Updated 11 August 2009

The recommended intervals for follow-up are every three months for three years, then every six months for two further years.

The follow-up provided to patients treated for colorectal cancer varies a great deal. The following suggestions are intended to encourage standardised follow-up, while maximizing benefits without wasteful use of resources. These recommendations apply to Stage II and III colorectal cancer patients who have undergone surgery with curative intent, whether or not they have also received adjuvant chemotherapy and/or radiation therapy. Most (but not all) recurrences from colorectal carcinoma occur within the first 2 to 3 years after primary therapy.

Purpose of Follow-up

1. To ensure that problems due to surgery or to therapy are identified and managed
2. To identify, at an early stage, evidence of disease recurrence which may be amenable to salvage by a secondary surgical procedure with curative intent
3. In patients with rectal carcinoma, to monitor for the possible development of recurrent disease in the pelvis or perineal scar after an abdominoperineal resection (APR), in order to manage this complication before it reaches an advanced stage
4. To detect and offer palliative therapy to patients with symptomatic recurrence. Most of these patients will present to the physician with symptoms, rather than being detected on routine follow-up
5. To detect the development of neoplastic colonic polyps, or second primary colonic or rectal neoplasms, which occur with increased frequency in patients with a prior history of colorectal cancer
6. To assess the results of therapy (outcome analysis)

Follow-up Responsibilities

Follow-up during the period of active adjuvant therapy (radiation and/or chemotherapy) will be conducted by the physician co-ordinating the adjuvant therapy (at BCCA or the Community Oncology Program). Thereafter, unless there are special concerns, follow-up is usually performed by the patient's family physician and, as appropriate, gastroenterologist or surgeon.

Specific Follow-up Recommendations

Patient Brochure: "Follow-up Program after Colorectal Cancer Treatments"

The recommended intervals for follow-up are every three months for three years, then every six months for two further years.

1. Each follow up visit should include a careful history to elicit gastrointestinal and constitutional symptomatology, including nutritional status, and physical examination with particular attention to the left supraclavicular fossa, the abdomen, liver and careful rectal evaluation (or perineal inspection and palpation in those patients who have had an APR.)
2. Routine laboratory investigations in the absence of symptoms are generally not useful. A possible exception is for the tumour marker, carcinoembryonic antigen (CEA). There is some evidence to suggest that CEA monitoring may increase the detection of patients with resectable metastases. Accordingly, if the patient's general medical status would permit consideration of resection of a solitary metastasis (usually hepatic or pulmonary), CEA should be checked at each visit. If the CEA is elevated, investigations (e.g. thoracic, abdominal imaging) should be performed to look for recurrence. This is important as a proportion of patients will relapse in a solitary site, and a proportion of these may be cured by resection. Five years following initial resection, if there is no evidence of recurrence, CEA testing should be discontinued
3. Colonoscopy should be performed either prior to surgery or within the first 12 months post surgery and then repeated at intervals of three to six years, to look for another primary colorectal malignancy or pre-malignant changes. For patients with specific genetic syndromes, the American Gastroenterological Association guidelines should be followed. Additionally, in those patients who have undergone anterior resection for Stage II (Duke's B) or III (Duke's C) rectosigmoid adenocarcinomas and who have not had radiation therapy, frequent flexible sigmoidoscopy is recommended to look for anastomotic recurrence.
   
   In persons in whom colonoscopy is not advisable or available, flexible sigmoidoscopy combined with double contrast barium enema is an alternative approach. Colonoscopy, however, is the preferred investigation, as it offers the advantage of greater accuracy and the ability to remove and/or biopsy suspicious or pre-malignant lesions.
4. The use of routine imaging may detect early metastases that would be amenable to potentially curative surgery in patients who could tolerate such a procedure. Liver imaging every 6 months for 3 years and then annually for 2 years is recommended for these patients. Chest x-ray every 6 - 12 months for 5 years is recommended for patients with rectal primaries

References:

1. Figueredo A, Rumble RB, Maroun J, et al. Follow-up of patients with curatively resected colorectal cancer: A practice guideline. BMC Cancer 2003; 3: 26
2. Renehan AG, Egger M, Saunders MP, et al. Impact on survival of intensive follow up after curative resection for colorectal cancer: Systematic review and meta-analysis of randomised trials. BMJ 2002; 324: 813.
3. Jeffery GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer. [The Cochrane Database of Systematic Reviews] Oxford, UK. The Cochrane Library 2005.
4. Desch CE, Benson AB, Somerfield MR, et al. Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol 2005; 23: 8512.
5. Van Cutsem EJD, Kataja VV. ESMO minimum clinical recommendations for diagnosis, adjuvant treatment and follow-up of colon cancer. Ann Oncol 2005; 16 (Suppl 1): i16.
6. Tveit KM, Kataja VV. ESMO minimum clinical recommendations for diagnosis, treatment and follow-up of rectal cancer. Ann Oncol 2005; 16 (Suppl 1): i20.
7. Engstrom PF, Benson AB, Chen YJ et al. NCCN colon cancer clinical practice guidelines in oncology 2006. http://www.nccn.org
8. National Institute for Clinical Excellence. Improving outcomes in colorectal cancers. 2004. http://www.nice.org.uk
9. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: Clinical guidelines and rationale —Update based on new evidence. Gastroenterology 2003; 124:544.
10. Chau I, Allen MJ, Cunningham D, et al. The value of routine serum carcino-embryonic antigen measurement and computed tomography in the surveillance of patients after adjuvant chemotherapy for colorectal cancer. J Clin Oncol 2004; 22: 1420.