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440
W. D. Buie and A. R. MacLean
Perforated Rectal Cancer
• Free intraperitoneal perforation.
– Urgent surgery is generally required.
– The operation ideally should include an
oncologic resection of the primary tumor.
– The decision on whether to perform a pri-
mary anastomosis (with or without and
proximal diverting stoma) or a Hartmann
procedure depends on several factors,
including the overall health of the patient,
their perioperative stability, the duration
and extent of fecal contamination, and the
anticipated intraoperative technical
difculties.
– Rarely should one simply divert these
patients, as they risk having ongoing intraperitoneal tumor dissemination.
• Contained intraperitoneal perforation.
– Percutaneous drainage and medical
management.
– Once the patient is stable and the perfora-
tion controlled, complete staging.
– Treatment decisions must take into account
the fact that tumor cells are likely spread
outside the rectum and mesorectum.
• Typically neoadjuvant chemotherapy or
chemoradiotherapy is administered.
• The benet of neoadjuvant therapy
should be balanced against the risk of
sepsis in an immunocompromised
patient. However, many patients will
tolerate neoadjuvant radiotherapy or
chemoradiotherapy in this situation.
• Contained extraperitoneal perforation.
– We typically advocate proximal fecal
diversion, drainage of sepsis, neoadjuvant
chemoradiation, followed by radical excision, to include all tissues felt to have been
contaminated by the perforation. This can
require an exenterative procedure and/or an
extrafascial dissection.
• In the situation where a rectal cancer presents
with perianal sepsis and stulas, we generally
ensure that the sepsis is well controlled,
strongly consider fecal diversion with a laparoscopic loop sigmoid colostomy, and then
arrange for neoadjuvant chemoradiotherapy.
This is then followed by an APR with wide
pelvic and perineal excision. These patients
typically have large perineal wounds, and
many benet from a rectus abdominis myocutaneous ap for perineal reconstruction.
Synchronous Hepatic Metastases
• Advancements in liver surgery, nonsurgical
treatment of hepatic metastases, and systemic
chemotherapy have made it possible to consider a myriad of approaches for patients suffering from stage IV rectal cancer with
synchronous hepatic metastases (Table32.2).
• Assuming that the patient is a surgical candidate, there are three overriding questions that
need to be answered:
– Is the primary tumor resectable?
– Is the metastatic liver disease resectable?
– Is there extrahepatic metastatic disease?
• Both the primary and hepatic metastases are
resectable, and there is no extrahepatic
disease.
– Multiple options are available, with their
inherent advantages and disadvantages.
– Neoadjuvant therapy.
• Cytotoxic chemotherapy will treat both
the tumor and the metastatic disease.
Tumor response in the liver can be
assessed prior to embarking upon
resection.
Table 32.2 Ideal criteria for liver-rst protocol
1 Local-regional control does not require
downstaging with neoadjuvant therapy
2 Liver metastases are very clearly resectable for
cure with adequate residual liver
3 Good overall operative risk patient with normal
physiologic status and no known risk factors for
perioperative infectious complications and major
morbidity
4 Surgery can be performed in a high-volume liver
unit with low operative mortality and acceptable
morbidity
5 Delays due to unexpected postoperative
complications will not jeopardize local control or
cure
32 Rectal Cancer Decision-Making
441
• Long-course pelvic radiotherapy will
treat only the primary and delay denitive treatment of metastatic disease.
– It should be remembered that the
typical chemotherapy utilized for
long-course chemoradiotherapy
treatment of rectal cancer is inadequate treatment of distant
metastases.
• Short course pelvic radiotherapy is an
attractive option as it is administered in
a single week and has been proven to be
equally effective as long-course chemoradiotherapy, even with locally advanced
primary tumors. It can be administered
after chemotherapy, just prior to
surgery.
– Surgical resection.
• Synchronous resection of the liver disease and primary tumor can be contemplated if the patient is healthy and the
lesions are amenable to relatively
straightforward operation by experienced teams.
– The patient should be brought to the
operating room with the understanding that if there is any concern
regarding physiologic response to
the initial resection, the secondary
resection will be postponed.
• Philosophy of staged resections.
– If the primary tumor is asymptom-
atic, it may be preferable to embark
upon the liver resection rst, as clearance of the liver disease may drive
decisions regarding proctectomy.
– If the primary tumor is symptomatic
or bulky with threatened resection
margins, strong consideration should
be given to resecting the rectal tumor
rst.
• Extrahepatic disease.
– Generally believed to be a contraindication
to hepatic resection for cure in stage IV
disease.
– However, in select situations, in a good
risk, highly motivated patient, we will consider a lung resection following curative
resection of the primary and all liver
lesions.
– Surgery should be done sequentially at a
reasonable time interval after recovery
from the previous resections to ensure that
the disease remains localized and the
patient is fully optimized.
Colorectal Cancer: Postoperative Adjuvant Therapy
StephenM.Sentovich andMarwanFakih
33
Key Concepts
• Patients with stage III colon cancer should be
considered for adjuvant chemotherapy.
• Oxaliplatin-based adjuvant chemotherapy
regimens improve survival of stage III colon
cancer patients by an absolute 20–25% at
5years versus no chemotherapy.
• Adjuvant chemotherapy has not been demonstrated to have signicant impact on survival
for stage II colon cancer patients, but it can be
considered for patients whose tumors have
high-risk features.
• In colon cancer patients, radiotherapy should
be considered when tumors penetrate other
xed structures (T4) and can be guided by
placing surgical clips at the time of
operation.
• Patients with clinical stage II and III rectal
cancers who undergo neoadjuvant chemoradiotherapy should be considered for postoperative adjuvant chemotherapy, regardless of
the nal pathologic staging, although the ef-
S. M. Sentovich (*)
Department of Surgical Oncology, City of Hope,
Duarte, CA, USA
e-mail: ssentovich@coh.org
M. Fakih
Department of Medical Oncology and Therapeutic
Diagnostics, City of Hope Medical Center,
Duarte, CA, USA
cacy of adjuvant chemotherapy in this setting
has not been rmly established.
Colon Cancer
Stage III Colon Cancer
• Adjuvant chemotherapy is recommended for
all stage III colon cancer patients because it
decreases recurrence and increases survival
when compared to surgery alone.
– After surgery alone for stage III colon can-
cer, overall 5-year survival is 40–60%.
Current chemotherapeutic regimens
improve overall survival to 70–80%. Thus,
5-year overall survival of stage III colon
cancer patients improves by an absolute
20–25% with adjuvant chemotherapy.
– Table 33.1 summarizes the results of key
clinical trials establishing the efcacy of
adjuvant chemotherapy for nonmetastatic
colon cancer. If all patients with stage III
colon cancer receive adjuvant chemotherapy, roughly 1/3 to 1/2 of disease recurrences would be prevented.
• The National Quality Forum has endorsed two
metrics regarding the treatment of stage III
colon cancer patients.
– The rst metric (measure 0385) determines
the percentage of patients ≥18 years old
who are either referred for adjuvant
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_33
443
444
Table 33.1 Key clinical trials establishing the efcacy of adjuvant chemotherapy for colon cancer
Trial
INT 0035
1990
IMPACT
1995
QUASAR
2000
IMPACT
1999
NSABP (CO-1,
CO-2, CO-3, and
CO-4)
1999
MOSAIC
2009
XELOXA
2011
Tumor
stage Comparison Results Conclusion
Stage
III
Stage
III
Stage
III
Stage IISurgery alone vs.
Stage IISurgery alone vs.
Stage
II and
III
Stage
III
Surgery alone vs.
5-FU/levamisole
Surgery alone vs.
5-FU/leucovorin
5-FU/levamisole vs.
5-FU/folinic acid vs.
5-FU/placebo
5-FU/leucovorin
5-FU +
FOLFOX vs. 5-FU/
leucovorin
XELOX vs. 5-FU/
leucovorin
3-year survival
5-FU/levamisole 71%
Surgery alone 55%
3-year survival
5-FU/leucovorin 71%
Surgery alone 62%
Decreased survival and
increased recurrence with
levamisole compared with
placebo
5-year survival =no
difference
5-FU/leucovorin 82%
Surgery alone 80%
5-year survival improved
with adjuvant treatment
30% mortality reduction
with adjuvant treatment
6-year survival in stage III
only
FOLFOX 73%
5-FU/leucovorin 68%
3-year disease-free survival:
XELOX 71%
5-FU/leucovorin 67%
S. M. Sentovich and M. Fakih
Post-op adjuvant chemo
improves survival for stage
III colon cancer
Post-op adjuvant chemo
improves survival for stage
III colon cancer
Post-op adjuvant chemo
with levamisole inferior to
placebo
Post-op adjuvant chemo
does not improve survival
for stage II colon cancer
Post-op adjuvant chemo
improves survival for stage
II colon cancer
FOLFOX superior to 5-FU/
LV for stage III colon cancer
Capecitabine plus
oxaliplatin superior to 5-FU/
leucovorin
Table 33.2 Current recommended adjuvant chemotherapy regimens for stage III colon cancer
Regimen Agents and dosage Frequency
mFOLFOX6 Oxaliplatin 85mg/m
CapeOx Oxaliplatin 130mg/m
over 2h, day 1
Leucovorin 400mg/m
over 2h, day 1
5-FU 400mg/m
on day 1 and then
1200mg/m
IV continuous infusion
over 2h, day 1
Capecitabine
850–1000mg/m
daily for 14days
2
2
IV
2
IV
2
IV bolus
/day x 2days
2
IV
2
PO twice
Every
2weeks
Every
3weeks
chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy in the last 12months.
– The other metric (measure 0223) deter-
mines the percentage of patients under the
age of 80 for whom adjuvant chemotherapy
is considered or administered within
4months of the diagnosis.
• For patients with stage III colon cancer, the
National Comprehensive Cancer Network
(NCCN) guidelines recommend adjuvant
treatment with FOLFOX or CapeOx for
6months (Table33.2).
• While used frequently in patients with metastatic disease, biologic therapy with antibodies directed at VEGF-A (bevacizumab) and
EGFR antibody (panitumumab, cetuximab) is
not recommended for adjuvant therapy of
stage III disease.
Stage II Colon Cancer
• Unlike stage III disease, the role of adjuvant
chemotherapy in stage II disease remains
controversial, with some studies showing a
benet and others showing no benet.
• Following surgery for stage II colon cancer,
the current NCCN guidelines (February 2015)
recommend observation (surgery alone),
enrollment in a clinical trial, or adjuvant che-
33 Colorectal Cancer: Postoperative Adjuvant Therapy
445
motherapy. To sort out these options, a detailed
discussion with the patient is recommended to
highlight the potential benets and risks of
chemotherapy.
– Any high-risk features should be identied
and discussed (Table33.3).
• Patients with or without high-risk features should consider observation, clinical trial, or chemotherapy with
capecitabine or 5-FU/leucovorin.
• In general, only those patients with
high- risk features should be considered
candidates for FOLFOX or CapeOx
regimens.
• Decision-making regarding the use of adjuvant chemotherapy for stage II disease may be
aided by performing genetic testing of the
tumor after surgical resection.
– High microsatellite instability (MSI-H) or
defective mismatch repair (dMMR) status
has been shown to be associated with a
lower recurrence rate (11% vs. 26%) after
surgical resection alone.
– In addition, MSI-H tumors do not benet
from 5-FU adjuvant therapy. Thus, MSI/
MMR testing is recommended in all
patients with stage II disease in order to
avoid giving adjuvant chemotherapy in
patients who will derive no benet from it.
– In addition to MSI/MMR testing, multi-
gene colon cancer assays such as Oncotype
Dx, ColoPrint, and ColDx are now available that can also predict prognosis and
risk of recurrence. All three of these multigene assays predict recurrence independent
from other factors such as TNM stage,
MMR status, tumor grade, and nodes.
While these assays provide additional
information regarding prognosis and recurrence risk, they are not predictive of the
potential benet of chemotherapy and consequently are, to date, of limited clinical
value.
Radiotherapy forColon Cancer
• Radiotherapy plays a limited role in patients
with colon cancer.
• A few retrospective, single institution studies
have shown that adjuvant radiotherapy
improves local control for colon cancer
patients at high risk of recurrence after surgery. Unfortunately, the single randomized
prospective trial comparing chemotherapy
alone with combined chemotherapy and radiotherapy lacks sufcient power to draw valid
conclusions.
• Current NCCN guidelines recommend that
radiotherapy for colon cancer be considered in
patients with T4 tumors with penetration to a
xed structure. The radiation eld should
include the tumor bed as dened by preoperative imaging and the placement of surgical
clips at the time of operation.
– Thus, the colorectal surgeon should always
be ready to place clips in and around the
tumor bed during operations involving the
resection of a xed T4 colon tumor in order
to help direct postoperative radiotherapy.
• Neoadjuvant chemoradiotherapy can be considered for select patients with bulky tumors
invading other structures.
Rectal Cancer
Table 33.3 High-risk factors for recurrence
Poorly differentiated histology (exclusive of those that
are MSI-H)
Lymphatic/vascular invasion
Perineural invasion
Close, indeterminate, or positive margins
Bowel obstruction
Localized perforation
Less than 12 lymph nodes examined
• Decisions regarding postoperative adjuvant
treatment for rectal cancer are based primarily
on tumor location, clinical stage, histologic
stage, and history of neoadjuvant therapy.
• Proximal rectal/rectosigmoid tumors are
located at least 12cm proximal to the anal
verge and are above the peritoneal reection.
Although somewhat controversial, nonadvanced proximal rectal/rectosigmoid
446
S. M. Sentovich and M. Fakih
tumors are treated in the same fashion as
tumors elsewhere in the colon, with surgical
resection followed by postoperative chemotherapy for stage III and select stage II
tumors.
• Tumors of the middle/lower rectum are
located from 0–12cm from the anal verge as
measured by rigid proctoscopy. They typically
have a worse prognosis, stage for stage, when
compared to more proximal tumors, and thus
treatment recommendations are slightly
different.
Patients Who Did Not Undergo Neoadjuvant Therapy
• Like stage I colon cancer, 5-year survival after
surgery alone for stage I rectal cancer exceeds
90%. Thus, no adjuvant treatment is recommended for patients undergoing proctectomy
alone who are found to have T1-2N0M0 disease, assuming that margins of resection are
negative for tumor.
• For those found to have stage II or III disease
after proctectomy, decision-making is more
complex. Postoperative chemotherapy is
indicated for patients with stage III disease,
but the benet for stage II disease is less
certain.
• Postoperative radiotherapy should be considered for patients with stage II and III disease,
but this recommendation is highly controversial, as it is primarily based on data from the
past, when there was little emphasis on surgical quality or assessment of circumferential
radial margins.
– Postoperative radiotherapy is also associ-
ated with substantial long-term toxicity,
most notable in patients undergoing restorative proctectomy.
– The recommendation for routine postoper-
ative radiotherapy for patients with T3N0
disease with negative circumferential mar-
gins has thus been questioned, including in
the most recent iteration of the ASCRS
Practice Parameters for the Management of
Rectal Cancer.
– Even for patients with N+ disease, it is
unclear whether the small benet of postoperative radiotherapy in terms of local
control is worth the risk of toxicity, which
can be substantial.
• If patients are to be treated with postoperative
chemoradiotherapy, it is usually administered
using a sandwich technique. This involves
giving chemotherapy (FOLFOX or CapeOx)
followed by chemoradiotherapy (capecitabine
+ radiation or infusional 5FU+radiation) followed by more chemotherapy (FOLFOX or
CapeOx).
• In stage II and III rectal cancer patients, postoperative chemotherapy should be administered as soon as the patient has recovered from
surgery as each 4-week delay in chemotherapy results in a 14% decrease in overall
survival.
Patients Who Underwent Neoadjuvant Radiotherapy/ Chemoradiotherapy
• Overall, there is a paucity of data on which to
rely when making decisions regarding postoperative chemotherapy for patients with rectal
cancer because neoadjuvant therapy regimens,
surgical quality control, and pathologic processing have evolved so rapidly in the past
30years.
• Traditionally, patients with ypT3 or ypN+
disease have been recommended to undergo
postoperative chemotherapy. However, a
recent meta-analysis of published data
found that adjuvant fluorouracil-based chemotherapy did not improve overall survival,
disease- free survival, or distant recur-
33 Colorectal Cancer: Postoperative Adjuvant Therapy
Table 33.4 Neoadjuvant and adjuvant treatment of stage II and III rectal cancer
447
Option
I
Option
II
Capecitabine + Radiotherapy FOLFOX
OR Surgery OR
Infusional 5-FU + Radiotherapy Capecitabine + Oxalplatin
FOLFOX Capecitabine + Radiotherapy
OR OR Surgery
Capecitabine + Oxaliplatin Infusional 5-FU + Radiotherapy
rences, calling these recommendations into
question.
• If chemotherapy is utilized, it is also controversial as to which regimen to utilize. Two
randomized clinical trials have reported a
disease- free survival advantage to FOLFOX
vs. uoropyrimidine monotherapy in patients
previously treated with neoadjuvant chemoradiotherapy followed by rectal surgery.
• Clinicians should be aware that current
NCCN guidelines for clinical stage II and
III rectal cancer recommend either (1) preoperative chemoradiotherapy, surgery, and
then postoperative chemotherapy or (2)
preoperative chemotherapy followed by
preoperative chemoradiotherapy and then
surgery (see Table 33.4). The total duration of perioperative therapy (preoperative
chemoradiotherapy and chemotherapy)
should not exceed 6months. However, as
noted above, these recommendations are
based on incomplete and sometimes conflicting data.
• A summary of several key clinical trials
regarding chemoradiotherapy for rectal cancer
is shown in Table33.4.
Patients Undergoing Local Excision
• Due to the oncologically inferior results of
local excision as compared to proctectomy,
even in highly select patients, many authors
have recommended treatment with adjuvant
chemoradiotherapy, either in the preoperative
or postoperative period.
– The advantage of utilizing chemoradio-
therapy in the postoperative period is that T
stage can be known with certainty, and one
can ensure healing of the wound prior to
institution of radiotherapy.
– The advantage of utilizing neoadjuvant
chemoradiotherapy is that ypT stage correlates more closely with ypN stage than T
stage correlates with N stage and there may
be downsizing of the tumor prior to excision. The major downside of neoadjuvant
therapy combined with local excision is
that wound healing may be impaired, and
patients may suffer substantial morbidity
as a result.
• Table 33.5 lists key clinical trials establishing
the efcacy of chemoradiotherapy for rectal
cancer.
448
Table 33.5 Key clinical trials establishing the efcacy of chemoradiotherapy for rectal cancer
Trial
Swedish Rectal
Cancer Trial
1993
Dutch TME
Rectal Cancer
Trial
2001
German CAO/
ARO/AIO-94
2003/2004
EORTC 22921
2006
Cochran
Review: Postop
Chemo
2012
ADORE
2014
German CAO/
ARO/AIO-04
2012/2014
XRT radiation therapy, TME total mesorectal excision, preop preoperative, postop postoperative, yr. year, chemoxrt
combined chemoradiation therapy
Tumor
stage Comparison Results Conclusion
Stage II
and III
Stage II
and III
Stage II
and III
Stage II
and III
Stage II
and III
Stage II
and III
Stage II
and III
Surgery alone vs. preop
short course XRT
TME alone vs. preop
XRT+TME
Preop chemoXRT vs.
postop chemo XRT
XRT vs. chemoXRT Survival benet for
No postop chemo vs.
postop chemo after
neoadjuvant
FOLFOX vs. 5-FU/
leucovorin after
neoadjuvant
Neoadjuvant and
adjuvant FOLFOX vs.
5-FU/leucovorin
Local recurrence:
27% vs. 12%
5-yr survival: 48%
vs. 58%
Local recurrence:
11.4% vs. 5.6%
Survival: no
difference
Local recurrence:
13% vs. 6%
Toxicity: 40% vs.
27%
Survival: no
difference
ypT0–2 responders
Recurrence reduced
25%
Deaths reduced 17%
3-yr disease-free
survival:
72% vs. 62%
Complete pathologic
response: 17% vs.
13%
3-yr survival: 76%
vs. 71%
S. M. Sentovich and M. Fakih
Preop XRT decreases local
recurrence, improves survival (?)
Preop XRT improves local
recurrence even with TME
Preop XRT no effect on survival
Decreased toxicity and local
recurrence with preop
chemoXRT
Pre vs. post: no effect on survival
Chemo in addition to XRT can
improve survival in the subgroup
of responders
Postop chemo reduces recurrence
and death rate after neoadjuvant
Postop FOLFOX superior to
5-FU after neoadjuvant
Preop and postop addition of
oxaliplatin improves survival and
pathologic response
Colorectal Cancer: Surveillance After Curative-Intent Therapy
ScottE.Regenbogen andKarinM.Hardiman
34
Key Concepts
• Liver metastases and locoregional recurrence
are more likely to be amenable to curativeintent salvage resection when detected in
asymptomatic patients. Therefore, active surveillance is indicated for patients who are
candidates for liver and/or intestinal
resection.
• Use of carcinoembryonic antigen testing and
computed tomography (CT) scans is associated with increased detection of asymptomatic
recurrence after curative resection for colorectal cancer. There is no evidence to support the
use of any other laboratory testing or positron
emission tomography (PET) scans in routine
surveillance.
• Patients with advanced age and comorbidity,
who would not be t to undergo therapy for
recurrence should not be subjected to active
surveillance. They should, however, receive
evaluation and treatment for symptoms suggestive of recurrence.
• Patients with resected rectal cancers are at
greater risk for locoregional recurrence. This
risk is increased by omission of chemoradiotherapy for locally advanced tumors, close or
S. E. Regenbogen (*) · K. M. Hardiman
Division of Colorectal Surgery, University of
Michigan, Ann Arbor, MI, USA
e-mail: sregenbo@med.umich.edu
positive margins, T4 and N2 histology.
Consideration should therefore be given to
local pelvic surveillance both endoluminally
and extraluminally in these patients at highest
risk.
• Surveillance after resection of Stage I colorectal cancer remains controversial. While the
recurrence rates are low, in general, there are
markers of relatively greater risk, including
margin positivity, unknown lymph node status
(e.g., local excision), inadequate lymph node
sampling, lymphovascular invasion, poorly
differentiated histology, and/or T2 disease.
Active surveillance may be considered for
patients with one or more of these risk
factors.
Introduction
• With improvements in screening, diagnosis,
surgical technique, and adjuvant therapy for
colon and rectal cancers, nearly two thirds of
patients who undergo surgical resection survive 5 years or more.
• As a result, there is a rapidly growing population of colorectal cancer survivors, exceeding
1.2 million in the United States alone.
• These individuals face varying risk for subsequent colorectal cancer throughout their lifetime, yet there is little consensus on optimal
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_34
449
450
S. E. Regenbogen and K. M. Hardiman
regimens for surveillance and survivorship
care.
• At face value, the primary goal of colorectal
cancer surveillance is to detect treatable
recurrent, metastatic, or metachronous
colorectal malignancy and optimize the
opportunities for potentially curative
intervention.
• Ultimately, however, the success of colorectal cancer surveillance should be measured
by improvements in overall survival, cancerspecic survival, disability, or quality of
life.
• Some studies have evaluated proxy measures,
such as the rate of curative-intent metastasectomy or resection of colorectal neoplasia, but
it is not clear to what degree these additional
interventions benet colorectal cancer survivors more broadly.
• Interpretation and synthesis of ndings of
published studies are complicated by the heterogeneity of the interventions and comparisons – the surveillance intervention in one
trial may be no more intensive than the control
group regimen of another– and the challenges
of obtaining adequate power to detect meaningful differences in survival and other objective oncologic outcomes in such studies.
• It is also important to consider the appropriateness of surveillance for patients who might
not be eligible for, or willing to undergo, treatment for recurrence. Recognizing that older
adults account for the majority of colorectal
cancer patients, patient preferences, age,
comorbidities, and functional status must all
contribute to the decision to pursue active
surveillance.
– There is little need, for example, to conduct
surveillance for asymptomatic liver metastases for a patient unwilling or unable to
undergo hepatic resection and/or chemotherapy. For such patients, symptom-driven
evaluations may sufce.
• At the same time, the landscape around both
the detection and treatment of recurrence
continues to evolve. It remains unclear
whether increased detection and aggressive
treatment of local or distant recurrence
results in true benet to patients or whether
stage migration and lead time bias produces
apparent gains.
Timing andChoice ofSurveillance
Modalities
Intensity ofSurveillance
• There are various clinical, laboratory, radiographic, and endoscopic methods available for
surveillance after treatment of colorectal cancer. Recommendations regarding their application and frequency of use vary between
agencies involved in scripting guidelines for
colorectal cancer care and are summarized in
Table34.1.
• Most guidelines include more intensive early
surveillance, with diminishing frequency after
2–5years, due to the recognition that 80% of
recurrences are detected within 3 years after
initial curative-intent surgical therapy, and at
least 95% are evident within 5years.
• After 3 years without evidence of disease,
cancer-specic mortality declines signicantly, and conditional survival thereafter is
very high.
• There have been at least eight prospective randomized trials addressing outcomes of surveillance after curative resection.
– Overall, there is a lack of high-level evi-
dence to support specic choices among
surveillance regimens, but their interpretation is complicated by the heterogeneity of
the surveillance regimens, changes in the
diagnostic and therapeutic technologies
available at the times they were conducted,
and limitations of sample size and duration
of follow-up.
– Nevertheless, we can likely conclude that
more frequent testing and the use of
advanced imaging will result in more
potentially curative surgery for recurrence
and a measurable, but small, improvement
in survival.