This is the current release of the guideline.

Colorectal cancer

Diagnosis
Evaluation
Prevention
Risk Assessment
Screening

Colon and Rectal Surgery
Family Practice
Gastroenterology
Geriatrics
Internal Medicine
Oncology

Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Physician Assistants
Physicians
Public Health Departments

To provide guidance for appropriate use of colonoscopy surveillance in patients after colorectal cancer resection

Patients with resected colorectal cancer:

• Endoscopically resected Stage I colorectal cancer
• Surgically resected Stage I, II, and III cancers
• Stage IV cancer resected for cure

• Consideration of interval between subsequent colonoscopies
• High-quality perioperative clearing by preoperative colonoscopy or, in the case of obstructing colon cancers, computed tomography colonography with intravenous contrast or double contrast barium enema followed by colonoscopy 3 to 6 months after resection
• Periodic examination of the rectum by rigid or flexible proctoscopy or endoscopic ultrasound to detect local recurrence

• Detection of metachronous colorectal neoplasms at a surgically curable stage
• Complication rates
• Rates of local recurrence of colon and rectal cancers
• Survival from recurrent colorectal cancer

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The literature search sought to identify randomized controlled trials and cohort studies in which patients with resected colorectal cancer and perioperative clearing of synchronous neoplasia by colonoscopy were followed to detect recurrent and/or metachronous neoplasms.

The guideline developers searched the medical literature using MEDLINE (1966-January 17, 2005), the Cochrane Database of Systematic Reviews (fourth quarter 2004 update), and the Database of Abstracts of Reviews of Effects (fourth quarter 2004 update). In MEDLINE, subject headings for colorectal neoplasms were combined with subheadings and keywords for "surgery," "resection," "colonoscopy," "surveillance," and "follow-up" to identify relevant citations. Only studies published in the English language were included. Surveillance studies in patients with inflammatory bowel disease or hereditary nonpolyposis colorectal cancer (HNPCC) were specifically excluded. Keyword searches were also performed in the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects to identify any additional systematic reviews. In addition, a manual search was performed using references from retrieved reports, review articles, guidelines, meta-analyses, editorials, and textbooks of gastroenterology.

Articles were excluded if there was no evidence of perioperative colonoscopic clearing or if a modality other than colonoscopy (flexible sigmoidoscopy, barium enema) was used for perioperative clearing.

A total of 66 studies were retrieved for detailed evaluation, and 43 were excluded: 26 because of incomplete perioperative colonoscopic clearing or because this was accomplished with modalities other than colonoscopy, 13 did not pertain to the focus of the guideline developer's paper, three were reports of work in progress that were published in final form in other studies included in the developer's analysis, and one reported the preliminary results of an ongoing trial. The remaining 23 studies were included in the analysis.

Expert Consensus

Not applicable

Systematic Review with Evidence Tables

Evidence tables were created to summarize the studies and were circulated to members of the US Multi-Society Task Force and the American Cancer Society (ACS) Colorectal Cancer Advisory Committee.

Expert Consensus

Evidence tables were created to summarize the studies and were circulated to members of the US Multi-Society Task Force and the American Cancer Society (ACS) Colorectal Cancer Advisory Committee. The evidence was reviewed and recommendations developed at a joint meeting.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Postcancer Resection Surveillance Colonoscopy Recommendations

Additional Recommendations Regarding Postcancer Resection Surveillance Colonoscopy

None provided

The type of evidence is not specifically stated for each recommendation.

Detection of metachronous colorectal cancers at a surgically curable stage, as well as the prevention of metachronous cancers through identification and removal of adenomatous polyps

Not stated

Limitations in the Selected Studies

Some limitations were identified in interpreting the selected studies on postcancer surveillance colonoscopy literature. For example, the term "metachronous cancer" had variable definitions. In some instances, it was based on the site of tumor appearance within the colon, and in others it was based on time after resection of the initial primary. Many studies made no mention of whether patients may have had hereditary nonpolyposis colorectal cancer. In some cohorts, there was incomplete follow up of patients. Surveillance intervals were different across studies. Some studies did not clearly separate metachronous tumors from anastomotic recurrences or anastomotic from local or regional recurrences. In some cases, there was also failure to report the stage of metachronous cancers and whether or not they were resectable for cure at the time they were diagnosed. In some studies, it was not clear whether colonoscopies were routine procedures in symptomatic surveillance patients versus diagnostic procedures based on symptoms or laboratory findings. Colonoscopy completion rates and complication rates were commonly not reported, and there was also frequently lack of information on mortality rates. Despite these limitations, a number of clinically relevant trends are evident regarding colorectal cancer recurrence, metachronous cancer, and the utility of surveillance procedures in patients with resected colorectal cancer.

The recommendation to perform a colonoscopy at 1 year does not diminish the need for high quality in the performance of the perioperative clearing examination(s) for synchronous neoplasms.

An implementation strategy was not provided.

Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

2006 May

American Cancer Society - Disease Specific Society
American Gastroenterological Association Institute - Medical Specialty Society

American Cancer Society, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

American Cancer Society Advisory Group on Colorectal Cancer, US Multi-Society Task Force on Colorectal Cancer

Advisory Group and Task Force Members: Douglas K. Rex, MD; Charles J. Kahi, MD, MSc; Bernard Levin, MD; Robert A. Smith, PhD; John H. Bond, MD; Durado Brooks, MD, MPH; Randall W. Burt, MD; Tim Byers, MD, MPH; Robert H. Fletcher, MD, MSc; Neil Hyman, MD; David Johnson, MD; Lynne Kirk, MD; David A. Lieberman, MD; Theodore R. Levin, MD; Michael J. O'Brien, MD, MPH; Clifford Simmang, MD; Alan G. Thorson, MD; Sidney J. Winawer, MD

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on February 4, 2008. The information was verified by the guideline developer on February 29, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.