Original Guideline: June 2002

• Patients with curatively resected colorectal cancer should be alerted to the future risk of disease recurrence, which is related to tumour stage, and to the development of a second colorectal cancer.
• There is evidence from one randomized trial and a meta-analysis of six randomized trials of a small survival benefit with more intensive follow-up compared to less intensive follow-up. This benefit is due to the early diagnosis and resection of limited recurrent disease in the liver, lungs, or local sites. It is not known at this time whether this diagnosis of resectable recurrences is due to the early assessment of symptoms or to the use of screening tests (blood carcinoembryonic antigen, chest-x-ray, liver ultrasound, or colonoscopy). There is insufficient evidence on which to base a recommendation for specific screening tests.
• In light of the uncertainty of the schedule of visits and screening tests to be recommended, and based on the rate of recurrent disease and second neoplasms, and on current practices, the guideline developers advise:
  1. In patients who are at high risk of relapse (stages IIb and III disease) and who are fit and willing to undergo investigations and treatment:
     • Prompt assessment for symptoms of potential disease relapse (see Appendix 1 of the original guideline document)

       January 2004 Update

     • For patients at high risk of recurrence (stages IIb and III), clinical assessment is recommended when symptoms occur or at least every six months for three years and then yearly for at least five years, instead of for at least three years as recommended in the original guideline.
     • During those visits patients may have blood carcinoembryonic antigen, chest x-rays, and liver ultrasound;
     • When recurrences of disease are detected, patients should be assessed by a multidisciplinary oncology team including surgical, radiation, and medical oncologists to determine the best treatment options.
  2. In patients at high risk of relapse but who have comorbidities that may interfere with prescribed tests or potential treatment for recurrence, or who are unwilling to undergo prescribed tests or potential treatment for recurrence:
     • Clinical assessments yearly or for suggestive symptoms of relapse.
  3. In all patients with resected colorectal cancer (stages I, II, and III) and based on the U.S. Polyp Study:
     • Colonoscopy postoperatively if not yet done:
       • If polyps are present, excise as they are potential precursors of colorectal cancer; repeat colonoscopy yearly as long as polyps are found.
       • If there are no polyps, repeat colonoscopy in three to five years.

     (see Appendix 2 in the original guideline document).

  • Patients should be encouraged to participate in clinical trials investigating screening tests added on to their clinical assessment. These trials of follow-up need to target patients with resectable recurrent disease who are fit for required surgery.

  January 2004 Update

  • For patients at lower risk of recurrence (stages I and Ia) or those with comorbidities impairing future surgery, only visits yearly or when symptoms occur are recommended. All patients should have a colonoscopy before or within 6 months of initial surgery, repeated yearly if villous or tubular adenomas >1 cm are found; otherwise, repeat every 3 to 5 years.

None provided

The recommendations are supported by randomized trials and meta-analyses.

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

2002 Jun (revised online 2004 Jan)

Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]

The Practice Guidelines Initiative (PGI) is the main project of the Program in Evidence-based Care (PEBC), a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Gastrointestinal Cancer Disease Site Group

Members of the Gastrointestinal Cancer Disease Site Group (DSG) disclosed potential conflict of interest information.

None available

This NGC summary was completed by ECRI on May 14, 2004. The information was verified by the guideline developer on June 2, 2004.