high risk (intensive follow-up) and at low risk (low-intensity follow-up) respectively.

RESULTS

At the end of the study, 52.6% of patients undergoing risk-adapted follow-up and 57.2% undergoing minimal follow-up had developed recurrence. In patients at high risk, a significant difference in the incidence of curative re-operations was observed between the subgroups undergoing risk-adapted follow-up and subgroups undergoing minimal surveillance (P<0.05). The actuarial 5 year survival of patients at high and at low risk of recurrence undergoing risk-adapted follow-up is significantly better than that of cases undergoing minimal follow-up. The economic costs for 34 patients in the intensive follow-up group and for the 57 patients in the low-intensity follow-up group who were free from disease after primary surgery was very similar.

CONCLUSIONS

Risk-adapted follow-up has significantly improved the targeting of curative re-operations and overall survival of patients independently of risk of recurrence and has allowed a reduction in the costs of following up of disease-free patients.

Follow-up strategies for patients treated for non-metastatic colorectal cancer

BACKGROUND

It is common clinical practise to follow patients with colorectal cancer (CRC) for several years following their definitive surgery and/or adjuvant therapy. 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.

OBJECTIVES

To review the available evidence concerning the benefits of intensive follow-up of colorectal cancer patients with respect to survival. Secondary endpoints include time to diagnosis of recurrence, quality of life and the harms and costs of surveillance and investigations.

SEARCH STRATEGY

Relevant trials were identified by electronic searches of MEDLINE, EMBASE, CINAHL, CANCERLIT, Cochrane Controlled Trials Register, Science Citation Index, conference proceedings, trial registers, reference lists and contact with experts in the field.

SELECTION CRITERIA

Only randomised controlled trials comparing different follow-up strategies for patients with non-metastatic CRC treated with curative intent were included.

DATA COLLECTION AND ANALYSIS

Trial eligibility and methodological quality were assessed independently by the three reviewers.

MAIN RESULTS

Five trials were included. There was evidence that an overall survival benefit at 5 years exists for patients undergoing more intensive follow-up (OR = 0.67, 95% confidence interval 0.53 - 0.84; RD = -0.07, CI -0.12 - -0.02). The absolute number of recurrences was similar (OR = 0.91; 95% confidence interval 0.72 - 1.14; RD = 0.00, CI -0.07 - 0.07) and although the weighted mean difference for the time to recurrence was significantly reduced by 6.75 (95% confidence interval -11.06 - -2.44) there was significant heterogeneity between the studies. Analyses demonstrated a mortality benefit for performing more tests versus fewer tests (OR = 0.66; 95% confidence interval 0.46 - 0.95) and liver imaging versus no liver imaging (OR = 0.66; 95% confidence interval 0.46 - 0.95). However when both these results are expressed as a risk difference this significance is lost (RD = -0.06; CI -0.25 - 0.13). No useful data on quality of life, harms or cost-effectiveness were available for further analysis.

REVIEWER'S CONCLUSIONS

The results of our review suggest that there is an overall survival benefit for intensifying the follow-up of patients after curative surgery for colorectal cancer. Because of the wide variation in the follow-up programmes used in the included studies it is not possible to infer from the data the best combination and frequency of clinic (or family practice) visits, blood tests, endoscopic procedures and radiological investigations to maximise the outcomes for these patients. Nor is it possible to estimate the potential harms or costs of intensifying follow-up for these patients in order to adopt a cost-effective approach in this clinical area. Large clinical trials underway or about to commence are likely to contribute valuable further information to clarify these areas of clinical uncertainty.