Colorectal Cancer Surveillance:

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Colorectal Cancer Surveillance 2005
Update Clinical Practice Guideline
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Introduction

• The 2005 guidelines are designed for the
  surveillance of patients following treatment for
  stage II or III colorectal cancer.
• Occasionally, guidelines for colon and rectal
  cancer may differ.
•  
• The rationale for the guideline is finding the
  balance between identifying curable recurrences
  and minimizing ineffective tests and the costs
  associated with them.
•  
• The panel limited its attention to sporadic cases
  of colon and rectal cancer. Patients with
  hereditable cancers may need more frequent
  attention.

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Background

• Estimated colorectal cancer cases (U.S.), 2005
  145,290
• 60 of these patients will present with stage II
  or III disease
• 35 to 40 of them will recur with metastatic or
  locally invasive disease
•  
• Hundreds of thousands of people with resected
  colorectal cancer are candidates for
  surveillance.

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Background (contd)

• The majority of recurrences in patients who have
  undergone a complete resection of a colorectal
  cancer will occur within 5 years, and usually
  within 3 years of surgery.
•  
• Because metastatic disease is usually fatal,
  effort has been focused on finding recurrences
  before symptoms develop, at a stage when another
  curative resection is still possible.

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Benefits from the Resection of Metastatic
Colorectal Cancer

• One third or more of patients with liver
  metastases can be cured with resection
• Over 50 percent of lung metastases can be cured
  by surgery

Fong Y, Cohen AM, Fortner JG, et al. Liver
resection for colorectal metastases. J Clin
Oncol. 1997 Mar15(3)938-46.
Kato T, Yasui K, Hirai T, et al. Therapeutic
results for hepatic metastasis of colorectal
cancer with special reference to effectiveness of
hepatectomy analysis of prognostic factors for
763 cases recorded at 18 institutions. Dis Colon
Rectum. 2003 Oct46(10 Suppl)S22-31.
Ike H, Shimada H, Ohki S, et al. Results of
aggressive resection of lung metastases from
colorectal carcinoma detected by intensive
follow-up. Dis Colon Rectum. 2002
Apr45(4)468-73.
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Background (contd)

• The findings from studies of postoperative
  monitoring in colorectal cancer have varied
  widely, leading to
•  
• Considerable variation in follow-up practice.
• Wide variation in follow-up costs.

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?

A 28-fold difference between Medicare-allowed
charges over a 5-year period ranged from 561 to
16,492
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Guideline Methodology

• An ASCO Expert Panel completed a review and
  analysis of data published since 1999
• MEDLINE
• Cochrane Collaboration Library

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2005 Categories of Recommendations (5) for
Colorectal Cancer Surveillance

• History and physical examination and risk
  assessment
• Laboratory tests
• Imaging Procedures
• Endoscopic surveillance techniques
• Laboratory-based prognostic and predictive
  factors

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History and Physical and Risk Assessment2005
Recommendations

• Coordinating physician visits
• Every 3-6 months during years 1, 2, 3
• Every 6 months during years 4, 5
• Subsequently, physicians discretion

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History and Physical and Risk Assessment2005
Recommendations (contd)

• Focus on initial risk assessment
• Implement surveillance strategy periodic
  counseling based on
• Estimated risk
• Feasibility of surgical interventions

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History and Physical and Risk AssessmentRationale
and Considerations

• 85 of colon cancer recurrences are diagnosed
  within the first 3 years after surgical resection
  of the primary tumor.
• The frequency, duration, and benefit of the
  follow-up visit itself have never been formally
  tested however, the concept of a risk-based
  plan, and the tools to formulate it, have
  improved.
• Longer follow-up may be appropriate for locally
  advanced rectal cancer patients with poor
  prognostic factors due to continuing risk of
  recurrence after 5 years.

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History and Physical and Risk AssessmentRationale
and Considerations (contd)

• Currently, other than stage and subsets within a
  stage, there is no single pathologic feature or
  statistical model that can be used to build a
  surveillance strategy.
• The Mayo Clinic calculator
• http//www.mayoclinic.com/calcs or
• http//www.adjuvantonline.com
• estimates 5-year relapse-free survival both with
  and without treatment using data available on
  most pathology reports.

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History and Physical and Risk AssessmentRationale
and Considerations (contd)
Data from Mayo Clinic Calculator
Selected Prognostic Factors and 5-Yr. RFS () Selected Prognostic Factors and 5-Yr. RFS ()
Prognostic Factors 5-yr. RFS ()
T3N0 (11-20 nodes analyzed) 79
T3N0 low grade 73
T3N0 (lt10 lymph nodes examined) 72
T3N0 high grade 65
T4N0 low grade 60
T4N0 high grade 51
T3N1 49
T3N2 15
Results were derived from the Mayo Clinic calculator using a referent age of 60-69 years. Survival results did not consider treatment benefits all stages in this table are M0. Data regarding numbers of lymph nodes analyzed came from Le Voyer et al. Results were derived from the Mayo Clinic calculator using a referent age of 60-69 years. Survival results did not consider treatment benefits all stages in this table are M0. Data regarding numbers of lymph nodes analyzed came from Le Voyer et al.
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Laboratory Tests2005 Recommendations

• Carcinoembryonic Antigen
• Every 3 months for at least 3 years after
  diagnosis
• If the patient is a candidate for surgery or
  systemic therapy
• Caution 5-FU-based therapy may falsely increase
  CEA values wait until adjuvant treatment is
  finished before initiating surveillance

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Laboratory Tests2005 Recommendations (contd)
CEA

• Blood Tests
• Routine blood tests (i.e., complete
• blood counts or liver function tests)
• are not recommended.
• Fecal Occult Blood Test
• Periodic fecal occult blood testing
• is not recommended.

CBC
LFTs
FOBT
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Imaging Procedures2005 Recommendations

• Computed Tomography
• Annual CT of the chest abdomen for 3 years
• Patients at higher risk, who could be candidates
  for curative-intent surgery
• Pelvic CT scan (rectal cancer)
• Especially for patients who have
• not been treated with
• radiotherapy.

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Imaging Procedures2005 Recommendations (contd)

• Chest X-Ray
• Annual chest X-rays
• are not recommended.

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Imaging ProceduresRationale and Considerations

• In patients undergoing liver imaging, there is a
  25 lower mortality compared to non-imaging
  strategies.
• Despite earlier controversy among Panel members
  about the value of chest x-rays, since the Panel
  has recommended annual CT scanning for high-risk
  patients who are candidates for resection,
  routine chest x-rays are probably not relevant.

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Qualifications to CT Recommendation

• There are no data that specify the frequency of
  CT scanning.
• CT scanning should not be routinely ordered in
  patients who would or could not undergo curative
  liver or pulmonary resection.
• The data do not justify routine pelvic imaging
  (although CT scans of the abdomen and pelvis are
  frequently ordered together).
• The Panel did not rigidly define higher risk
  the risk-based plan developed by the doctor and
  patient at the beginning of the follow-up period
  cannot be underemphasized.

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Endoscopic Surveillance Techniques2005
Recommendations

• Colonoscopy
• For the pre- or perioperative documentation
• of a cancer- and polyp-free colon.
• Normal risk a colonoscopy at 3 years
• and then, if normal, every 5 years
• thereafter.
• High-risk genetic syndromes consider the
• guideline published by the AGA.

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Endoscopic Surveillance Techniques2005
Recommendations (contd)

• Flexible Protosigmoidoscopy
• (Rectal Cancer)
• Every 6 months for 5 years
• In patients who have not
• received pelvic radiation

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Laboratory-Derived Prognostic and Predictive
Factors2005 Recommendations

• Use of molecular or cellular markers
• should not influence the surveillance
• strategy.

Cellular Markers
Molecular Markers
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Summary

• Recommended
• Coordinating physician visits
• Risk assessment
• CEA testing
• CT scans
• Colonoscopy
• Flexible proctosigmoidoscopy

• Not Recommended
• CBC
• LFT
• FOBT
• Chest X-ray
• Molecular or cellular markers

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Additional ASCO Resources

• The full text of the 2005 updated guideline is
  available at http//www.jco.org/cgi/reprint/JCO.20
  05.04.0063v1
• A Patient Guide is available at
  http//www.plwc.org/plwc/external_files/Colorectal
  _Cancer_Patient_Guide.pdf
• A Guideline Summary, Surveillance Flow Sheets for
  individual patient follow up , and links to the
  resources listed above are available online at
  http//www.asco.org/guidelines/crcfollowup

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Additional ASCO Resources (contd)Print Flow
Sheet (Rectal Cancer)
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Additional ASCO Resources (contd)Interactive
Flow Sheet (Rectal Cancer)
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ASCO Guidelines