Follow-up
of Patients after Curative Resection
of Colorectal Cancer
This guideline provides follow-up
recommendations for asymptomatic patients after curative resection of colorectal cancer. These
recommendations are intended to rationalize follow-up of the initial cancer and to prevent the development of
additional colorectal cancer. They do not apply to patients with familial adenomatous polyposis (FAP), hereditary non-polyposis colon
cancer (HNPCC) or inflammatory bowel disease. Recommendations for the detection of colorectal neoplasms in
asymptomatic patients are found in the guideline, Detection of Colorectal Neoplasms in Asymptomatic
Patients.
RECOMMENDATION
1: Clearing Colonoscopy
Ideally, colonoscopy should be
performed pre-operatively. If this is not feasible, then it may be done three
to six months post-operatively if no metastases were found. Air-contrast barium
enema combined with sigmoidoscopy
is an acceptable alternative where colonoscopy is not readily available.
RECOMMENDATION 2: Post-operative follow-up
After recovery from surgery, visits
should only be scheduled as needed. The routine use of liver enzyme tests and abdominal ultrasound is not
recommended in the absence of symptoms.
RECOMMENDATION
3: Tumour markers
The value of carcinoembryonic antigen
(CEA) testing in the post-operative period is controversial and its usefulness is therefore limited. However, in individuals who
would be candidates for resection of isolated hepatic or pulmonary metastases, serial measurement of CEA levels
post-operatively (every three months for two years) may be of value in detecting recurrence that is treatable
in up to 25 per cent of patients.
RECOMMENDATION
4: Prevention of new cancers
Repeat colonoscopy once every three
years until no new adenomas are discovered. Thereafter, repeat colonoscopy every five years until the
detection of new tumours is unlikely to influence the patient’s lifespan. Air-contrast barium enema combined with
sigmoidoscopy is an acceptable alternative where colonoscopy is not readily
available.
RECOMMENDATION 5: Low rectal cancer
For patients who have undergone low
anterior resection of rectal cancers, digital rectal examinations and proctoscopy or
sigmoidoscopy should be undertaken at three months, six months, one year and
two years to look for anastomotic recurrence. Thereafter, Recommendation 4
should be followed.
Colorectal cancer (CRC) is the second
leading cause of cancer-related deaths in North America. A number of circumstances increase the likelihood of developing CRC,
including:
previous history of CRC • history of colorectal adenomas
family history of CRC (first degree
relative) • chronic inflammatory
bowel disease
The vast majority of CRCs develop from
adenomas. In long-standing inflammatory bowel disease
cancers usually develop from non-polypoid dysplasia which
is not detected on barium enema.
Detection and removal of adenomas has
been clearly demonstrated to reduce CRC mortality, and identification of cancer at an early
stage markedly increases survival rates. Therefore, periodic surveillance of high-risk individuals
is useful to reduce CRC mortality.
The typical growth rates of adenomas suggest
that annual colonoscopy is no longer justified. The usual progression from normal mucosa to cancer is five to ten years.
“Routine” clinical and laboratory follow-up to
detect metastatic disease is seldom beneficial. In some cases, the detection of isolated liver metastases with subsequent treatment may improve
survival.
Patients with low rectal cancer have
higher rates of local recurrence and need closer surveillance
of the anastomotic site. Resection
margins for tumours above the rectum are generally wider and therefore
colonoscopy need not be performed more frequently than every three to five
years to detect anastomotic
recurrence.
1.
American Society of Clinical Oncology:
2000 Update of American Society of Clinical Oncology Colorectal Cancer Surveillance Guidelines. J Clin Oncol 2000;18:3586-8.
2.
Bond JH. Colorectal Cancer Update:
Prevention, screening, treatment and surveillance for high-risk groups. Med Clin North Am 2000;84:1163-82.
3.
Byers T, Levin B, Rothenberger D, et
al. American Cancer Society guidelines for screening and surveillance for early detection of colorectal polyps and cancer: update
1997. CA Cancer J Clin 1997;47:154-60.
4.
Fong Y, Fortner J, Sun RL, et al.
Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999;230:309-18.
5.
Lieberman D. Endoscopic
screening for colorectal cancer. Gastroenterol Clin North Am
1997;26:71-83.
6.
Rex DK. Surveillance colonoscopy
following resection of colorectal polyps and cancer. Can J
Gastroenterol 2001;15:57-9.
7.
Schoemaker D, Black R, Giles L, Toouli
J. Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer
patients. Gastroenterology 1998;114:7-14.
8.
Winawar SJ, Fletcher RH, Miller L, et
al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642.
9.
Zauber AG, Winawer SJ. Initial
management and follow-up surveillance of patients with colorectal adenomas. Gastroenterol Clin North Am 1997;26:85-101.
Effective Date: July 1, 2004