Guidelines for Colonoscopy Surveillance After Cancer Resection

Guidelines for Colonoscopy Surveillance After Cancer Resection: A Consensus Update by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer

 

Recommendations (Table 1Table
1) on the use of surveillance colonoscopy after resection of
colorectal cancer were produced jointly by the US Multi-Society Task
Force on Colorectal Cancer and the American Cancer Society (ACS). They
constitute the updated recommendations of both organizations. The
rationale for combined guidelines by organizations is discussed in the
accompanying joint recommendations on postpolypectomy surveillance.¹Winawer,
S.J., Zauber, A.G., Fletcher, R.H., Stillman, J.S., O’Brien, M.J.,
Levin, B., Smith, R.A., Lieberman, D.A., Burt, R.W., Levin, T.R., Bond,
J.H., Brooks, D., Byers, T., Hyman, N., Kirk, L., Thorson, A., Simmang,
C., Johnson, D., and Rex, D.K. Guidelines for Colonoscopy Surveillance
After Polypectomy (a consensus update by the US Multi-Society Task Force
on Colorectal Cancer and the American Cancer Society) .
Gastroenterology. ;
: 1872–1885

Abstract | Full Text | Full Text PDF | PubMed | Scopus (437)See all References
These guidelines were endorsed by the Colorectal Cancer Advisory
Committee of the ACS and by the governing boards of the American College
of Gastroenterology, the American Gastroenterological Association
Institute, and the American Society for Gastrointestinal Endoscopy.

Table 1Postcancer Resection Surveillance Colonoscopy Recommendations

1.  Patients with colon and rectal cancer should undergo high-quality perioperative clearing. In the case of nonobstructing tumors, this can be done by preoperative colonoscopy. In the case of obstructing colon cancers, computed tomography colonography with intravenous contrast or double-contrast barium enema can be used to detect neoplasms in the proximal colon. In these cases, a colonoscopy to clear the colon of synchronous disease should be considered 3 to 6 months after the resection if no unresectable metastases are found during surgery. Alternatively, colonoscopy can be performed intraoperatively.

2.  Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the performance of the colonoscopy that was performed to clear the colon of synchronous disease). This colonoscopy at 1 year is in addition to the perioperative colonoscopy for synchronous tumors.

3.  If the examination performed at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that colonoscopy is normal, then the interval before the next subsequent examination should be 5 years.

4. Following the examination at 1 year, the intervals before subsequent examinations may be shortened if there is evidence of hereditary nonpolyposis colorectal cancer or if adenoma findings warrant earlier colonoscopy.1Winawer, S.J., Zauber, A.G., Fletcher, R.H., Stillman, J.S., O’Brien, M.J., Levin, B., Smith, R.A., Lieberman, D.A., Burt, R.W., Levin, T.R., Bond, J.H., Brooks, D., Byers, T., Hyman, N., Kirk, L., Thorson, A., Simmang, C., Johnson, D., and Rex, D.K. Guidelines for Colonoscopy Surveillance After Polypectomy (a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society) . Gastroenterology. ; : 1872–1885 Abstract | Full Text | Full Text PDF | PubMed | Scopus (437)See all References

5.  Periodic examination of the rectum for the purpose of identifying local recurrence, usually performed at 3- to 6-month intervals for the first 2 or 3 years, may be considered after low anterior resection of rectal cancer. The techniques utilized are typically rigid proctoscopy, flexible proctoscopy, or rectal endoscopic ultrasound. These examinations are independent of the colonoscopic examinations described above for detection of metachronous disease.

Table 2Table 2 summarizes the differences in this guideline from previous guidelines on postcancer resection surveillance colonoscopy.

Table 2Differences Between This Guideline and Previous Guidelines on Postcancer Resection Surveillance Colonoscopy

In addition to careful perioperative clearing of the colorectum for synchronous lesions, a colonoscopy is recommended 1 year after surgical resection because of high yields of detecting early second, apparently metachronous cancers
Clinicians can consider periodic examination of the rectum for the purpose of identifying local recurrence after low anterior resection of rectal cancer. Candidates for Postcancer Resection Surveillance Colonoscopy In general, patients who undergo surgical resection of Stage I, II, or III colon and rectal cancers or curative-intent resection of Stage IV cancers are candidates for surveillance colonoscopy. Patients who undergo curative endoscopic resection of Stage I colon cancers are also candidates for surveillance colonoscopy. Patients with Stage IV colon or rectal cancer that is unresectable for cure are generally not candidates for surveillance colonoscopy because their chance of survival from their primary cancer is low, and the risks of surveillance outweigh any potential benefit. PubMedSee all References In summary, performance of annual colonoscopy for the purpose of detecting recurrent disease does not have an established survival benefit for patients with colorectal cancer. (However, as noted below, there is a rationale for surveillance of the rectum after resection of rectal cancer for the detection of local recurrence.) The primary goal of surveillance colonoscopy after resection of colorectal cancer is the detection of metachronous neoplasms. Distinguishing Rectal Cancer Versus Colon Cancer Follow-up Although there is no established benefit from endoscopic surveillance for the purpose of detecting early recurrences of the original cancer, in clinical practice many clinicians distinguish between rectal and colon cancer in this regard. The distinction is based on differences in the rates of local recurrence of rectal vs colon cancer. Specifically, in the case of colon cancer, recurrence at the anastomosis occurs in only 2%–4% of patients.2Barillari, P., Ramacciato, G., Manetti, G., Bovino, A., Sammartino, P., and Stipa, V. Surveillance of colorectal cancer (effectiveness of early detection of intraluminal recurrences on prognosis and survival of patients treated for cure) . Dis Colon Rectum. ; : 388–393 Detection of Metachronous Neoplasms A second potential benefit of surveillance colonoscopy is the detection of metachronous cancers at a surgically curable stage, as well as the prevention of metachronous cancers via identification and removal of adenomatous polyps. The incidence of metachronous cancers, the timing at which metachronous cancers occur, and the stage of these cancers at presentation or identification by surveillance colonoscopy should determine the optimal intervals for performance of surveillance colonoscopy directed toward metachronous disease. The evidence from published studies of postcancer resection surveillance in colonoscopy was reviewed to determine what these rates and timing of metachronous cancers are (Table 3Table 3). Limitations in interpretation of this literature were described earlier. Table 3Metachronous Cancers in Postcancer Resection Surveillance Colonoscopy Studies Study N Colonoscopies Metachronous CRCs (all) Metachronous CRCs (within 24 mo) Dukes’ A or B Number asymptomatic Reoperation for cure Barillari 481 12 6a 9 6b 7 Barrier 61c 0 Carlsson 129 546 1 0 NS NS NS Castells 199 0 Chen 231 4 0 NS 4 4 Eckardt 212 0 Granqvist 390 600 12 7 5d 6d 10 Green 3278 42 24 23 NS NS Juhl 133 316 4 0 4 4 4 Khoury 389 3889 2 1 NS NS NS Kjeldsen 597 10 NS NS 8 8 Kronborg 239 710 4 3 4 NS 4 Makela 106 1 NS NS NS 1 McFarland 74 237 0 Obrand 444 0 Ohlsson 53e 0 Patchett 132 2 NS NS 0 NS Pietra 207 1 NS NS NS NS Schoemaker 325 733 8 5 5 1 NS Skaife 611 609f 5 1 NS NS NS Stigliano 322 5 0 NS NS NS Togashi 341 1570 22 9 17 NS 22 Weber 75 197 2 1 2 NS 2 Total 9029 9407 137 57 69 29 62 aReport states that “more than one half” arose in first 24 months. bReports 46 combined local recurrences with metachronous tumors, of which 22 were asymptomatic; number calculated assumes similar proportion for metachronous cancers. cSubgroup who underwent perioperative colonoscopy. dReports 26 combined local recurrences with metachronous tumors, of which 10 were Dukes’ A or B and 14 were asymptomatic; numbers calculated assume similar proportion for metachronous cancers. eIntensive surveillance subgroup (control group did not undergo routine colonoscopy). fTwo patients underwent barium enema for completion of incomplete colonoscopy. From 2% to 7% of patients with colorectal cancer have 1 or more synchronous cancers in the colon and rectum at the time of initial diagnosis.3Barrier, A., Houry, S., and Huguier, M. The appropriate use of colonoscopy in the curative management of colorectal cancer. Int J Colorectal Dis. ; : 93–98 Alternatives to Colonoscopy for Surveillance Colonoscopy is considered the test of choice for detection of metachronous neoplasms in the postcancer resection surveillance colonoscopy setting (Table 4Table 4). Double-contrast barium enema was less sensitive than colonoscopy for large and small polyp detection after resection of adenomas.59National Polyp Study Work Group, Winawer, S.J., Stewart, E.T., Zauber, A.G., Bond, J.H., Ansel, H., Waye, J.D., Hall, D., Hamlin, J.A., Schapiro, M., O’Brien, M.J., Sternberg, S.S., and Gottlieb, L.A. A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. N Engl J Med. ; : 1766–1772 CrossRef | PubMed | Scopus (437)See all References Table 4Additional Recommendations Regarding Postcancer Resection Surveillance Colonoscopy 1. These recommendations assume that colonoscopy is complete to the cecum and that bowel preparation is adequate 2.  There is clear evidence that the quality of examinations is highly variable; continuous quality improvement process is critical to the effective application of colonoscopy in colorectal cancer prevention50Rex, D., Cummings, O., and Ulbright, T. Coming to terms with pathologists over colon polyps with cancer or high-grade dysplasia. J Clin Gastroenterol. ; : CrossRef | PubMedSee all References 3. Endoscopists should make clear recommendations to primary care physicians about when the next colonoscopy is indicated 4. Performance of fecal occult blood text is discouraged in patients undergoing colonoscopic surveillance 5.  Discontinuation of surveillance colonoscopy should be considered in persons with advanced age or comorbidities (<10 years life expectancy), according to the clinician’s judgment 6. Surveillance guidelines are intended for asymptomatic people; new symptoms may need diagnostic work-up 7. Chromoendoscopy (dye-spraying) and magnification endoscopy are not established as essential to screening or surveillance 8. Computed tomography colonography (virtual colonoscopy) is not established as a surveillance modality CT colonography has not been evaluated adequately in the surveillance setting, and results for polyp detection are quite mixed.60Rockey, D., Paulson, E., Favis, W. et al. Multicenter prospective comparison of colon imaging tests. (abstr)Gastroenterology. ; : A2004 See all References, 61Johnson, C.D., Harmsen, W.S., Wilson, L.A., McCarty, R.L., Welch, T.J., Ilstrup, D.M., and Ahlquist, D.A. Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps. Gastroenterology. ; : 311–319 Abstract | Full Text | Full Text PDF | PubMed | Scopus (289)See all References, 62Cotton, P.B., Durkalski, V.L., Pineau, B.C., Palesch, Y.Y., Mauldin, P.D., Hoffman, B., Vining, D.J., Small, W.C., Affronti, J., Rex, D.K. et al. Computed tomographic colonography (virtual colonoscopy). A multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. . ; : 1713–1719 CrossRef | PubMed | Scopus (512)See all References, 63Pickhardt, P.J., Choi, J.R., Hwang, I., Butler, J.A., Puckett, M.L., Hildebrandt, H.A., Wong, R.K., Nugent, P.A., Mysliwiec, P.A., and Schindler, W.R. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. ; : 2191–2200 CrossRef | PubMed | Scopus (1288)See all References Guaiac-based fecal occult blood testing generally has been considered to have very low positive predictive value after clearing colonoscopy. This was confirmed for the first 5 years after colonoscopy in a recent large study.64Finkelstein, S. and Bini, E.J. Annual fecal occult blood testing can be safely suspended for up to 5 years after a negative colonoscopy in asymptomatic average-risk patients. Gastrointest Endosc. ; : AB250 Abstract | Full Text | Full Text PDFSee all References Immunochemical fecal occult blood testing warrants additional evaluation as an adjunct to colonoscopy65Bampton, P.A., Sandford, J.J., Cole, S.R., Smith, A., Marcon, J., Cadd, B., and Young, G.P. Interval faecal occult blood testing in a colonoscopy based screening programme detects additional pathology. . ; : 803–806 CrossRef | PubMed | Scopus (45)See all References in this setting. Fecal DNA testing66Imperiale, T.F., Ransohoff, D.F., Itzkowitz, S.H., Turnbull, B.A., and Ross, M.E. Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med. ; : 2704–2714 CrossRef | PubMed | Scopus (486)See all References has not been evaluated for postcancer resection surveillance and is not recommended for this indication. Key Research Questions There are a number of questions that cannot be addressed fully by currently available evidence. Some of these key research questions are listed in Table 5Table 5.55Lieberman, D., Weiss, D., Bond, J., Ahnen, D., Garewal, H., and Chejfec, G. 380. VACSG. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. N Engl J Med. ; : 162–168 CrossRef | PubMed | Scopus (1219)See all References Table 5Key Research Questions Regarding Surveillance of the Colorectum After Resection of Colorectal Cancer 1.  What clinical, genetic, or biologic markers predict development of metachronous cancers (ie, stratify risk) in colorectal cancer patients without hereditary nonpolyposis colorectal cancer? 2.  Are new colorectal cancers in the short-term interval after surgical resection true metachronous cancers or missed synchronous lesions? 3.  Do follow-up procedures (flexible sigmoidoscopy, endoscopic ultrasound) after resection of rectal cancer improve any outcomes? 4.  Should the treatment of rectal cancer (eg, neoadjuvant chemoradiation, total mesorectal excision) influence whether follow-up evaluation for local recurrence is justified? 5. Should adjunctive testing (eg, immunochemical fecal occult blood testing) be added to colonoscopy in the surveillance of patients who have undergone resection of colorectal cancer?