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Summary of professional guidelines regarding posttreatment surveillance for resected colon and rectal cancer

Summary of professional guidelines regarding posttreatment surveillance for resected colon and rectal cancer
Organization History and physical examination CEA testing CT scanning Endoscopic surveillance Comments
ASCO[1] and CCO[2] Every 3 to 6 months for 5 years. Every 3 to 6 months for 5 years. Abdomen and chest annually for 3 years; pelvis: rectal cancer only, annually for 3 to 5 years. Colonoscopy at 1 year*; subsequent studies dictated by prior findings. If negative, every 5 years. Proctosigmoidoscopy every 6 months for 2 to 5 years if rectal cancer and no pelvic RT. Posttreatment surveillance strategy guided by the estimated risk of recurrence and functional status. These recommendations are for resected stage II and III colon and rectal cancer. Recommendations not provided for resected stage I or IV disease due to lack of data to guide recommendation.
American Cancer Society[3] Every 3 to 6 months for the first 2 years, then every 6 months to 5 years. Every 3 to 6 months for the first 2 years, then every 6 months to 5 years if the patient is a potential candidate for further intervention. Abdomen/pelvis and chest every 12 months for 5 years for stage III and high-risk stage I/II disease.  Colonoscopy in year 1; if advanced adenoma, repeat in 1 year; otherwise, repeat in 3 years. If no advanced adenoma in year 4, repeat every 5 years. High-risk stage I/II disease not defined.  
NCCN[4] Every 3 to 6 months for 2 years, then every 6 months for 3 years. Every 3 to 6 months for 2 years for ≥T2 disease, then every 6 months for 3 years. For resected metastatic disease, every 3 to 6 months for 2 years, then every 6 months for 3 to 5 years.

Colon: Abdomen/pelvis and chest every 6 to 12 months for up to 5 years for those at high risk of recurrence. For rectal cancer, CT chest/abdomen and pelvis every 3 to 6 months for 2 years, then every 6 to 12 months for up to 5 years for those at high risk of recurrence. For resected metastatic disease, CT abdomen/pelvis and chest every 3 to 6 months for 2 years, then every 6 to 12 months up to a total of 5 years.

Colonoscopy at 1 yearΔ; subsequent studies dictated by prior findings. If no advanced adenoma, repeat at 3 years, then every 5 years; if advanced adenoma at 1 year, repeat at 1 year.

Flexible sigmoidoscopy with EUS or MRI every 3 to 6 months for 2 years, then every 6 months to complete 5 years for patients with rectal cancer undergoing transanal excision only.

Recommendations apply to stage II, III, and resected stage IV colon cancer, and for stage I, II, III, or resected stage IV rectal cancer.
ESMO colon cancer[5] Every 3 to 6 months for 3 years, then every 6 to 12 months for 2 more years. Every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years. Abdomen, chest, and pelvis every 6 to 12 months for 3 years, then every 12 months for 2 more years. Colonoscopy at 1 year; every 3 to 5 years thereafter.

Guidelines are for localized colon cancer; do not explicitly state if applicable to resected stage I disease.

 

More intensive surveillance in first 3 years for resected metastatic disease[6]. Refer to UpToDate topic on "Surveillance after colorectal cancer resection."
ESMO rectal cancer[7] Every 6 months for 2 years◊. Every 6 months for the first 3 years. A minimum of 2 CT scans of the chest, abdomen, and pelvis in the first 3 years. Colonoscopy every 5 years up to age 75.

High-risk patients (eg, circumferential resection margin positive) may merit more proactive surveillance for local recurrence.

 

More intensive surveillance in first 3 years for resected metastatic disease[6]. Refer to UpToDate topic on "Surveillance after colorectal cancer resection."
New Zealand[8] Clinical assessment§ stratified according to risk of recurrence:
  • High-risk cancer (stage IIB, III): Every 6 to 12 months for 3 years, then annually for 2 years.
  • Lower risk (stage I, IIA), or with comorbidities restricting future surgery: Annual review for 5 years or when symptoms occur.

For high-risk cancer (stage IIB, III): Every 6 to 12 months for 3 years, then annually for 2 years.

For lower risk (stage I, IIA), or with comorbidities restricting future surgery: Annually for 5 years.		 All individuals with stages I to III colorectal cancer should have liver imaging between years 1 and 3.

Colonoscopy at 1 year¥; colonoscopy every 6 to 12 months for 3 years for high-risk patients (stages IIB, III), then annually for at least 5 years.

For low-risk patients, colonoscopy every 3 to 5 years. For rectal cancer, proctoscopy or sigmoidoscopy at 3, 6, 12, and 24 months postsurgery; colonoscopy at 3- to 5-year intervals thereafter.		 Recommendations cover stages I, II, and III colorectal cancer.
US Multi-Society Task Force on Colorectal Cancer[9]      

Colonoscopy 1 year after surgery (or 1 year after the clearing perioperative colonoscopy). The interval to the next colonoscopy should be 3 years and then 5 years. If neoplastic polyps are detected, the intervals between colonoscopies should be shorter and in accordance with published guidelines for polyp surveillance intervals[10]. These intervals do not apply to patients with Lynch syndrome.

For rectal cancer, flexible sigmoidoscopy or EUS every 3 to 6 months for the first 2 to 3 years after surgery for patients at high risk for local recurrence. Refer to UpToDate topic on "Surveillance after colorectal cancer resection."

  
British Columbia Medical Association[11] Every 3 to 6 months for 2 years, then every 6 months for 3 years. Every 3 months for 3 years, then every 6 months for 2 years. Liver ultrasound or CT scans (preferred) every 6 months for 3 years, then annually for 2 years. Annual chest CT for 3 years. Colonoscopy at 1 year; if normal, repeat 3 years later and, if normal, every 5 years thereafter. These guidelines are for resected stage II and III colon and rectal cancer. Patients with significant comorbidities, very advanced age, or limited 5-year life expectancy are not routinely offered surveillance.
 American Society of Colon and Rectal Surgeons[12] Every 3 to 12 months for 2 years, then every 6 to 12 months for 3 years.  Every 3 to 12 months for 2 years, then every 6 to 12 months for 3 years.  Twice in 5 years or up to annually for 5 years. Colonoscopy at 1 year (or 1 to 6 months after surgery if inadequate colonoscopy preoperatively, and depending on findings, repeat at 3 years, then every 5 years or more frequently as indicated). Proctoscopy ±endoscopic ultrasound every 6 to 12 months after rectal cancer resection with anastomosis (no RT), or every 6 months following local excision for 3 to 5 years. Recommendations apply to higher-risk stage I (eg, rectal cancer posttransanal excision, colorectal cancers with endoscopic excision only, or non-guideline based therapy), stage II, stage III, and stage IV disease treated by curative intent. Refer to UpToDate topic on "Surveillance after colorectal cancer resection."
CEA: carcinoembryonic antigen; CT: computed tomography; ASCO: American Society of Clinical Oncology; CCO: Cancer Care Ontario; RT: radiation therapy; NCCN: National Comprehensive Cancer Network; EUS: endoscopic ultrasound; MRI: magnetic resonance imaging; ESMO: European Society for Medical Oncology.
* Except if no preoperative colonoscopy because of obstructing lesion; do as soon as possible after completion of adjuvant chemotherapy rather than waiting until 1 year.
¶ Features suggesting a high risk of recurrence: poorly differentiated histology, lymphatic or venous invasion.
Δ Except if no preoperative colonoscopy because of obstructing lesion; recommend at 3 to 6 months rather than waiting until 1 year.
◊ Minimum provisional recommendation.
§ Clinical assessment for patients with colon cancer includes physical examination, CEA, chest/abdominal and pelvic CT scans, colonoscopy, and liver ultrasound. Clinical assessment for rectal cancer patients includes physical examination, CEA, chest/abdominal and pelvic CT scans, colonoscopy, and proctoscopy or sigmoidoscopy.
¥ If no complete colonoscopy before surgery, perform colonoscopy within 6 months.
References

  1. Meyerhardt JA, Mangu PB, Flynn PJ, et al. Follow-Up Care, Surveillance Protocol, and Secondary Prevention Measures for Survivors of Colorectal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 2013; 31:4465.
  2. Cancer Care Ontario. Available at: https://www.cancercareontario.ca/en/content/follow-care-surveillance-protocols-and-secondary-prevention-measures-survivors-colorectal-cancer.
  3. American Cancer Society Colorectal Cancer Survivorship Care Guidelines. CA Cancer J Clin 2015; 65:427.
  4. National Comprehensive Cancer Network. Available at: www.nccn.org.
  5. Argiles G, Tabernero J, Labianca R, et al. Localised colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up. Ann Oncol 2020; 31:1291.
  6. Van Cutsem E, Cervantes A, Nordlinger B, et al.  Metastatic colorectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii1.
  7. Glynne-Jones R, Wyrwicz L, Tiret E, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28 (suppl 4):iv22.
  8. Guidance on Surveillance for People at Increased Risk of Colorectal Cancer. Published by the New Zealand Guidelines Group for the Ministry of Health PO Box 10 665, Wellington 6143, New Zealand. Available at: www.health.govt.nz/publication/guidance-surveillance-people-increased-risk-colorectal-cancer.
  9. Colonoscopy surveillance after colorectal cancer resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer (American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy). Gastroenterology 2016; 150:758.
  10. Guidelines for colonoscopy surveillance after screening and polypectomy from the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 20121; 143:844.
  11. British Columbia Medial Association. Follow-up of Colorectal Polyps or Cancer (2013). Available at: www.bcguidelines.ca/pdf/colorectal_followup.pdf.
  12. Hardiman KM, Felder SI, Friedman G, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surveillance and Survivorship care of patients after curative treatment of colon and rectal cancer. Dis Colon Rectum 2021; 64:517.
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