Guidelines for Follow-up of Colorectal Cancer Patients

Zosia Chustecka

November 14, 2013

Once patients with colorectal cancer finish their treatment, they are often discharged from specialist care, and their follow-up is carried out by community-based family physicians or institution-based nurse-coordinated care. As there is a transfer of responsibilities, it is important to have guidelines for the follow-up of these patients. A new set was published November 12 in the Journal of Clinical Oncology as a special article from the American Society of Clinical Oncology (ASCO).

The guidelines were prepared by Cancer Care Ontario, and ASCO has reviewed and endorsed them and added a few qualifying statements.

"A treatment plan from the specialist should be sent to the patient's other providers, particularly the primary care physician, and it should have clear directions on appropriate follow-up," the guidelines state.

The surveillance measures proposed in the guidelines apply to survivors of colorectal cancer stages II and III, and not to patients with stage I or with resected metastatic disease, as both of these have minimal data to provide guidance.

In addition, these surveillance measures only apply to patients who are candidates for further surgery or systemic therapy. If the patient has severe comorbid conditions that would preclude further treatment, these surveillance tests should not be performed, the guideline authors comment.

Surveillance Important for 2 to 4 Years

Surveillance is especially important in the first 2 to 4 years after treatment, the guidelines note, citing data showing that 80% of recurrences occur in the first 2 to 2.5 years from the date of surgery, and 95% of recurrences occur within 5 years.

Hence, the guidelines propose that patients are followed for 5 years, with regular reviews of medical history, physical examination, and carcinoembryonic antigen testing performed every 3 to 6 months.

In addition, CT scans of the abdomen and chest are recommended annually for 3 years. However, PET scans are not recommended outside of clinical trials.

For patients with rectal cancer, a pelvic CT is also recommended, for example, annually for 3 to 5 years, although clinical judgment should be used when deciding on frequency, the guidelines state. For patients who have not received pelvic radiation, a rectosigmoidoscopy should be performed every 6 months for 2 to 5 years.

A surveillance colonoscopy is recommended approximately 1 year after initial surgery. The timing of subsequent colonoscopies will depend on the results, but if all looks fine, they are generally performed every 5 years.

However, there is no need to wait for a year in patients who did not have a colonoscopy performed before diagnosis, the ASCO editors note in their qualifying comments. In these cases, a colonoscopy should be performed as soon as is reasonable after completion of adjuvant therapy.

In addition, patients should be counseled on maintaining a healthy body weight, being physically active, and eating a healthy diet, the guidelines state.

The ASCO editors add a few notes to this, suggesting that patients should be encouraged to follow recommendations from the American College of Sports Medicine to try to engage in at least 150 minutes a week of moderate-intensity or 75 minutes of high-intensity exercise each week. "However, any level of activity that the patient can do is considered better than being physically inactive," they add.

In addition, the ASCO editors add a note about chemoprevention, and comment that there is uncertainty over the benefit of regular use of aspirin or a cyclooxygenase inhibitor in colorectal cancer survivors. There is a randomized trial in progress investigating celecoxib in this patient population.

The authors have disclosed no relevant financial relationships.

J Clin Oncol. Published online November 12, 2013. Abstract

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