Optimal surveillance strategies for stage III colorectal cancer (CRC) are lacking, and intensive surveillance has not conferred a significant survival benefit.

To examine the association between surveillance intensity and recurrence and survival rates in patients with stage III CRC.

Data from patients with pathologic stage III CRC who underwent radical surgery between January 2005 and December 2012 at Asan Medical Center, Seoul, Korea were retrospectively reviewed. Surveillance consisted of abdominopelvic computed tomography (CT) every 6 mo and chest CT annually during the 5 year follow-up period, resulting in an average of three imaging studies per year. Patients who underwent more than the average number of imaging studies annually were categorized as high intensity (HI), and those with less than the average were categorized as low intensity (LI).

Among 1888 patients, 864 (45.8%) were in HI group. Age, sex, and location were not different between groups. HI group had more advanced T and N stage (P = 0.002, 0.010, each). Perineural invasion (PNI) was more identified in the HI group (21.4% vs 30.3%, P < 0.001). The mean overall survival (OS) and recurrence-free interval (RFI) was longer in the LI group (P < 0.001, each). Multivariate analysis indicated that surveillance intensity [odds ratio (OR) = 1.999; 95% confidence interval (CI): 1.680-2.377; P < 0.001], pathologic T stage (OR = 1.596; 95%CI: 1.197-2.127; P = 0.001), PNI (OR = 1.431; 95%CI: 1.192-1.719; P < 0.001), and circumferential resection margin (OR = 1.565; 95%CI: 1.083-2.262; P = 0.017) in rectal cancer were significantly associated with RFI. The mean post-recurrence survival (PRS) was longer in patients who received curative resection (P < 0.001). Curative resection rate of recurrence was not different between HI (29.3%) and LI (23.8%) groups (P = 0.160). PRS did not differ according to surveillance intensity (P = 0.802).

Frequent surveillance with CT scan do not improve OS in stage III CRC patients. We need to evaluate role of other surveillance method rather than frequent CT scans to detect recurrence for which curative treatment was possible because curative resection is the important to improve post-recurrence survival.

This study aimed to assess whether surveillance intensity is associated with recurrence and survival in colorectal cancer (CRC) patients. Overall, 3794 patients with pathologic stage I-III CRC who underwent radical surgery between January 2012 and December 2014 were examined. Surveillance comprised abdominopelvic computed tomography (CT) every 6 months and chest CT annually for 5 years. Patients who underwent more than and less than an average of three imaging examinations annually were assigned to the high-intensity (HI) and low-intensity (LI) groups, respectively. Demographics were similar in both groups. T and N stages were higher and perineural and lymphovascular invasion were more frequent in the HI group (p < 0.001 each). The mean overall survival (OS) was similar for both groups; however, recurrence-free survival (RFS) was longer (p < 0.001) and post-recurrence survival (PRS) was shorter (p = 0.024) in the LI group. In the multivariate analysis, surveillance intensity was associated with RFS (p < 0.001) in contrast to PRS (p = 0.731). In patients with high recurrence risk predicted using the nomogram, OS was longer in the HI group (p < 0.001). A higher imaging frequency in patients at high risk of recurrence could be expected to lead to a slight increase in PRS but does not improve OS. Therefore, rather than increasing the number of CT scans in high-risk patients, other imaging modalities or innovative approaches, such as liquid biopsy, are required.

A wide variety of follow-up strategies are used for patients with colorectal cancer (CRC) after curative surgery. The aim of this study is to review the evidence of the impact of different follow-up strategies in patients with nonmetastatic CRC after curative surgery, in relation to overall survival and other outcomes.

A systematic search of PubMed, EMBASE, SCOPUS and ISI Web of Knowledge up to June 2014 was carried out. Eligible studies were all randomized clinical trials comparing the effectiveness of different follow-up strategies after curative resection in nonmetastatic CRC.

Eleven studies with n = 4055 participants were included in a meta-analysis. A significant improvement in overall survival was observed in patients with more intensive follow-up strategies [hazard ratio = 0.75; 95% confidence interval (CI) 0.66-0.86]. A higher probability of detection of asymptomatic recurrences [relative risk (RR) = 2.59; 95% CI 1.66-4.06], curative surgery attempted at recurrences (RR = 1.98; 95% CI 1.51-2.60), survival after recurrences (RR = 2.13; 95% CI 1.24-3.69), and a shorter time in detecting recurrences (mean difference = -5.23 months; 95% CI -9.58 to -0.88) was observed in the intervention group. There were no significant differences in the total tumor recurrences, nor in the mortality related to disease.

Intensive follow-up strategies improve overall survival, increase the detection of asymptomatic recurrences and curative surgery attempted at recurrence, and are associated with a shorter time in detecting recurrences. This more intensive follow-up could not be associated with an improvement in cancer-specific survival nor with an increased detection of total tumor recurrences. Follow-up with serum carcinoembryonic antigen and colonoscopies are related to an increase in overall survival.

Recent evidence suggests that intensive follow-up after curative resection of colorectal cancer is associated with a small but significant improvement in survival. Regimens that employ cross-sectional imaging and carcinoembryonic antigen determination appear to have the greatest benefit. A risk-adapted approach to follow-up, intensively following patients at highest risk of recurrence, increases efficacy and cost-effectiveness. Ongoing improvements in risk stratification, disease detection, and treatment will increase the benefits of postoperative surveillance. Large randomized controlled trials are needed to determine the optimal surveillance regimen and must include an analysis of survival, quality of life, and cost-effectiveness to assess efficacy properly.

The role of carcinoembryonic antigen (CEA) in the early detection of recurrence during the postoperative follow-up of colorectal cancer remains unclear. We hypothesize that the tumor with longer lead time of CEA elevation to the definite recurrence may have a better prognosis because of its slower growth rate and closer observation.

From 1995 to 2003, 4,841 consecutive patients who received curative resection of localized colorectal adenocarcinoma were enrolled from a prospective database. The patients with persisting CEA elevation after operation had been already excluded. Postoperative follow-up, including physical examination, imaging, and CEA test, were performed according to a surveillance program. A CEA >/=5 ng/mL was defined as elevated. The definition of the CEA lead time was the period between CEA elevation and detection of recurrence. All statistical analyses were performed by SPSS package for Windows (Microsoft, Redmond, WA, USA).

The postoperative median follow-up time for the 4,841 patients was 68 months. A total of 999 patients (20.6%) had CEA elevation and recurrence. Among these patients, recurrence was confirmed in 727 patients (72.8%)before, at the same time, or within 3 months of CEA elevation and thus had a short lead time of CEA elevation (SLT group). In 272 patients (27.2%), recurrence was confirmed after more than 3 months of CEA elevation and thus had a longer lead time of CEA elevation (LLT group). The recurrence pattern showed similarities in these two groups. A total of 193 patients (193/999, 19.3%) received a second radical operation, and 806 patients (80.7%) were inoperable. The re-resection rate between the SLT group (146 patients, 20.1%) and the LLT group (47 patients, 17.3%) was not significantly different. The overall survival rate after recurrence showed no difference between these two groups (P = 0.123).

Most cases of recurrence were detected at nearly the same time when the CEA level was elevated. Therefore, a more sensitive test is needed for early detection. The relationship between the lead time of CEA and the clinical outcome was not statistically significant. A more aggressive approach to the patient who has CEA elevation and is highly suspect of recurrence may be needed.

The risk of a cancer recurrence has been correlated with the stage of the primary tumour at the time of presentation. However, once a recurrence has developed, the primary tumour stage may not be the determining prognostic factor anymore. The objective of this study was (i) to evaluate the association between the recurrence interval and the outcome of the recurrence, and (ii) to determine whether that interval was affected by the use of adjuvant radiation and/or chemotherapy.

This retrospective study analysed 212 patients who developed recurrent colorectal cancer from 1987 to 1993. Primary parameters such as age, gender, primary tumour site and stage, and use of postoperative adjuvant treatment were correlated with the recurrence interval, the type and site of the recurrence (i.e. locoregional vs distant metastases), and the outcome. Uni- and multivariate analysis was used to compare the recurrence interval and survival between different subgroups as defined by risk factors.

The mean time between the primary and the recurrent tumour was 25 months (range 1-252 months) with 82% of the recurrences developing within 3 years after surgery. The recurrence interval was inversely correlated with the initial tumour stage. Poor survival was associated with a short recurrence interval (less than 12 months) and a distant recurrence site. Even after adjusting for the initial tumour stage, the use of adjuvant treatment did not prolong the interval, i.e. delay the onset of recurrent cancer.

The recurrence interval of colorectal cancer is a prognostic factor. However, the use of adjuvant therapy did not prolong that interval.

Colon cancer is relatively common; however, the results of treatment have marginally improved over the last half century. Though about 85% of patients have colorectal tumors resected with curative intent, a significant number of these patients will eventually die from cancer. As a result, many clinicians have advocated intensive follow-up in such patients as an attempt to increase survival.

A review of the literature focusing on studies that have specifically addressed postoperative surveillance programs in patients with colorectal cancer was conducted. Only studies with level A evidence were included. Further references were obtained through cross-referencing the bibliography cited in each work.

One of the six prospective randomized studies demonstrated a statistically significant survival benefit. Undoubtedly, survival benefits can be shown with a well-designed evidence-based follow-up strategy. However, well-designed large prospective multi-institutional randomized studies are needed to establish a consensus for follow-up.

The optimum protocol for colonoscopic surveillance following curative resection for colorectal cancer has not been established. The aim was to assess the incidence of recurrence and metachronous tumours in our less intensive colonoscopic surveillance programme and compare our results with those reported from intensive surveillance programmes.

Colonoscopic records of patients who had surveillance colonoscopy following curative resection from April 1998 to March 2003 for cancer were available from the endoscopy department computer database. The variables studied included the tumour site, Duke's stage, number of recurrences, number of metachronous tumours, size and number of polyps and their biopsy results.

There were a total of 105 patients. Two patients were diagnosed with metachronous tumours and three with recurrence. Adenomatous polyps were identified in 24 patients of which nine had multiple/advanced adenomas (equal to or more than 1cm adenomatous polyps, or with severe dysplasia).

The risk of development of colonic pathology following curative resection for colorectal cancer is low. More intensive follow-up should be reserved for patients with additional risk of developing further cancers.

The treatment of colorectal cancer has evolved dramatically over the last 15 years. Advances in surgery, radiotherapy and chemotherapy have enabled oncologists to cure more patients and offer improved quality of life to patients not amenable to cure. Specific knowledge of colorectal cancer care of the elderly, while lagging behind the treatment of younger patients, is beginning to emerge. Informed by recent trials, the approach towards elderly patients is shifting towards more aggressive treatment and multimodal therapy. Surgeons are operating on the elderly with greater frequency, less operative mortality and greater success; 5-year survival following potentially curative surgery has risen from 50% to 67%.Research of adjunctive therapy for colorectal cancer is enrolling more elderly patients, and with this has come an understanding of the role of chemotherapeutic agents in the treatment of the elderly, used individually and within multi-drug regimens. This research offers insight into how the elderly respond to chemotherapy, informing clinicians on anticipated benefits and toxicities of treatment. Fluorouracil-based regimens, which have long been the standard adjuvant chemotherapy, have been shown to offer benefits to the elderly compared with those not receiving adjuvant chemotherapy (71% versus 64% 5-year survival), and to cause similar toxicities as seen in younger patients. The role of novel chemotherapeutic agents in the treatment of elderly patients with colorectal cancer is also emerging, with studies finding that irinotecan, in combination with a fluorouracil-based regimen, can offer a further survival benefit of over 2 months compared with fluorouracil alone. While newer agents such as capecitabine, oxaliplatin, raltitrexed and tegafur/uracil (UFT) have been focused upon by clinical researchers, data on their use in the elderly remain unconvincing. Not only are we approaching a clearer understanding of the effectiveness of cancer care among the elderly, but research is also beginning to identify the cost effectiveness of both standard and emerging chemotherapeutic agents. Cost effectiveness of fluorouracil-based regimens, depending on delivery strategy, use of modulating agents and stage of cancer vary from US dollars 2000 per quality-adjusted life-year (QALY) to US dollars 20200 per QALY (1992 values). Irinotecan therapy has not been fully investigated from the perspective of cost effectiveness; the figure of US dollars 10000 per QALY (1998 values) for irinotecan monotherapy over fluorouracil regimens is likely an underestimate, while cost analysis of irinotecan and fluorouracil combination therapy has not yet been reported. Our understanding of cost effectiveness of other novel agents has lagged behind; further research on these agents is needed. Nonetheless, as the effects of these novel agents upon both outcomes and costs continue to be defined, both curative and palliative treatment of colorectal cancer in the elderly patient will become more sophisticated and effective.

A systematic review was conducted to evaluate the literature regarding the impact of follow-up on colorectal cancer patient survival and, in a second phase, recommendations were developed.

The MEDLINE, CANCERLIT, and Cochrane Library databases, and abstracts published in the 1997 to 2002 proceedings of the annual meeting of the American Society of Clinical Oncology were systematically searched for evidence. Study selection was limited to randomized trials and meta-analyses that examined different programs of follow-up after curative resection of colorectal cancer where five-year overall survival was reported. External review by Ontario practitioners was obtained through a mailed survey. Final approval of the practice guideline report was obtained from the Practice Guidelines Coordinating Committee.

Six randomized trials and two published meta-analyses of follow-up were obtained. Of six randomized trials comparing one follow-up program to a more intense program, only two individual trials detected a statistically significant survival benefit favouring the more intense follow-up program. Pooling of all six randomized trials demonstrated a significant improvement in survival favouring more intense follow-up (Relative Risk Ratio 0.80 (95%CI, 0.70 to 0.91; p = 0.0008). Although the rate of recurrence was similar in both of the follow-up groups compared, asymptomatic recurrences and re-operations for cure of recurrences were more common in patients with more intensive follow-up. Trials including CEA monitoring and liver imaging also had significant results, whereas trials not including these tests did not.

Follow-up programs for patients with curatively resected colorectal cancer do improve survival. These follow-up programs include frequent visits and performance of blood CEA, chest x-rays, liver imaging and colonoscopy, however, it is not clear which tests or frequency of visits is optimal. There is a suggestion that improved survival is due to diagnosis of recurrence at an earlier, asymptomatic stage which allows for more curative resection of recurrence. Based on this evidence and consideration of the biology of colorectal cancer and present practices, a guideline was developed. Patients should be made aware of the risk of disease recurrence or second bowel cancer, the potential benefits of follow-up and the uncertainties requiring further clinical trials. For patients at high-risk of recurrence (stages IIb and III) clinical assessment is recommended when symptoms occur or at least every 6 months the first 3 years and yearly for at least 5 years. At the time of those visits, patients may have blood CEA, chest x-ray and liver imaging. For patients at lower risk of recurrence (stages I and Ia) or those with co-morbidities impairing future surgery, only visits yearly or when symptoms occur. All patients should have a colonoscopy before or within 6 months of initial surgery, and repeated yearly if villous or tubular adenomas >1 cm are found; otherwise repeat every 3 to 5 years. All patients having recurrences should be assessed by a multidisciplinary team in a cancer centre.

The current methods of detection of recurrent colorectal cancer after surgical treatment are inaccurate using conventional imaging. This study set out to detect early recurrence by means of PET in patients treated surgically for colorectal cancer by curative resection.

Thirty-one disease-free patients were recruited and underwent FDG-PET. The results were verified by clinical, surgical and radiological follow up and/or biopsy to evaluate the accuracy for detecting recurrence.

PET detected 6 sites of increased activity in 5 patients. Three of these underwent surgery. One was false positive with no evident tumour and two underwent an hepatic resection with removal of a homental metastasis. The sensitivity was 100% and specificity 83.3%. Clinical management was altered in two cases (6.4%).

This study demonstrates that PET is more accurate than conventional imaging for the evaluation of recurrence in colorectal cancer patients. FDG-PET should be considered in the follow-up of patients after treatment for colorectal cancer in addition to other imaging methods.

Consensus is lacking as to the best strategy for following patients who have undergone definitive surgical medical treatment for colon cancer. The goal of any surveillance program should be detection of recurrent disease at a sufficiently early time to allow subsequent curative therapy. Although periodic clinical examinations, laboratory tests, radiographic imaging, and carcinoembryonic antigen (CEA) testing have been utilized as a form of surveillance, such aggressive and costly intervention has not been validated through clinical studies. Four of the five randomized trials comparing such an intensive surveillance strategy to less frequent testing have not demonstrated the intensive approach to lead to an improvement in overall survival. Furthermore, intensive testing is both costly and has been shown not to improve quality of life. Further research designing appropriate postoperative testing is needed to guide physicians and patients after the curative resection of a colorectal cancer.

Only a small proportion of cervical cancer recurrences is detected during routine follow-up. We investigated which percentage of recurrences is detected during follow-up, which diagnostic tools are helpful to detect recurrent disease and which factors are of prognostic significance once recurrent disease has been established in patients treated for cervical cancer stage IB-IVA.

Characteristics of the primary tumor, characteristics of recurrent disease and follow-up were collected retrospectively from clinical records of 277 patients who achieved a complete remission of at least 3 months after primary treatment for cervical cancer in 1992, 1993 and 1994 in three university hospitals in the Netherlands.

Of 277 patients, 47 (17%) developed recurrent disease; this was most often detected after self-referral (45%), and in 32% during routine follow-up. Survival did not differ significantly between these two groups. The presence of symptoms (87%) was the most important first abnormal test result leading to diagnosis of recurrence. In univariate analysis, disease-free interval (DFI) and treatment modality were significant prognostic factors for crude survival of recurrence. However, treatment modality varied considerably and the subgroups were small. Therefore, multivariate analysis was not feasible and clinically valid conclusions could not be drawn.

In only 32% of all cases, recurrence was detected during a scheduled follow-up visit. In the majority of patients, recurrent cervical cancer was detected by symptoms (87%). In recurrent disease, DFI was a prognostic factor for survival.

Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.

One of the main problems in the treatment of rectal cancer is the development of local recurrences. In the last decades, major improvements have been realized in the surgical treatment of rectal cancer. The introduction of TME-surgery has led to a large reduction in local recurrence rates and improved survival. TME-based operations are now established as the standard of care for rectal cancer, and should form the basis for trials concerning the role of (neo)adjuvant therapy. However, training and quality control are prerequisites to obtain good results in all surgeons' hands. Furthermore, standardization in the description of operations and reporting of pathology specimens should be implemented as important features of quality control. In general, it is thought that high volume and specialist care produces superior results to low volume and non-specialist care, especially for those less frequent forms of cancer and in technically difficult operations, like those for rectal cancer. However, limiting the performance of rectal cancer surgery to highly specialized surgeons or to only those general surgeons who perform more than a certain volume is impractical in view of the prevalence of rectal cancer. This article reviews developments in the treatment of especially mobile rectal cancer and pays attention to variability in outcomes and quality assurance of surgery.

A retrospective review of all women diagnosed with endometrial adenocarcinoma over a 5-year period was performed. One hundred and eleven women had not defaulted from follow-up and were thought to be disease-free following primary treatment. Seventeen (15.3%) of this group of women developed recurrent disease; four of these being detected in asymptomatic patients at routine follow-up visits. Women with asymptomatic recurrences had a significantly better survival than those presenting with symptoms (25% vs. 8%, P = 0.048). On the basis of previous findings, a limited hospital surveillance protocol was applied retrospectively to these patients with an estimated financial saving of over 2500 per annum. However, as one asymptomatic recurrence was detected by vault cytology during the 2 years after primary treatment, it may be worthwhile continuing to perform vault cytology during this period.

Current surveillance methods for detecting recurrence after apparently curative colorectal cancer resection are insensitive and have not been shown to significantly improve survival. New surveillance methods based on molecular, flow cytometric and immunohistochemical detection of small numbers of tumour cells may prove more sensitive in detecting early recurrent cancer and may improve outcome.

Despite limited evidence of its effectiveness, most guidelines recommend colorectal cancer survivors undergo posttreatment surveillance care. This article describes the posttreatment use of colon examinations, carcinoembryonic antigen (CEA) testing, and metastatic disease testing among a managed care population.

Two hundred fifty-one patients with colorectal cancer enrolled in a managed care organization at diagnosis (1/1/90-12/31/95) and treated with curative intent. Patients were identified via a Cancer Registry maintained by a large group practice. Cumulative incidences of service receipt were estimated using actuarial (Kaplan-Meier) survival analyses. Co- Proportional Hazard Models were used to evaluate the relation of patient sociodemographic and clinical characteristics to service receipt. Average 8-year medical care expenditures were calculated.

Within 18 months of treatment, 55% of the cohort received a colon examination, 71% received CEA testing, and 59% received metastatic disease testing. Whites were more likely than minorities to receive CEA testing (RR = 1.47, P = 0.04) and tended to be more likely to receive a colon examination (RR = 1.43, P = 0.09). As the median household income of a patient's zip code of residence increased, so too did the likelihood of colon examination and metastatic disease testing receipt (RR = 1.09, P = 0.03 and RR = 1.12, P <0.01, respectively). Average 8-year medical care expenditures among the cohort were $30,247.

Among a population with financial access to care, differences were found in the receipt of colorectal cancer surveillance care by race and income. Additional investigations are needed to understand why minorities and those residing in low-income areas are less likely to receive surveillance care.

A case of a solitary pancreatic metastasis from a primary colonic carcinoma is reported.

The history and use of carcinoembryonic antigen, computed tomography, and positron emission tomography in this case and the follow-up of colorectal cancer are reviewed.

Recurrent disease was suspected by an increasing carcinoembryonic antigen level. However, conventional imaging with computed tomography on more than one occasion failed to identify any recurrence. The pancreatic metastasis was accurately localized by positron emission tomography scanning and confirmed on subsequent laparotomy. A histologically complete resection was performed and the patient remained in remission with a normal carcinoembryonic antigen 12 months postoperatively.

This case reports an unusual site of solitary metastasis in colorectal cancer and supports the further investigation of positron emission tomography in follow-up of colorectal cancer.

The oncological applications of positron emission tomography (PET) have gained widespread acceptance. This rapidly evolving technology has been applied successfully to colorectal cancer, but has not yet become part of routine clinical practice. This review considers (1) the biological basis for the use of PET in colorectal cancer, (2) the technical aspects of PET relevant to the referring clinician and (3) the application of PET to the management of primary and recurrent disease.

A Medline database search was performed for the period 1980-2000. Experience was also drawn from the first 40 patients with colorectal cancer investigated at this institution.

PET has a proven role, and is cost effective in the management of recurrent cancer and the monitoring of therapy. However, further evaluation is still required to justify its routine use for other indications in colorectal cancer. Development of new positron-labelled radio- pharmaceuticals, in parallel with advances in detector technology and innovative models for tracer production and distribution, means that the availability of PET and its applications in the management of colorectal cancer will expand over the coming years.

This paper reviews some of the issues involved in the planning and execution of studies to assess the effect of different follow-up strategies for colorectal cancer patients. Mathematical models and many previous studies have failed to indicate strong support for the hypothesis that extensive follow-up leads to an increase in survival rates. In order to assess the best follow-up strategies, at present, within the different Dukes' stages, extremely large trials are required and none of the previous studies have satisfied this criterion, though recently planned studies will, if recruitment targets are met. The large number of patients required, the length of time the study must run, existing accepted follow-up practices in different countries, and the difficulty of managing patients on different follow-up strategies within the same centre all pose problems for the design of a randomized trial. These are not insurmountable, but do contribute to a possible downfall of a large multicentre randomized trial of follow-up strategies. Although such a trial will require considerable international cooperation it will have enormous benefits and implications if it is managed and completed successfully.

Colorectal cancer is an important cause of death in the Western world, with a propensity of cancer recurrence even after resection with curative intent. Active follow-up has been advocated as a means to detect cancer recurrence at an earlier stage and thereby improve the survival of colorectal cancer patients. The present study assesses published evidence on the effectiveness of follow-up. Articles were obtained from a 20-year Medline search and from cross-references between articles. Articles were included, scored for quality, and extracted by explicit criteria. Regression analysis and chi-squared analysis was performed to assess (1) whether detection of recurrence at earlier asymptomatic disease stage leads to better post-treatment prognosis, and (2) whether active follow-up does improve overall (quality adjusted) survival, as compared to symptom-guided care only. The relationship between disease stage of recurrence (symptoms, number and size) and survival was analysed from 42 articles, 10 of which provided adequate data. Absence of symptoms and small number of recurrence were significantly related to better survival, smaller size insignificantly so. The potential of active follow-up seemed related to a marginally better outcome, larger gains being found in lower quality studies. Available data do suggest that survival gains vary between 0.5 and 2%, 1% seeming to be a best estimate of overall survival gain. Neither the notion that earlier detection of recurrences does significantly improve outcome, nor the hope that active follow-up provides a statistically and clinically significant gain in (quality adjusted) survival, are so far supported by adequate evidence. Colorectal cancer follow-up still fails to meet the criteria for evidence based medicine.

Because more than 90% of local recurrences after curative surgery for rectal cancer appear within the first 36 months after surgery, an intensive and strict follow-up program during this period could improve early diagnosis and, thus, prognosis of patients.

Of the 216 patients who underwent surgery for rectal cancer, 127 entered an intensive follow-up program (median follow-up: 42 months); the clinical outcome of the remaining 89 patients was reconstructed with the help of their general practitioners.

Fifty eight (26.8%) of the 216 patients who were treated with curative surgery alone developed a local recurrence; pelvic recurrences were prevalent. Eleven (30.5%) of the 36 patients who had recurrence during follow-up, and 6 of the 22 who had not undergone follow-up, had a reoperation with curative intent; the median survival was 19 months vs. 8 months, respectively (P = ns). Four (44.4%) curative reoperations were performed on the 9 asymptomatic patients and in 13 (26.5%) of the 49 cases with symptomatic local recurrences. Median survival was 15 months vs. 14 months, respectively (P = n.s). All patients except one (living after 42 months from reoperation) died within 48 months.

In our study, adherence to a strict follow-up program unfortunately proved to be ineffective for improving long-term survival for patients who underwent reoperation with curative intent.

Surgery is currently the only available treatment option which offers the potential for cure for patients with liver metastases from colorectal cancer. Of those who undergo a potentially curative operation for their primary tumour but subsequently recur, almost 80% will develop evidence of metastatic disease within the liver. Greater experience and improvements in technique in liver surgery, with an increasingly aggressive surgical approach to metastatic colorectal cancer to the liver, has resulted in prolonged disease-free survival with 5-year rates varying from 21% to 48%. In order to increase these numbers further and to treat patients not eligible for surgical therapy, new treatment modalities and strategies have been developed. This review presents an update of the current treatment for colorectal disease metastatic to the liver.

To determine the most effective, evidence-based, postoperative surveillance strategy for the detection of recurrent colon and rectal cancer. Tests are to be recommended only if they have an impact on the outcomes listed below.

All tests described in the literature for postoperative monitoring were considered. In addition, the data were critically evaluated to determine the optimal frequency of monitoring.

Outcomes of interest included overall and disease-free survival, quality of life, toxicity reduction, and cost-effectiveness. The American Society of Clinical Oncology (ASCO) Colorectal Cancer Surveillance Expert Panel was guided by the principle of cost minimization, ie, when two strategies were believed to be equally effective, the least expensive test was recommended.

A complete MEDLINE search was performed of the past 20 years of the medical literature. Keywords included colorectal cancer, follow-up, and carcinoembryonic antigen, as well as the names of the specific tests. The search was broadened by articles from the tumor marker ASCO panel literature search, as well as from bibliographies of selected articles.

Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a randomized design. BENEFITS/HARMS/COSTS: The possible consequences of false-positive and false-negative tests were considered in evaluating a preference for one of two tests that provide similar information. Cost alone was not a determining factor.

The expert panel's recommended postoperative monitoring schema is discussed in this article.

Five outside reviewers, the ASCO Health Services Research Committee, and the ASCO Board of Directors examined this document.

American Society of Clinical Oncology.

Followup care of men who have undergone potentially curative surgical treatment for prostate cancer varies widely among clinicians. To determine current practice patterns we mailed a custom designed questionnaire to American and nonAmerican urologists who were American Urological Association (AUA) members.

Surveys were mailed to a random sample of the approximately 12,000 AUA members, comprising 3,205 Americans and 1,262 nonAmericans. Evaluable surveys were returned by 760 American (24%) and 290 nonAmerican (23%) urologists. Our analysis is based on these 1,050 responses.

In generally healthy patients after radical prostatectomy for stages T1 to 2NOMO and T3a to cNOMO prostate cancer the most frequently recommended followup diagnostic tests included office visit with digital rectal examination, serum prostate specific antigen (PSA) and urinalysis. Although there is appreciable variation in the frequency of use of these methods, respondents generally recommended office visit with digital rectal examination, serum PSA and urinalysis every 3 months in year 1, every 6 months in years 2 to 5 and annually thereafter. Other tests, such as serum prostatic acid phosphatase, bone scan, and abdominal and pelvic computerized tomography and magnetic resonance imaging, are rarely recommended.

Our survey provides information regarding current followup strategies recommended by AUA urologists after radical prostatectomy for stages T1 to 2NOMO and T3a to cNOMO disease. Office visits and digital rectal examination, urinalysis and PSA measurement are the main tools that urologists currently use. Although optimal strategy remains unknown, these data permit the rational design of clinical trials of alternate followup strategies based on actual current practice to answer this important question.

Cancer of the colon and rectum is a significant health problem in the United States. Nearly 50% of the 186,000 patients diagnosed annually with colorectal cancer will eventually die of their disease. Because development of a colorectal carcinoma is most frequently preceded by the development of a well-recognized pre-malignant lesion, screening modalities can significantly impact the incidence and mortality rate of this disease. Population screening employing digital rectal examination, fecal occult blood testing and endoscopic examination of the rectum and colon has been demonstrated to reduce the risk of death from colorectal cancer. Screening regimens should be instituted at an earlier age and with increased frequency for patients in the highest risk categories. Patients who have been treated for a cancer of the colon or rectum should undergo surveillance at regular intervals in an attempt to identify recurrences of disease both in the residual colon and rectum and at distant sites. Most physicians and patients believe that intensive follow-up strategies will afford improved survival and quality of life, however few randomized studies examining the utility of intensive follow-up programs have been performed and the quality of cancer-related follow-up literature is generally poor. Good-quality clinical trials are needed to sort out which tests make a difference in the patient's long-term outcome. The algorithm for surveillance for recurrence in the future may be altered as newer testing modalities are developed.

This prospective, randomized, single-center study was designed to evaluate the influence of follow-up on detection and resectability of local recurrences and on survival after radical surgery for colorectal cancer.

Between 1987 and 1990, 207 consecutive patients who underwent curative resections for primary untreated large-bowel carcinoma were randomly assigned to a conventional follow-up group (Group A; n = 103) and to an intense follow-up group (Group B; n = 104). All the patients were followed up prospectively, and the outcome was known for all of them at five years. Patients in Group A were seen at six-month intervals for one year, and once a year thereafter. Patients in Group B were checked every three months during the first two years, at six-month intervals for the next three years, and once a year thereafter.

Of the 103 patients in Group A, local recurrence was detected in 20; 9 (13 percent) of these patients had colon cancer, and 11 (29 percent) had rectal cancer. Of the 104 patients in Group B, local recurrence was detected in 26; 12 (16 percent) of these patients had colon cancer, and 14 (45 percent) had rectal cancer. Twelve cases (60 percent) of local recurrence in Group A and 24 cases (92 percent) in Group B were detected at scheduled visits (P < 0.05). Local recurrences were detected earlier in patients of Group B (10.3 +/- 2.7 vs. 20.2 +/- 6.1 months; P < 0.0003). Curative re-resection was possible in 2 patients (10 percent) in Group A, 1 with colon cancer and 1 with rectal cancer, and in 17 patients (65 percent) in Group B, 6 with colon cancer and 11 with rectal cancer (P < 0.01). Of the Group B patients who had curative re-resections of local recurrence, 8 (47 percent) were disease-free and long-term survivors as of the last follow-up, and 2 (11.7 percent) were alive, but with a new recurrence. The 2 patients in Group A who had curative re-resections died as a result of cancer. The five-year survival rate in Group A was 58.3 percent and in Group B was 73.1 percent. The difference is statistically significant (P < 0.02).

Our data support use of an intense follow-up plan after primary resection of large-bowel cancer, at least in patients with rectal cancer.

The value of intensive follow-up for patients after resection of colorectal cancer remains controversial. This study reviews all randomized and prospective cohort studies to assess the value of aggressive follow-up.

The literature was searched from the years 1972 to 1996 for studies reporting on the follow-up of patients with colorectal cancer. Randomized and comparative-cohort studies that included history, physical examination, and carcinoembrionic antigen values at least three times a year for at least two years were included in a meta-analysis. Single-cohort studies with intensive follow-up and traditional follow-up were also included in a two-group comparative analysis for each outcome indicator. Outcome indicators were 1) curative resection rates after recurrent cancer, 2) survival rates of curative re-resections, 3) length of survival after recurrence, and 4) cumulative five-year survival.

Two randomized and three comparative-cohort studies met these criteria and included 2,005 patients, which were evaluated in the meta-analysis. The cumulative five-year survival was 1.16 times higher in the intensively followed group (P = 0.003). Two and one-half times more curative re-resections were performed for recurrent cancer in those patients undergoing intensive follow-up (P = 0.0001). Those patients in the intensive follow-up group with a recurrence had a 3.62-times higher survival rate than the control (P = 0.0004). Fourteen single-cohort studies were also included in the comparative analysis of 6,641 patients. The findings from these aggregated studies support the results of the meta-analysis.

Our study concludes that intensive follow-up detects more recurrent cancers at a stage amenable to curative resection, resulting in an improvement in survival of recurrences and an increased overall five-year cumulative rate of survival.

Early detection of recurrence after curative resection for primary colorectal cancer should improve patients' prognosis. However, the usefulness of postoperative surveillance programs has not been clarified yet. The present cohort study was aimed at assessing the effectiveness of systematic follow-up in patients with colorectal cancer who were operated on for cure, regarding both rate of tumor recurrence amenable to curative-intent surgery and rate of survival.

One hundred ninety-nine colorectal cancer patients who underwent radical primary surgery were followed according a well-defined postoperative surveillance program, which consisted of laboratory studies (including serum carcinoembryonic antigen assay) every three months, physical examination and abdominal ultrasound or computed tomography every six months, and chest radiograph and total colonoscopy once per year. Cohorts were defined according to patients' compliance with the proposed follow-up program. A multivariate regression model was constructed to predict survival.

One hundred forty patients were considered to be compliant with the surveillance program, whereas the remaining 59 patients occasionally attended follow-up investigations or did not comply at all. Although there were no differences in the overall recurrence rate (38 vs. 41 percent; P = 0.52), curative-intent reoperation was possible in 18 patients (34 percent) of those with tumor recurrence in the compliant cohort but in only 3 patients (12 percent) in the noncompliant cohort (P = 0.05). Similarly, the probability of survival was higher in the compliant cohort, both regarding overall (63 vs. 37 percent at 5 years; P < 0.001) and cancer-related (69 vs. 49 percent at 5 years; P < 0.02) rates. Cox regression analysis disclosed that only a more advanced TNM stage (odds ratio, 8.17; 95 percent confidence interval, 1.13-59.29) and noncompliance with the postoperative surveillance program (odds ratio, 2.32; 95 percent confidence interval, 1.50-3.60) had an independent negative impact on survival.

Systematic postoperative surveillance in patients with colorectal cancer who were operated on for cure increases both the rate of tumor recurrence amenable to curative-intent surgery and rate of survival.

The nature of 'local recurrence' of rectal cancer remains unclear.

Fifty-nine patients with locally recurrent rectal cancer who underwent extended repeat resections including total pelvic exenteration (39) and sacrectomy (43) were reviewed. Twelve patients had distant metastases before or at the time of repeat resection.

The 5-year survival rate was 25 per cent. A second recurrence occurred in 45 patients including five of the eight 5-year survivors. Thirty-six of these recurrences had locoregional manifestations and 29 had distant metastases. Of 18 prognostic factors examined, the most significant determinant was the postoperative carcinoembryonic antigen doubling time (CEADT), followed by the preoperative CEADT, carcinoembryonic antigen (CEA) level and occurrence of distant metastases, in decreasing order. Late onset of first recurrence was also a favourable indicator. Thus, the growth rate of the tumour had a more profound impact on survival than the current extent of tumour progression. After operation the CEADT was reduced in patients with second recurrence (P = 0.05).

Locally recurrent rectal cancer is a manifestation of disseminated disease spreading locoregionally and often to distant organs with a low probability of long-term cure. However, survival varies widely depending on the tumour growth rate, which is biologically predetermined and is also influenced by surgery.

Guidelines on the type and frequency of follow-up of patients after curative surgery for colorectal cancer are unclear. The aim of this study was to determine the survival benefit of a planned follow-up program.

Three hundred twenty-five patients who underwent curative resection of colorectal cancer were prospectively randomized to either intensive or standard follow-up. After stratification according to Dukes' stage and site in the colon or rectum, patients were randomized to intensive follow-up of yearly colonoscopy, computerized tomography (CT) of the liver, and chest radiography and clinical review and simple screening vs. structured clinical review and simple screening tests only.

On completion of 5-year follow-up, there was no significant difference in survival between the two groups. Yearly colonoscopy failed to detect any asymptomatic local recurrences. Only one asymptomatic curable metachronous colon tumor was detected. Liver CT resulted in earlier detection of hepatic metastases but did not increase the number of curative hepatectomies. Only 1 patient had an asymptomatic CT-detected liver metastasis, and another had an asymptomatic chest radiography-detected lung metastasis. Both had curative resections.

Yearly colonoscopy, liver CT, and chest radiography will not improve survival from colorectal cancer when added to symptom and simple screening review.

Although extended surgery has been established as an effective method for the treatment of advanced carcinoma of the colon, there are no reports in the literature of en bloc resection of the tumor together with the iliac bone. We report herein a 46-year-old woman with a second local recurrence after right colectomy, with the main objective of showing the possibility of indicating this type of surgery in selected cases.

In view of the lack of therapeutic options for the case and the absence of metastases, extended curative surgery for recurrent carcinoma of the colon was performed, with en bloc resection of the right iliac bone and of the crural nerve (Type I internal hemipelvectomy).

After a 27-month follow-up, the patient is asymptomatic, with no signs of local recurrence or metastases.

In selected cases, recurrent carcinoma of the colon can be treated by extended and aggressive surgery, including bone resection, to obtain an appropriate safety margins.

This study evaluates the clinical value of positron emission tomography (PET) with 2-[F-18] fluoro-2-deoxy-D-glucose (FDG) as compared to computed tomography (CT) in patients with suspected recurrent or metastatic colorectal cancer (CRC).

A retrospective review of the records of 58 patients who had FDG-PET for evaluation of recurrent or advanced primary CRC was performed. FDG-PET results were compared with those of CT and correlated with operative and histopathologic findings, or with clinical course and autopsy reports.

Recurrent or advanced primary CRC was diagnosed in 40 and 11 patients, respectively. The sensitivity and specificity of FDG-PET were 91% and 100% for detecting local pelvic recurrence, and 95% and 100% for hepatic metastases. These values were superior to CT, which had sensitivity and specificity of 52% and 80% for detecting pelvic recurrence, and 74% and 85% for hepatic metastases. FDG-PET correctly identified pelvic recurrence in 19 of 21 patients; CT was negative in 6 of these patients and equivocal in 4. FDG-PET was superior to CT in detecting multiple hepatic lesions and influenced clinical management in 10 of 23 (43%) patients.

FDG-PET is more sensitive than CT in the clinical assessment of patients with recurrent or metastatic CRC, and provides an accurate means of selecting appropriate treatment for these patients.

To propose a risk-specific follow-up protocol for endometrial carcinoma patients.

A retrospective cohort of endometrial carcinoma patients was used to identify risk factors for recurrence. Based on a profile of risk factors, women were classified at either low or high risk for recurrence (median follow-up 70 months). The classification system was validated on a subsequent cohort.

Surgical stage, grade, and histology were found to be significant predictors (P < 0.001) of recurrence. In the original cohort, patients with stage Ia, grade 1 or 2, or stage Ib, grade 1 adenocarcinoma, had a recurrence rate of 4/98 (4.1%). The remaining high-risk patients had a recurrence rate of 37/158 (23.4%). When applied to the subsequent cohort, the rates were similar: low risk 3/113 (2.7%) and high risk 30/140 (21.4%). Seventy-five percent of recurrences occurred within 3 years of diagnosis and the majority were heralded by site-specific symptoms.

Women with endometrial carcinoma can be successfully classified for low or high risk of recurrence. It is proposed that low-risk patients not be maintained on routine follow-up and that a tailored schedule of follow-up be used for high-risk patients. These changes would serve patients more appropriately and use health care resources more efficiently.

Routine follow-up visits and vault cytology following treatment for endometrial carcinoma generates a considerable workload and takes up valuable resources. A review is needed to evaluate the usefulness of this practice. Eighty six patients treated and follow-up from January, 1987 to July, 1994 were reviewed. The standard follow-up protocol consisted of physical assessment and vault cytology every 1 to 2 months for the first 2 years, every 3 months for the third year and every 6 months thereafter for at least 5 years. Recurrences were defined as histologically proven disease after a 3-month disease free interval. Fourteen patients (17%) developed recurrences. Two of the 14 patients (14%) had local recurrences in the pelvis. Only 3 of these recurrences were detected during routine follow-up. Vault cytology was negative in all patients with recurrences even when the recurrence occurred locally in the pelvis. Traditional surveillance protocols were ineffective in the detection of recurrences. Vault cytology was particularly ineffective. It was calculated that 1 recurrence was detected for every 606 visits. In this age of budgetary constraints, alternative follow-up protocols should be explored.

To study the effectiveness of follow up surveillance in detecting recurrent disease following radical hysterectomy for Stage IB cervical carcinoma.

Retrospective analysis of clinical records using a computerised database.

Six hundred and seventy-four patients with Stage IB carcinoma of the cervix underwent radical hysterectomy and lymph node dissection.

Standard follow up surveillance consisted of clinical history and physical examination six weeks post surgery, and subsequently three monthly for the first year, six monthly for the second year, and yearly thereafter until 10 years post-treatment.

Of the 674 patients, 112 (17%) developed recurrent disease. In only 29/112 (26%) was recurrent disease detected at the time of routine follow up visits. Nearly half of the patients (44%) were referred by their general practitioner between visits to the clinic because of suspicion of recurrent disease.

Routine follow up surveillance is ineffective in detecting recurrent cervical carcinoma. Only one in four recurrences were detected at the time of a clinical visit.

The main rationale for follow-up of colorectal cancer patients resected for "cure" is that early detection and treatment of recurrence and metachronous disease should result in improved survival. Our purpose was to assess in a prospective fashion the impact on survival of a follow-up program versus that of undergoing nonscheduled visits.

Within the 14-year period from 1975 through 1988, a prospective study was carried out on 800 patients with colorectal adenocarcinoma radically resected with no evidence of synchronous cancers of the colon and rectum or in other organs, of whom 322 patients were to attend a 5-year follow-up, and 478 patients were free to make nonscheduled visits on account of symptoms.

Asymptomatic recurrence was found at follow-up in 92 (28%) of 322 patients, whereas 175 (36%) of 478 patients had a symptomatic recurrence detected at a nonscheduled visit. Diagnosis of resectable recurrence was established within a median time of 21.5 months. Surgical resection of recurrence was performed in 30 (32%) of 92 and in 13 (7%) of 175 patients (32 vs. 7%; p < 0.001). Resection was curative in 13 (14%) of 92 and in two (1%) of 175. Five-year survival of resected recurrence was 10% in 30 of 92 patients and 0.8% in 13 of 175 (10 vs. 0.8%; p < 0.01). Two patients are alive with no evidence of disease or two (2%) of 92. Metachronous colorectal lesions were treated for cure in 63 (19.5%) of 322 patients. The effectiveness of scheduled follow-up was 4% (13 of 322 patients).

These results underline the rationale for a follow-up program in early detection and surgical treatment of recurrent disease in patients operated on for colorectal cancer.

To evaluate the clinical benefit of routine follow up of women after treatment for endometrial adenocarcinoma.

Retrospective case analysis.

All cases diagnosed and treated for endometrial adenocarcinoma in Tayside, Scotland during 1982 to 1984 inclusive.

Case-note and cancer registration document review.

Of 102 patients, 97 had complete follow up for 10 years or until death. Recurrent disease was diagnosed in 17 women, only six of whom were asymptomatic at the time of diagnosis. There was no difference in survival between cases with symptomatic and asymptomatic recurrences. No recurrences were diagnosed more than six years after initial diagnosis.

The diagnosis of asymptomatic recurrent endometrial carcinoma was not associated with improved long term survival. This small study showed no evidence of improved survival from the current practice of routine clinical review following treatment for endometrial adenocarcinoma. The effect of follow up on patient anxiety remains to be assessed.

No conclusive evidence exists concerning the effectiveness of follow-up programs after curative surgery for colorectal cancer, and presently cost-benefit analyses have not indicated that follow-up strategies increase survival or quality of life.

Five hundred five patients who survived curative surgery for stage I-III colorectal adenocarcinoma were closely followed for at least 4 years.

One hundred forty-one (28%) patients had recurrence. Of these, 32 underwent one or more surgical procedures for cure, whereas 109 could only benefit from palliation. Eighteen were cured. The mean survival of all recurrent cases was 44.4 months. Of those operated on with curative intent, the mean survival was 69.3 months compared with 37.1 months in those operated on with palliative intent. Of those 18 patients who were cured by reoperative surgery, the average survival was 81.4 months. The overall follow-up cost was $1,914,900 (U.S.) for the 505 patients; $13,580 (U.S.) for each recurrence, $59,841 (U.S.) for each case treated for cure, and $136,779 (U.S.) for those effectively cured.

Careful postoperative monitoring is expensive yet effective when one considers that one-quarter of the detected recurrences were suitable for potentially curative second surgery; however, only 3.6% of the original group were effectively cured. Follow-up programs should be tailored according to the stage and site of the primary to reduce costs.

Screening of the average-risk individual for disease creates a different relationship between practitioner and subject than the normal doctor-patient relationship. Screened individuals are asymptomatic, have a whole range of motivations from denial to neurosis, and, for the most part, derive no benefit from the screen, as they are destined never to contract the disease. Rewards to the few must clearly outweigh the risks to the many. The screening strategy must be economical when applied to a large population, safe, and effective in achieving the ultimate goal, which, in the case of colorectal cancer, is reduction in the mortality rate. Prediagnostic screening of asymptomatic adults over the age of 45 years for primary disease has been shown to fulfill all of these criteria. Postoperative screening of asymptomatic individuals after curative resection of colorectal cancer for recurrence has been shown to fulfill none of them.