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Surgeons' follow-up practice after resection of colorectal cancer

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J Mella
J Mella
J Mella
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S N Datta
S N Datta
S N Datta
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A Biffin
A Biffin
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Abstract and Figures

Consultant surgeons in two United Kingdom Health Regions were invited to complete a questionnaire on details of their personal management of patients with colon and rectal cancer, with particular emphasis on follow-up. Replies from 140 (94%) were analysed by the surgeon's subspecialty of colorectal and gastrointestinal surgery (group 1) and all others (group 2). There was a wide variation in the duration of followup, but no difference between the two groups. More group 1 surgeons carried out investigations as a routine after colonic (P < 0.01) and rectal (P < 0.01) resection. Colonoscopy was used more frequently by group 1 (P < 0.0001) and barium enema by group 2 surgeons (P < 0.05). Investigations to detect asymptomatic metastases were used as a routine by 33.3% of surgeons, in whom there was no concordance over the choice or combination of tests and no difference between the two groups of surgeons. There is no consensus among surgeons as to the ideal duration, intensity and method of follow-up after resection for colorectal cancer and little difference between the practice of colorectal and gastrointestinal surgeons and that of other specialists, except in the use of colonoscopy and barium enema. These results reflect the continuing lack of evidence on which to base the follow-up of patients after surgery for colorectal cancer.
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Ann
R
Coll
Surg
Engl
1997;
79:
206-209
Surgeons'
follow-up
practice
after
resection
of
colorectal
cancer
Judy
Mella
FRCS'
Research
Registrar
S
N
Datta
FRCS2
Senior
Surgical
SHO
Anne
Biffin
BSc3
Data
Manager
A
G
Radcliffe
MS
FRCS4
Consultant
Surgeon
R
J
C
Steele
MD
FRCS1
Reader
in
Surgery/Honorary
Consultant
Surgeon
J
D
Stamatakis
BSc
MS
FRCS2
Consultant
Surgeon
Audit
and
Epidemiology
Unit,
The
Royal
College
of
Surgeons
of
England,
London
Key
words:
Colorectal
cancer;
Follow-up
Consultant
surgeons
in
two
United
Kingdom
Health
Regions
were
invited
to
complete
a
questionnaire
on
details
of
their
personal
management
of
patients
with
colon
and
rectal
cancer,
with
particular
emphasis
on
follow-up. Replies
from
140
(94%)
were
analysed
by
the
surgeon's
subspecialty
of
colorectal
and
gastro-
intestinal
surgery
(group
1)
and
all
others
(group
2).
There
was
a
wide
variation
in
the
duration
of
follow-
up,
but
no
difference
between
the
two
groups.
More
group
1
surgeons
carried
out
investigations
as
a
routine
after
colonic
(P
<0.01)
and
rectal
(P
<0.01)
resection.
Colonoscopy
was
used
more
frequently
by
group
1
(P<0.0001)
and
barium
enema
by
group
2
surgeons
(P<0.05).
Investigations
to
detect
asympto-
matic
metastases
were
used
as
a
routine
by
33.3%
of
surgeons,
in
whom
there
was
no
concordance
over
the
choice
or
combination
of
tests
and
no
difference
between
the
two
groups
of
surgeons.
There
is
no
consensus
among
surgeons
as
to
the
ideal
duration,
intensity
and
method
of
follow-up
after
resection
for
colorectal
cancer
and
little
difference
between
the
practice
of
colorectal
and
gastrointestinal
surgeons
and
that
of
other
specialists,
except
in
the
use
of
colonoscopy
and
barium
enema.
These
results
reflect
the
continuing
lack
of
evidence
on
which
to
base
the
follow-up
of
patients
after
surgery
for
colorectal
cancer.
1
Queen's
Medical
Centre,
Nottingham
2
Bridgend
and
District
NHS
Trust,
Bridgend
3
Clinical
Effectiveness
Resource
Unit,
Llandough
NHS
Trust,
Penarth
4
Llandough
NHS
Trust,
Penarth
Correspondence
to:
Mr
J
D
Stamatakis,
Department
of
Surgery,
Princess
of
Wales
Hospital,
Bridgend
CF31
1RQ
It
has
been
suggested
that
intensive
follow-up
of
patients
after
surgery
for
colorectal
cancer
will
detect
recurrent
tumour
at
an
early,
asymptomatic
stage,
when
further
curative
treatment
might
be
possible
(1,2).
Outpatient
review
also
provides
the
opportunity
to
audit
the
results
of
treatment,
provide
psychological
support
for
the
cancer
patient
and
detect
metachronous
cancers.
This
study
investigates
how
surgeons
in
two
United
Kingdom
(UK)
Health
Regions,
Wales
and
Trent,
follow
up
patients
after
apparent
curative
surgery
for
colorectal
cancer.
The
methods
of
follow-up
by
colorectal
and
gastrointestinal
surgeons
is
compared
with
that
of
all
other
surgeons,
who
also
treat
colorectal
cancer
in
the
two
regions.
Methods
Consultant
surgeons
who
had
taken
part
in
The
Royal
College
of
Surgeons
of
England
Colorectal
Cancer
Audit
were
invited
to
complete
a
questionnaire
on
their
management
of
colorectal
cancer.
The
audit
was
held
in
two
UK
Health
Regions,
Wales
and
Trent.
In
all,
161
surgeons
in
the
two
regions
treated
patients
with
colorectal
cancer
during
the
12-month
audit.
Question-
naires
were
sent
to
149
of
this
group,
the
remainder
had
died,
retired
or
emigrated
during
the
study
period.
The
questionnaire
asked
for
details
on
the
length
of
outpatient
follow-up
after
curative
resection
of
colorectal
cancer.
Additional
information
was
requested
on
out-
patient
investigations
used
to
look
for
local
recurrence,
metachronous
tumours
and
systemic
metastasis.
Data
for
colon
and
rectal
cancer
were
collected
separately.
Details
of
the
surgeon's
usual
practice
were
requested,
accepting
Follow-up
after
resection
of
colorectal
cancer
207
Table
1.
Duration
and
frequency
of
outpatient
follow-up
after
surgery
Rectum
Colon
Group
1
Group
2
Group
1
Group
2
No
appointment
0
0
0
0
One
appointment
then
discharge
1
(1.8)
2
(2.3)
1
(1.8)
2
(2.3)
One
appointment
then
see
as
required
3
(5.5)
7
(8.2)
5
(9.2)
9
(10.6)
Regular
outpatient
appointments
for
<
1
year
2
(3.7)
5
(5.9)
2
(3.7)
4
(4.7)
1-2
years
4
(7.4)
11
(12.9)
5
(9.2)
13
(15.2)
2-5
years
30
(55.6)
33
(38.9)
24
(44)
28
(33)
5-10
years
9
(16.7)
13
(15.3)
10
(18.5)
12
(14.1)
>
10
years
5
(9.3)
14
(16.5)
7
(12.9)
17
(20)
Number
of
surgeons
in
each
group,
percentage
in
parentheses,
group
1,
colorectal
and
gastrointestinal
surgeons,
group
2
all
other
surgeons
that,
for
a
few
patients,
follow-up
might
not
be
appropriate
because
of
frailty,
infirmity
or
other
reasons.
Data
collection
was
anonymous
but
surgeons
were
asked
if
they
had
a
subspecialty
within
general
surgery.
Answers
were
entered
onto
a
computer
database
(Epi
Info)
for
analysis.
Statistical
analysis
was
by
the
x2
test
with
Yates'
correction.
Results
Questionnaires
were
sent
to
149
consultant
surgeons
and
140
replied,
a
response
rate
of
94%.
The
data
for
colorectal
(n=14)
and
gastrointestinal
(n=40)
surgeons
have
been
combined
and
are
presented
as
group
1.
Of
the
remaining
86
surgeons,
22
considered
themselves
general
surgeons
with
no
subspecialty
interest.
Others
declared
subspecialty
interests
in
vascular
(n
=
28),
breast
(n
=
15),
endocrine
(n
=
5),
urology
(n=
11)
and
other
(n
=
5).
The
combined
data
of
these
86
surgeons
is
presented
as
group
2.
All
140
surgeons
reviewed
patients
at
least
once
after
discharge
from
hospital,
although
the
frequency
of
clinic
appointments
varied
from
once
to
lifelong
surveillance.
There
was
no
difference
in
appointment
practice
between
the
two
groups
of
surgeons
and
no
difference
in
the
outpatient
follow-up
of
colon
and
rectal
cancer
(Table
I).
There
were
differences
between
the
two
groups
of
surgeons
in
the
use
of
investigations
for
detecting
recurrence
or
metachronous
tumours
after
resection
of
colonic
cancer
(Table
II).
The
majority,
87%,
of
group
1
carried
out
investigations
compared
with
65.1%
of
group
2
(P<0.01).
Significant
differences
were
in
the
more
Table
III.
Combinations
of
tests
used
for
follow-up
of
rectal
cancer
Table
II.
Combinations
of
tests
used
for
follow-up
of
colon
cancer
according
to
surgeon's
declared
subspecialty
interest
Group
1
Group
2
Routine
tests*
47
(87)
56
(65.1)
Colonoscopy
and
CEA
7
(13)
1
(1.2)
Colonoscopy
alone
22
(40.8)
12
(14)
Barium
enema
1
(1.8)
10
(18.6)
Flexible
sigmoidoscopy
1
(1.8)
2
(2.3)
Colonoscopy
and
barium
enema
1
(1.8)
6
(7)
Colonoscopy
and
abdominal
ultrasound
1
(1.8)
3
(3.5)
Other
tests
used
by
two
or
fewer
surgeons
14
(26)
22
(25.6)
Group
1,
colorectal
and
gastrointestinal
surgeons,
group
2
all
others,
numbers
of
surgeons
with
percentage
in
parentheses
*P
<0.01
Barium
enema
±
other
tests,
P
<
0.05
Colonoscopy
±
other
tests,
P
<
0.0001
Routine
tests*
Colonoscopy
alone
Rigid
sigmoidoscopy
alone
Rigid
sigmoidoscopy
and
CEA
Rigid
and
flexible
sigmoidoscopy
Rigid
sigmoidoscopy
and
colonoscopy
Rigid
sigmoidoscopy,
colonoscopy
and
CEA
Rigid
and
flexible
sigmoidoscopy
and
CEA
Rigid
sigmoidoscopy
and
barium
enema
Rigid
sigmoidoscopy,
barium
enema
and
CEA
Other
tests
used
by
two
or
fewer
surgeons
Group
1
Group
2
52
(96.3)
65
(75.6)
3
(5.6)
6
(7)
9
(16.7)
13
(15.1)
1
(1.9)
3
(3.5)
3
(5.6)
2
(2.3)
6
(11.1)
3
(3.5)
4
(7.4)
0
1
(1.9)
4
(4.7)
0
6
(7)
2
(3.7)
1
(1.2)
23
(42.6)
27
(31.4)
*
P<0.01
Number
of
surgeons
with
percentage
in
parentheses
208
J
Mella
et
al.
Table
IV.
Investigations
carried
out
as
a
routine
for
asymptomatic
metastatic
disease
Group
I
Group
2
Liver
function
tests
13
(24)
13
(15.1)
Ultrasound
liver
15
(27.8)
17
(19.8)
CEA
12
(22.2)
15
(17.4)
Chest
radiographs
4
(7.4)
4
(4.6)
Thoracic
CT
3
(5.5)
1
(1.2)
Liver
CT
3
(5.5)
2
(2.3)
Pelvic
CT
(rectal
cancer
only)
5
(9.2)
2
(2.3)
Group
1,
colorectal
and
gastrointestinal
surgeons,
group
2
all
others,
numbers
of
surgeons
with
percentage
in
parentheses
frequent
use
of
colonoscopy,
with
or
without
other
investigations,
by
group
1
(57.4%
vs
25.6%,
P<0.0001)
and
the
more
frequent
use
of
barium
enema
by group
2
(18.6%
vs
3.7%, P<0.05).
There
was
no
apparent
agreement
between
and
within
groups
about
which
combination
of
tests
might
be
the
most
effective
(Table
II).
Follow-up
practice
for
colon
cancer
by
26%
of
group
1
and
25.6%
of
group
2
surgeons
was
either
unique
or
in
common
with
one
other
surgeon.
The
results
for
rectal
cancer
are
given
in
Table
III.
More
surgeons
in
group
1
carried
out
routine
investiga-
tions
compared
with
those
in
group
2
(96.3%
vs
75.6%,
P
<0.01).
However,
unlike
colonic
cancer,
there
was
no
difference
between
the
two
groups
in
the
methods
of
investigation.
The
follow-up
practice
for
rectal
cancer
by
42.6%
of
group
1
and
31.4%
of
group
2
surgeons
was
either
unique
or
in
common
with
one
other
surgeon.
Routine
investigation
for
asymptomatic
metastases
was
carried
out
by
47
(33.5%)
of
surgeons.
These
employed
various
combinations
of
the
following:
liver
function
tests
(26
surgeons),
liver
ultrasound
(32
surgeons),
carcinoma
embryonic
antigen
(CEA)
levels
(27
surgeons),
chest
radiographs
(eight
surgeons),
thoracic
computed
tomo-
graphy
(CT)
(four
surgeons),
liver
CT
(five
surgeons)
and
pelvic
CT
(five
surgeons).
There
was
no
difference
between
group
1
and
group
2
surgeons
in
the
use
of
any
of
these
tests.
Discussion
The
results
of
this
study
emphasise
the
lack
of
a
consensus
among
surgeons
in
two
UK
Health
Regions
over
surveillance
strategy
after
surgery
for
colorectal
cancer.
The
lack
of
conformity
is
equally
true
for
colorectal
and
gastrointestinal
surgeons
(group
1),
when
compared
with
all
other
'non-abdominal'
surgeons
(group
2).
There
are
some
differences
between
the
two
groups.
More
patients
with
rectal
or
colonic
cancer,
treated
by
group
1
surgeons,
were
found
to
undergo
investigation
for
local
recurrence
and
metachronous
tumour.
This
may
be
because
of
a
greater
commitment
to
audit
in
their
field
of
interest
by
colorectal
and
gastrointestinal
surgeons.
There
was
also
a
difference
between
specialist
and
non-specialist
surgeons
in
the
use
of
colonoscopy
and
barium
enema.
This
may
reflect
the
involvement
and
easier
access
of
colorectal
and
gastrointestinal
surgeons
to
endoscopy.
Whether
these
differences
in
practice
result
in
better
outcome
for
the
individual
patient
is
not
known.
A
more
uniform
follow-up
practice
is
reported
by
specialist
surgeons
in
the
United
States
of
America
(3).
In
a
survey
of
the
American
Society
of
Colon
and
Rectal
Surgeons,
more
than
75%
of
respondents
follow-up
their
patients
every
3-6
months
for
the
first
2
years,
with
80%
doing
CEA
assays
every
3
months
for
3
years.
However,
there
was
considerable
variation
in
the
use
of
investiga-
tions
such
as
colonoscopy,
chest
radiographs,
CT
scanning
and
liver
function
tests.
Evidence
to
support
individual
practice
was
not
discussed
in
this
survey.
These
variations
reflect
a
lack
of published
evidence
on
which
to
base
clinical
practice.
No
prospective,
random-
ised,
controlled
trial
of
follow-up
versus
minimal
surveillance
has
been
carried
out,
although
the
protocol
for
such
a
study
has
been
drawn
up
(4).
Meta-analysis
has
been
used
in
an
attempt
to
define
any
benefit
from
postoperative
surveillance.
The
results
from
seven
studies,
each
comparing
the
outcome
of
two
follow-up
programmes,
of
varying
intensity,
after
surgery
for
colorectal
cancer,
have
been
analysed
(5).
However,
none
of
these
studies
were
randomised.
In
three,
patients
undergoing
intensive
follow-up
were
compared
with
contemporary
controls
who
elected
to
opt
out
of
post-
operative
surveillance.
In
the
remaining
four
studies,
patients
were
compared
with
historic
controls.
The
meta-
analysis
showed
no
increase
in
5-year
survival
of
patients
undergoing
intensive
follow-up
unless
CEA
levels
were
measured.
However,
the
authors
highlighted
the
poor
quality
of
the
data
available
and
were
unable
to
give
an
unequivocal
answer
about
the
value
of
intensive
follow-
up.
Although
published
studies
neither
support
nor
disprove
routine
follow-up
as
a
means
to
improve
survival,
a
special
case
may
be
made
for
the
detection
of
metastatic
liver
disease.
There
is
good
evidence
that
1-3%
of
all
patients
with
colorectal
cancer
may
benefit
from
resection
of
liver
metastases
(6).
For
a
common
disease,
this
small
percentage
translates
into
a
significant
number
of
cases
and
supports
a
follow-up
strategy
that
includes
liver
imaging
for
metachronous
metastases.
In
the
present
survey,
only
26.4%
of
surgeons
use
ultrasound
or
computed
tomography
to
screen
for
asymptomatic
liver
disease.
It
was
disappointing
to
find
that
there
has
been
no
real
change
in
surgeons'
follow-up
practice
since
a
report
from
Wales
and
the
South-West
of
England
almost
10
years
ago
(7).
The
continued
lack
of
evidence
on
which
to
base
clinical
practice
is
one
reason
for
the
persistent
wide
variation
in
follow-up.
Until
such
evidence
is
available,
there
will
be
continuing
diversity
in
surgeons'
follow-up
activity.
Studies
are
needed
on
audit
of
cancer
care,
as
highlighted
by
the
Calman-Hine
Report
(8),
psychologi-
cal
support
for
the
patient,
screening
for
metachronous
tumours
and
survival,
before
standards
for
follow-up
can
be
defined.
Follow-up
after
resection
of
colorectal
cancer
209
The
authors
wish
to
thank
the
general
surgeons
of
Wales
and
Trent
who
took
part
in
the
audit
and
completed
questionnaires.
We
also
thank
the
Clinical
Effectiveness
Support
Unit
(Wales)
for
data
processing
and
the
Welsh
Office
and
Department
of
Health
for
financial
support.
References
1
Eckart
VF,
Stamm
H,
Kanzler
G,
Bernhard
G.
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Ovaska
J,
Jarvinen
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Mecklin
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Vernava
AM,
Longo
WE,
Virgo
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AM,
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J,
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DF,
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Int
J
Colorectal
Dis
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2:
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8
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Advisory
Group
on
Cancer
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CMOs
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England
and
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A
policy
framework
for
commissioning
cancer
services.
London:
Department
of
Health,
1995.
Received
26
June
1996
... 5 There is currently wide variation in follow up. [6][7][8] For example, the Wales and Trent audits reported that among colorectal and gastrointestinal surgeons, 57% included the use of colonoscopy in their surveillance programme at a frequency of three times over five years to annually. Furthermore, some 13% of gastrointestinal surgeons offered no routine testing at all. ...
... Furthermore, some 13% of gastrointestinal surgeons offered no routine testing at all. 6 Among these many different protocols, the costs to health services are considerable and need to be justified with evidence. ...
... We performed a subgroup analysis based on the a priori hypothesis that the early detection of extramural recurrent disease (namely, local pelvic recurrences and solitary hepatic metastases), with investigations such as computed tomography or frequent measurements of serum carcinoembryonic antigen (at least every three months for two years and then every six months thereafter), or both, was more likely to be effective in improving survival related to cancer than strategies directed only at the detection of intraluminal disease (such as the use of colonoscopy). 6 Statistical analysis-We have expressed the main results as combined risk ratios with the fixed effects method and performed tests for heterogeneity. 13 We combined data on the duration to first relapse using differences in means. ...
Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials
Article
  • Apr 2002
Objective To review the evidence from clinical trials of follow up of patients after curative resection for colorectal cancer. Design Systematic review and meta-analysis of randomised controlled trials of intensive compared with control follow up. Main outcome measures All cause mortality at five years (primary outcome). Rates of recurrence of intraluminal, local, and metastatic disease and metachronous (second colorectal primary) cancers (secondary outcomes). Results Five trials, which included 1342 patients, met the inclusion criteria. Intensive follow up was associated with a reduction in all cause mortality (combined risk ratio 0.81, 95% confidence interval 0.70 to 0.94, P=0.007). The effect was most pronounced in the four extramural detection trials that used computed tomography and frequent measurements of serum carcinoembryonic antigen (risk ratio 0.73, 0.60 to 0.89, P=0.002). Intensive follow up was associated with significantly earlier detection of all recurrences (difference in means 8.5 months, 7.6 to 9.4 months, P<0.001) and an increased detection rate for isolated local recurrences (risk ratio 1.61, 1.12 to 2.32, P=0.011). Conclusions Intensive follow up after curative resection for colorectal cancer improves survival. Large trials are required to identify which components of intensive follow up are most beneficial. What is already known on this topic What is already known on this topic There is a lack of direct evidence that intensive follow up after initial curative treatment for colorectal cancer leads to increased survivalGuidelines are inconclusive and clinical practice varies widely What this study adds What this study adds The cumulative analysis of available data supports the view that intensive follow up after curative resection for colorectal cancer improves survivalIf computed tomography and frequent measurements of serum carcinoembryonic antigen are used during follow up mortality related to cancer is reduced by 9-13% This survival benefit is partly attributable to the earlier detection of all recurrences, particularly the increased detection of isolated recurrent disease
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... However, there is still an ongoing debate on the appropriate management of recurrent CRC patients. Although there is an opinion supporting aggressive management of these patients to improve the outcome, another strategy is the intensive follow-up of the patients [3,8]. Thus, establishing the role of FDG PET-CT in predicting survival outcomes of recurrent CRC patients can help to clarify the most efficient management protocol. ...
Prognostic value of FDG PET-CT in suspected recurrence of colorectal carcinoma: survival outcomes of a 10-year follow-up: FDG PET in recurrent colorectal CA
Article
  • Oct 2021
Objective We aimed to evaluate the predictive value of FDG PET-CT scan and CEA measurements in recurrent colorectal cancer (CRC) patients.Methods The records of 211 CRC patients who had FDG PET-CT scans between April 2009 and June 2011 due to suspicion of recurrence were extracted from the data of our previous report of 235 patients after 24 patients were excluded from the study due to lack of follow-up data or death unrelated to CRC. FDG PET-CT findings, simultaneous CEA levels, and survival data were evaluated retrospectively to determine the prognostic factors that affected the overall survival (OS) of the patients.ResultsThe mean age of 211 patients was 60.2 ± 12.8 years. The median follow-up time was 39 months (CI 95%: 4–123 months). The CRC-related death rate was 71.6% and the median OS time was measured 39 months (CI 95%: 27–50 months) for 211 patients. The median OS time for the patients with positive findings for recurrence in PET scans was 28 months (CI 95%: 22–33 months) which was significantly shorter (p < 0.001) than that of PET-negative patients (median OS was not reached; mean OS: 105 months; CI 95%: 95–116 months). CEA positivity also had a significant negative effect on survival (p < 0.001). Median OS times in patients with elevated and normal levels of CEA were 24 months (CI 95%: 17–30 months) and 85 months (CI 95%: 62–107 months), respectively. When the effect of CEA positivity was evaluated in patients with negative PET scans for recurrence, no statistically significant difference was determined (p = 0.209), but PET positivity had a significant negative effect on OS in patients with normal levels of CEA (p < 0.001). On the other hand, PET negativity had a significant positive effect on OS in patients with elevated CEA levels (p = 0.002). The extend of recurrent disease had also a significant effect on OS. The patients with distant metastasis had less favorable OS than those patients with only local recurrence (p < 0.001). The presence of liver metastasis also diminished the OS, but this effect was not statistically significant (p = 0.177).ConclusionFDG PET-CT scan which is a reliable imaging method to detect recurrence in CRC patients, regardless of CEA levels, can also provide valuable prognostic information, even superior to that of CEA measurement.
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... 1 Approximately 20% of all patients with colorectal cancer are diagnosed with stage IV cancer, and approximately 80% of those patients cannot undergo curative resection of the distant metastasis. 2,3 The effectiveness of palliative primary tumor resection (PTR) for incurable stage IV patients is still controversial. 4-6 PTR could prevent tumor-related complications, such as intestinal obstruction, perforation, bleeding, or fistula. ...
Impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer: A multicenter retrospective cohort study
Article
Full-text available
  • Jan 2021
Aims Primary tumor resection for patients with incurable stage IV colorectal cancer can prevent tumor‐related complications but may cause postoperative complications. Postoperative complications delay the administration of chemotherapy and can lead to the spread of malignancy. However, the impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer remains unclear. Therefore, this study aimed to investigate how postoperative complications after primary tumor resection affect survival in this patient group. Methods We reviewed data on 966 patients with stage IV colorectal cancer who underwent palliative primary tumor resection between January 2006 and December 2007. We examined the association between major complications (National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 grade 3 or more) and overall survival using Cox proportional hazard model and explored risk factors associated with major complications using multivariable logistic regression analysis. Results Ninety‐three patients (9.6%) had major complications. The 2‐year overall survival rate was 32.7% in the group with major complications and 50.3% in the group with no major complications. Patients with major complications had a significantly poorer prognosis than those without major complications (hazard ratio: 1.62; 95% confidence interval: 1.21‐2.18; P < .01). Male, rectal tumor, and open surgery were identified to be risk factors for major complications. Conclusions Postoperative complications after primary tumor resection was associated with decreased long‐term survival in patients with incurable stage IV colorectal cancer.
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... Despite the common belief among the oncology community that aggressive management of oligo-metastatic disease in CRC leads to better survival outcomes, significant variations in what is meant by "intensive follow-up" exist in clinical practice [5,22]; moreover, in patients with raised CEA and normal conventional investigations, there are limited data to inform appropriate management. In the current study we sought to (a) evaluate the utility of PET-CT in detecting occult disease recurrence with raised CEA and (b) establish the prognostic effects of early detection of disease recurrence. ...
Survival Outcomes in Asymptomatic Patients With Normal Conventional Imaging but Raised Carcinoembryonic Antigen Levels in Colorectal Cancer Following Positron Emission Tomography-Computed Tomography Imaging
Article
  • Oct 2016
Background: This study had two aims: (a) to evaluate the utility of fluorine 18-fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) in detecting occult disease recurrence with raised carcinoembryonic antigen (CEA) and (b) to establish the prognostic effects of early detection of disease recurrence in patients with colorectal cancer (CRC). Patients and methods: Clinico-pathological data were obtained from all consecutive patients undergoing CRC surveillance from 2004 to 2010 who had an elevated CEA level (>3 ng/mL in nonsmokers, >5 ng/mL in smokers) but normal or equivocal conventional investigations. Histopathological confirmation or a minimum of 12 months' clinical and radiological follow-up were required to ascertain disease relapse. Results: A total of 1,200 patients were screened; of those, 88 (59% men; mean age, 66 years [SD, 9.6]) eligible patients (67 with normal and 21 with equivocal results on conventional investigations) were identified. Recurrent disease was detected in 56 of 88 patients (64%). The sensitivity of FDG PET-CT to detect recurrence was 49 of 56 (88%; 95% confidence interval [CI], 76%-95%) and specificity was 28 of 32 (88%; 95% CI, 71%-97%). Twenty-seven of 49 (55%) patients with PET-CT-detected relapsed disease were deemed eligible for further curative therapy; 19 (70%) went on to receive potentially curative therapy. The median time to progression (8.8 months [interquartile range (IQR), 4.5-19.1 months] vs. 2.2 months [IQR, 0.7-5.6]), median overall survival (39.9 months [IQR, 23.6-65.4 months] vs. 15.6 months [IQR, 7.3-25.7 months]), and 5-year survival (36.8% [95% CI, 16.5%-57.5%] vs. 6.1% [95% CI, 1.1%-17.6%]; p ≤ .001) were higher in patients who received potentially curative therapy than in those who received noncurative therapy. Conclusion: FDG PET-CT is a highly sensitive and specific tool for the detection of occult CRC recurrence. In >50% of patients, recurrent disease may still be potentially amenable to curative therapy. Long-term survival can be achieved in such patients. Implications for practice: Colorectal cancer (CRC) patients who, on follow-up, have normal or equivocal results on clinical investigations but raised carcinoembryonic antigen (CEA) levels pose a significant challenge to treating physicians. This study supported the notion that the early use of fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) may have predictive and prognostic value in management of such patients. Long-term disease control and cure can be achieved in a subgroup of this patient population with low-volume disease relapse who are amenable to potentially curative treatment strategies. Reassuringly, the sensitivity and specificity for recurrence did not significantly vary as a function of the CEA level, suggesting that even with a minimal CEA rise, benefit can be attained by conducting FDG PET-CT in a timely manner.
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... Colorectal cancer is common [1,2]. Late presentation with metastases occurs in 20-25% of patients [3,4]. There is controversy regarding the management of incurable Stage IV colorectal cancer. ...
Palliative resection of the primary tumour in patients with Stage IV colorectal cancer: Systematic review and meta-analysis of the early outcome after laparoscopic and open colectomy
Article
Full-text available
  • Apr 2013
  • COLORECTAL DIS
Resection of the primary tumour in patients with stage IV colorectal cancer may be performed for related local symptoms to avoid future tumour-related complications whilst on systemic treatment. We compared the safety and efficacy of laparoscpic and open colectomy in this patient group. Pubmed, Medline and Cochrane library were searched in the English literature for studies between January 2000 to October 2012 dealing with the laparoscopic resection of the primary tumour in Stage IV disease. Single-arm laparoscopic studies were systematically reviewed. Prospective and retrospective studies were included for meta-analysis. Endpoints include safety, complications, mortality an cancer specific outcome including 5-year and median survival. Eleven studies comprising 1165 patients undergoing palliative laparoscopic colectomy for stage IV colorectal cancer were included. Five studies were comparative studies of laparoscopic and open colectomy. The former took longer (Pooled mean difference (MD) = 41.52; 95% CI = 11.47 to 71.56; Z = 2.71; p = 0.007), but resulted in shorter length of stay (Pooled MD = -2.41; 95% CI = -3.84 to -0.99; Z = 3.32; p = 0.0009), with fewer postoperative complications (pooled odds ratio = 0.53; 95% CI = 0.32 to 0.87; Z = 2.51; p = 0.01) and less estimated blood loss (Pooled MD = -47.71; 95% CI = -80.00 to -15.42; Z = 2.90; p = 0.004). Median survival ranged between 11.4 and 30.1 months. Palliative colectomy performed laparoscopically is safe and is associated with a better perioperative outcome than open colectomy. The survival in this group of patients remains dependant on the response to systemic chemotherapy. This article is protected by copyright. All rights reserved.
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Medical Needs
Chapter
  • Jan 2003
Due its relative low cost, safety and availability, conventional ultrasound (US) remains the most widely used cross-sectional imaging modality in routine clinical practice worldwide. Recent advances in nonlinear imaging together with a whole new generation of echo-enhancing agents have improved the clinical applications of US. Indeed there are now increasing reports of single-and multicenter studies confirming improved detection and characterization of focal liver lesions with contrast-enhanced US (Albrecht et al. 2001; Bernatik et al. 2001; Needleman et al. 2000; Wilson et al. 2000; Leen et al. 2002a). In a study comparing unenhanced versus contrast-enhanced US in the detection of liver metastases, the average number of confirmed metastases increased from 3.06 to 5.42 following contrast administration; the sensitivity for detecting individual metastases significantly improved from 63% to 91 %.
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The follow-up in colorectal cancer
Chapter
  • Jan 1999
After an overview of the various procedures best able to achieve early diagnosis of recurrence of colorectal cancer, two different follow-up plans were compared in 207 consecutive patients, who had undergone curative resections for primary untreated large bowel carcinoma, at Parma University’s Istituto di Clinica Chirurgica Generale e Terapia Chirurgica. The intense follow-up led to more frequent identification of local recurrences without distant metastases, and to the detection of local recurrences in a high percentage of cases with as yet no manifestation of symptoms clearly indicative of recurrence. The intense follow-up led to a greater number of re-resections for local recurrences than those performed in the control group submitted to conventional follow-up (17 versus 2; p<0.01), and we observed an improved 5-year survival in patients undergoing intense follow-up (73.1% versus 58.3%; p<0.02).
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Can postoperative surveillance with serial CEA immunoscintigraphy detect resectable rectal cancer recurrence and potentially improve tumor-free survival? 1 1 Dr Goldenberg is a member of the board of Immunomedics and a shareholder. Immunomedics markets CEA-Scan (arcitumomab)
Article
  • Dec 2000
Background: This study was performed to determine if postoperative serial monitoring of rectal cancer patients can be performed with an immunoscintigraphic imaging test for carcinoembryonic antigen (CEA). It was also of interest to assess whether this test, in combination with standard monitoring procedures used in an intensive surveillance plan, can result in the identification of surgically salvageable patients. Study design: Forty consecutive resected Dukes' B and C rectal cancer patients underwent a prospective, single-institution, surveillance trial of physical examination (including digital rectal examination), endoscopy, CT of the abdomen and pelvis, liver ultrasound, chest x-ray, blood CEA, and CEA immunoscintigraphy with arcitumomab (CEA-Scan, Immunomedics, Morris Plains, NJ) every 6 months for the first 2 years and every 12 months for the next 3 years after initial operation. Outcomes were compared with those from a similar group of 69 patients treated previously at the same institution but without CEA imaging. Results: A total of 219 CEA imaging studies were performed without any significant adverse effects or immune responses, and resulted in lesion sensitivity, specificity, accuracy, and positive and negative predictive values of 94.1%, 97.5%, 97.3%, 76.2%, and 99.5%, respectively. Of the 40 patients, 16 developed 22 surgically confirmed local or distant recurrences, and CEA imaging correctly disclosed 82% of these lesions pre-operatively. All of the patients found to have recurrences had at least one tumor site by CEA imaging; only 6 of 16 had elevated blood CEA titers. On a patient-basis, there was a sensitivity of 100%, a specificity of 79.2%, an accuracy of 87.5%, and positive and negative predictive values of 76.2% and 100%, respectively. The potential therapeutic benefit of serial arcitumomab imaging is suggested by the fact that 6 of 16 patients (37.5%) with recurrence underwent potentially curative second-look operations, compared with 6 of 69 (8.7%) of a comparable population studied at this institution during an earlier 6-year period, using all of the same tests except CEA imaging. None of the patients in this historic control group survived more than 21 months, although the mean survival of the six patients resected for cure in the study population was 35 months (range 11 to 69 months). During 6 years of followup, three of the six re-resected patients eventually died of cancer recurrence, two died from other causes (and were confirmed by necropsy to be tumor-free), and one patient is still free of disease in the sixth year. CEA scanning appeared to be more predictive of recurrence than blood CEA testing or other diagnostic modalities. Conclusions: Arcitumomab inclusion in intensive surveillance of patients with resected rectal cancer can disclose tumor recurrence at a stage that allowed surgical salvage therapy in 37.5% of the 16 patients with recurrence who had second-look surgery, and in 19% the patients were free of disease during longterm followup. This pilot study suggests that a randomized prospective trial comparing standard surveillance procedures to the use of CEA imaging added thereto should be undertaken.
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Die Anti-CEA-Immunszintigraphie ermöglicht den Nachweis kolorektaler Karzinome in einem potenziell kurativ behandelbaren Stadium
Article
  • Feb 2000
  • Coloproctology
Locoregional recurrence of resected rectal cancer occurs in 7 to 33% of patients.Data suggest surgery to be the best prospect of cure if recurrent disease can be identified early and accurately. Goal of this study was to determine if an immunoscintigraphic imaging test for carcinoembryonic antigen (CEA), when added to other intensive surveillance procedures, can result in the identification of surgically salvageable patients. Forty consecutive resected Dukes' B and C rectal cancer patients underwent a prospective, single-institution, surveillance trial of endoscopy, CT, ultrasound, chest X-ray, blood CEA, and CEA immunoscintigraphy with CEA-Scan? every 6 months for the first 2 years and every 12 months for the next 3 years post initial surgery. Of the 40 patients, 16 developed 22 surgically confirmed local or distant recurrences. A total of 219 CEA imaging studies were performed without any significant adverse effects or immune response, and resulted in a lesion sensitivity, specificity, accuracy, and positive and negative predictive values of 94.1, 97.5, 97.3, 76.2, and 99.5%, respectively. The therapeutic benefit of serial CEA-Scan? imaging is demonstrated by 6 (37.5%) of 16 patients with recurrence undergoing potentially curative second-look surgery, compared to 6 of 69 (8.7%) of a comparable population studied at this institution during a prior 6-year period. During a 6-year follow-up, half of the 6 re-resected patients died of cancer recurrence, 2 of other causes, and 1 is still free of disease in the 6th year, computing to a mean disease-free survival of 41 months (range 11 to 69 months). The inclusion of CEA-Scan? in intensive surveillance of patients with resected rectal cancer can disclose tumor recurrence at a stage that allows surgical salvage therapy in over 30% of the re-resected patients.
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Current Follow-Up Strategies after Resection of Colon Cancer
Article
  • Jun 1994
The follow-up of patients after potentially curative resection of colon cancer has important clinical and financial implications for patients and society, yet the ideal surveillance strategy is unknown. PURPOSE: The aim of this study was to determine the current follow-up practice pattern of a large, diverse group of experts. METHODS: The 1,663 members of The American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request nine discrete follow-up evaluations in their patients treated for cure with TNM Stage I, II, or III colon cancer over the first five post-treatment years. These evaluations were clinic visit, complete blood count, liver function tests, serum carcinoembryonic antigen (CEA) level, chest x-ray, bone scan, computerized tomographic scan, colonoscopy, and sigmoidoscopy. RESULTS: Forty-six percent (757/1663) completed the survey and 39 percent (646/1663) provided evaluable data. The results indicate that members of The American Society of Colon and Rectal Surgeons generally conduct follow-up on their patients personally after performing colon cancer surgery (rather than sending them back to their referral source). Routine clinic visits and CEA levels are the most frequently performed items for each of the five years. The large majority (>75 percent) of surgeons see their patients every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3, 4, and 5. Approximately 80 percent of respondents obtain CEA levels every 3 to 6 months for years 1,2, and 3, and every 6 to 12 months for years 4 and 5. Colonoscopy is performed annually by 46 to 70 percent of respondents, depending on year. A chest x-ray is obtained yearly by 46 to 56 percent, depending on year. The majority of the members of The American Society of Colon and Rectal Surgeons do not routinely request computerized tomographic scan or bone scan at any time. There is great variation in the pattern of use of complete blood count and liver function tests. Members of The American Society of Colon and Rectal Surgeons from the United States tend to follow their patients more closely than do those living in other countries. The intensity of follow-up does not markedly vary across TNM Stages I to III. CONCLUSION: The surveillance strategies reported here rely most heavily on clinic visits and CEA level determinations, generally reflecting guidelines previously proposed in the current literature.
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Follow-up of patients operated on for colorectal carcinoma
Article
  • Jul 1990
  • AM J SURG
In order to evaluate the effectiveness of follow-up in detecting potentially curable recurrences after radical surgery for colorectal cancer, we compared the results in 368 patients undergoing regular follow-up with those in 139 patients outside the follow-up program. The cancer-related 5-year survival rate was 72% in the follow-up group and 62% in the non-follow-up group (difference not significant). Cancer recurrences were more common in the follow-up group than in the group that was not followed (32% versus 21%; p less than 0.02). Curative reoperations were performed in 21% and 7%, respectively (p less than 0.01) of patients with recurrent cancer in these two groups. The cancer-related 5-year survival rate after curative reoperations was 47%. Despite these differences, only the initial Dukes' classification had an independent influence on the survival rate. It is concluded that regular follow-up detects more recurrent cancers, enabling radical reoperations significantly more often than when there is no follow-up. The outcome after curative reoperations is encouraging. These aspects favor regular follow-up of patients with colorectal carcinoma after curative operations.
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Follow-Up After Radical Surgery for Colorectal Cancer. Design of a Randomized Study
Article
  • Feb 1988
  • Scand J Gastroenterol Suppl
The value of different follow-up examinations after radical surgery for colorectal cancer has not been proven. The risk of such programmes, including invasive examinations, may invalidate the possible benefit from early diagnosis of recurrent and metachronous cancer. The present trial is a randomized study, evaluating possible benefit from a very detailed programme compared to that of virtually no follow-up. The design is presented, but so far no more than 207 of the 600 patients wanted for trial, have been included. Differences in mortality rates, survival and morbidity will be evaluated and the influence of repeated polypectomy upon risk of metachronous colorectal cancer will also be estimated.
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Follow-up after colorectal cancer - current practice in Wales and South West England
Article
  • Jul 1987
The necessity for follow-up after curative resection of colorectal cancer remains controversial. Many studies have failed to demonstrate the increase in survival which might be anticipated when detailed follow-up methods are used. In the United Kingdom no single policy has evolved. This study has examined, therefore, the current follow-up practice of a large group of British surgeons. Six per cent carried out no routine postoperative follow-up and there was great variation in the methods used and the regularity of visits. There is a need for a rational policy based on controlled studies to determine whether follow-up is of benefit to the patient and to identify the most effective methods.
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Improved Survival after Colorectal Cancer in Patients Complying with a Postoperative Endoscopic Surveillance Program
Article
  • Sep 1994
This study investigates whether compliance with a postoperative surveillance program in patients with surgically treated colorectal cancer leads to prolongation of life. The clinical course of 212 patients who had undergone curative resections for colorectal cancer was monitored for at least five years. Eighty-eight patients adhered strictly to a rigid endoscopic surveillance program, and 124 did not. Tumor recurrences occurred in 10% of compliant and 14% of noncompliant patients. Patients with asymptomatic tumor recurrences survived significantly longer (p < 0.05; five-year actuarial survival: 42%) than those who were symptomatic (five-year actuarial survival: 8%). The overall survival rate was significantly higher (p < 0.0002) in compliant patients (five-year actuarial survival: 80%) than in noncompliant patients (five-year actuarial survival: 59%). Noncompliance increased the risk of early death by a factor of 2.5 (95% CI = 1.5; 4.2). It is concluded that postoperative endoscopic surveillance leads to early tumor detection, and is associated with an improvement in survival in patients with colorectal cancer.
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Follow-Up of Patients with Colorectal Cancer A Meta-Analysis
Article
  • Mar 1994
The authors sought to determine whether intensive follow-up improves 5-year survival rates in patients with colorectal cancer who were operated on for cure. Intensive follow-up of patients with colorectal cancer is still controversial. The present uncertainty in regard to the value of intensive follow-up could be the result of the absence of prospective randomized studies comparing patients with and without follow-up. Studies comparing two follow-up programs of different intensities were identified in the medical literature and were aggregated in a meta-analysis using the "random effects method." Seven nonrandomized studies describing 3283 patients were analyzed. Patients with intensive follow-up did have 9% better 5-year survival rates than did those with minimal or no follow-up, only when intensive follow-up included carcinoembryonic antigen (CEA) assays. In addition, more asymptomatic recurrences were detected and more recurrences were resected in patients with intensive follow-up. This meta-analysis indicated that intensive follow-up using CEA assays can identify treatable recurrences at a relatively early stage. Treatment of these recurrences appears to be associated with improved 5-year survival rates. However, not all intensive follow-up strategies will be equally effective. Follow-up may yield the best results if diagnostic tests are used only to detect those recurrences that can be operated on with curative intent and when follow-up is "individualized," according to patient characteristics.
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Current follow-up strategies after resection of colon cancer. Results of a survey of members of the American Society of Colon and Rectal Surgeons
Article
  • Jul 1994
The follow-up of patients after potentially curative resection of colon cancer has important clinical and financial implications for patients and society, yet the ideal surveillance strategy is unknown. The aim of this study was to determine the current follow-up practice pattern of a large, diverse group of experts. The 1,663 members of The American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request nine discrete follow-up evaluations in their patients treated for cure with TNM Stage I, II, or III colon cancer over the first five posttreatment years. These evaluations were clinic visit, complete blood count, liver function tests, serum carcinoembryonic antigen (CEA) level, chest x-ray, bone scan, computerized tomographic scan, colonoscopy, and sigmoidoscopy. Forty-six percent (757/1663) completed the survey and 39 percent (646/1663) provided evaluable data. The results indicate that members of The American Society of Colon and Rectal Surgeons generally conduct follow-up on their patients personally after performing colon cancer surgery (rather than sending them back to their referral source). Routine clinic visits and CEA levels are the most frequently performed items for each of the five years. The large majority (> 75 percent) of surgeons see their patients every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3, 4, and 5. Approximately 80 percent of respondents obtain CEA levels every 3 to 6 months for years 1, 2, and 3, and every 6 to 12 months for years 4 and 5. Colonoscopy is performed annually by 46 to 70 percent of respondents, depending on year. A chest x-ray is obtained yearly by 46 to 56 percent, depending on year. The majority of the members of The American Society of Colon and Rectal Surgeons do not routinely request computerized tomographic scan or bone scan at any time. There is great variation in the pattern of use of complete blood count and liver function tests. Members of The American Society of Colon and Rectal Surgeons from the United States tend to follow their patients more closely than do those living in other countries. The intensity of follow-up does not markedly vary across TNM Stages I to III. The surveillance strategies reported here rely most heavily on clinic visits and CEA level determinations, generally reflecting guidelines previously proposed in the current literature.
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