CRC Return Often Tipped by Symptoms at 'Interval' Visits

Liam Davenport

May 16, 2016

Almost half of colorectal cancer recurrences are detected at unscheduled "interval" visits prompted by patients experiencing symptoms, the results of a Dutch analysis reveal.

The most prevalent symptoms were abdominal pain, altered defecation, weight loss, and pain in back or pelvis.

Laura Duineveld, MD, a primary care physician at the Academic Medical Centre, University of Amsterdam, The Netherlands, and colleagues found that only 58% of disease recurrences were detected using diagnostic tests at scheduled visits.

It is estimated that the rate of recurrence following colorectal cancer can be as high as 60%, with the majority presenting as distant metastases in the liver or lungs or as locoregional recurrence in the pelvis or peritoneum 2 to 3 years following initial treatment.

The research, published online in the Annals of Family Medicine on May 16, showed that patients with recurrence detected at interval visits had significantly worse survival than patients identified at scheduled follow-up.

The team says that, while scheduled follow-up "seems important" for the identifying recurrent disease, the number of cases detected at interval visits underlines the importance of being aware of the symptoms of recurrent disease.

They add: "Considering the fact that primary care-led follow-up might be more cost-effective and that more generalist care is desired in the care of patients after their initial treatment, the role of coordinating follow-up care might be shifted toward primary care physicians."

Speaking to Medscape Medical News, Dr Duineveld said that it is important that primary care physicians adhere to the follow-up schedule for colorectal cancer patients, "because it finds a lot of recurrent disease."

Furthermore, physicians "should ask whether a patient has complaints and report all their signs and symptoms," as that will help to ensure that more recurrences are picked up during visits, she said.

The team conducted a retrospective analysis of all colorectal cancer patients with stage I through stage III disease operated on between 2007 and 2012 at two hospitals in The Netherlands and who had scheduled follow-up.

Dutch guidelines state that scheduled follow-up should include carcinoembryonic antigen testing every 3 to 6 months during the first 3 years and every 6 months for the next 2 years, with a cut-off of 5.5 µg/L. Abdominal imaging was performed every 6 months for 2 years, and then annually for the next 3 years.

Of 823 colorectal cancer patients operated on during the study period, 446 were included in the final analysis, of whom 93 (21%) had stage I disease, 176 (39%) stage II disease, and 176 (39%) stage III carcinoma.

The median follow-up time was 34 months, and 338 (87%) were followed-up for at least 2 years. Recurrent disease developed in 74 (17%) of patients, of whom 35 were female.

Recurrences were detected during scheduled follow-up visits in 43 (58%) of cases. All cases were identified on routine diagnostic testing, and 41 were recorded as asymptomatic. The median time to recurrence detection was 13.7 months.

In 22 (47.8%) of cases, the recurrence location was the liver, while it was the peritoneum in 10 (21.7%) patients, the lung in nine (19.6%) cases, and local in 12 (26.1%) patients.

Thirty one (42%) of recurrences were detected on interval visits, the majority of which were due to the presence of symptoms suggestive of recurrent disease. Nine symptomatic patients presented at the emergency department, while two were referred to the hospital by their primary care physicians.

The most prevalent symptoms were abdominal pain (n = 15, 57.7%), altered defecation (n = 11, 42.3%), weight loss (n = 6, 23.1%), and pain in back or pelvis (n = 4, 15.4).

There were few differences between patients with symptomatic recurrences and those with asymptomatic recurrences, except that the site of recurrence was significantly less likely to be the liver and significantly more likely to be the lymph nodes, and in more than one location in patients with symptomatic recurrences.

Nevertheless, the researchers found that overall survival was significantly worse for patients with symptomatic than those with asymptomatic recurrences (P = .001).

Given that there were few differences between the two groups, Dr Duineveld suspects that patient symptoms may have been under-reported for the recurrences detected at scheduled follow-up.

Moreover, physicians should ensure that patients attend all of their scheduled visits. "If someone doesn't show up, for example, just be sure that he shows and gets his follow-up diagnostic tests," she emphasized.

The authors have disclosed no relevant financial relationships.

Ann Fam Med. Published online May 16, 2016. Full text