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The review should consist of history and examination, including digital examination of the rectum, and sigmoidoscopy in patients who had an anterior resection of the rectum. Regular CEA measurement and CT should be considered in follow-up protocols as they may provide useful clinical information. Colonoscopy should be performed three to five years after the initial operation in order to detect any metachronous tumour, and repeated at three to five-yearly intervals thereafter. The role of FOBT remains contentious. The optimal schedule, including duration, is not yet clear. Future studies should focus on the cost-effectiveness and efficiency of investigations employed. 29 17.6 Summary The debate regarding the rigour and intensity of follow-up investigations is complex. The benefits from follow up include: • the provision of audit and survival data • patient support • the ability to remove metachronous polyps and to detect early metachronous cancers • the detection of potentially curable recurrent disease. Current literature, based on meta-analyses of randomised controlled trials, 12,13 supports small but significant survival advantages for patients who are followed up intensively after curative resection of Colorectal Cancer. Although the costs and complications of follow-up investigations can be considerable, the cost may be economically justified. 28 Further large-scale trials are recommended to determine cost in the Australian setting, the impact of follow up on quality of life, exactly which tests should be used, and the timing of these tests, and to compare specialist follow up with general practitioner follow up. The Followup after Colorectal Surgery (FACS) study is in progress in the United Kingdom and is designed to answer these questions. 30 These recommendations are for asymptomatic patients. All patients who develop symptoms should be investigated rigorously. Follow up after curative resection for colorectal cancer 203
References 1. Nava HR, Pagana TJ. Postoperative surveillance of colorectal carcinoma. Cancer 1982; 49: 1043-7. 2. Beck DE, Opelka FG, Hicks TC, Timmcke AE, Khoury DA, Gathright JB, Jr. Colonoscopic follow-up of adenomas and colorectal cancer. South Med J 1995; 88: 567-70. 3. Kievit J, Bruinvels DJ. Detection of recurrence after surgery for colorectal cancer. Eur J Cancer 1995; 31A: 1222-5. 4. Cochrane JP, Williams JT, Faber RG, Slack WW. Value of outpatient follow-up after curative surgery for carcinoma of the large bowel. Br Med J 1980; 280: 593-5. 5. Kjeldsen BJ, Kronborg O, Fenger C, Jorgensen OD. A prospective randomized study of followup after radical surgery for colorectal cancer. Br J Surg 1997; 84: 666-9. 6. Ohlsson B, Breland U, Ekberg H, Graffner H, Tranberg KG. Follow-up after curative surgery for colorectal carcinoma. Randomized comparison with no follow-up. Dis Colon Rectum 1995; 38: 619-26. 7. Makela JT, Laitinen SO, Kairaluoma MI. Five-year follow-up after radical surgery for colorectal cancer. Results of a prospective randomized trial. Arch Surg 1995; 130: 1062-7. 8. Schoemaker D, Black R, Giles L, Toouli J. Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients. Gastroenterology 1998; 114: 7-14. 9. Pietra N, Sarli L, Costi R, Ouchemi C, Grattarola M, Peracchia A. Role of follow-up in management of local recurrences of colorectal cancer: a prospective, randomized study. Dis Colon Rectum 1998; 41: 1127-33. 10. Bruinvels DJ, Stiggelbout AM, Kievit J, van Houwelingen HC, Habbema JD, van de Velde CJ. Follow-up of patients with colorectal cancer. A meta-analysis. Ann Surg 1994; 219: 174-82. 11. Rosen M, Chan L, Beart RW, Jr., Vukasin P, Anthone G. Follow-up of colorectal cancer: a meta-analysis. Dis Colon Rectum 1998; 41: 1116-26. 12. Renehan AG, Egger M, Saunders MP, O'Dwyer ST. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002; 324: 813-21. 13. Jeffery GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2002; CD002200. 14. Oberg AN, Lindmark GE, Israelsson AC, Hammarstrom SG, Hammarstrom ML. Detection of occult tumour cells in lymph nodes of colorectal cancer patients using real-time quantitative RT-PCR for CEA and CK20 mRNAS. Int J Cancer 2004; 111: 101-10. 15. Secco GB, Fardelli R, Gianquinto D et al. Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial. Eur J Surg Oncol 2002; 28: 418-23. 16. The Royal College of Surgeons of England, Association of coloproctology of Great Britain and Ireland. Guidelines for the Management of Colorectal Cancer.: 1996. 204 The prevention, early detection and management of colorectal cancer
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Clinical Practice Guidelines FOR TH
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© The Cancer Council Australia/Aus
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2.11 Conclusions...................
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11.2 High ligation ................
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17.4 Cost effectiveness of follow u
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Table 14.3 Pathological TNM staging
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Executive Summary • Colorectal Ca
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STRENGTH OF RECOMMENDATIONS 2,3 The
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Should red meat intake be altered t
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Chapter Recommendations 4 COMMUNICA
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Chapter 8 Recommendations How shoul
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Chapter Recommendations Should bowe
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Chapter Recommendations When should
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Chapter 17 Recommendations What pos
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Section I Early Colorectal Cancer
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Adenomatous polyps (adenomas) are b
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17. South Australian Cancer Registr
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CHAPTER 2 PRIMARY PREVENTION Studie
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Colorectal adenomas, especially adv
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vegetable (3.5 serves/1000 kcals) d
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mustard greens, swedes and turnips)
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for protection against Colorectal C
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Does selenium supplementation reduc
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the optimal duration of use, and ad
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References 1. Jass JR. Pathogenesis
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34. Kushi L, Giovannucci E. Dietary
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67. Fearon ER, Vogelstein B. A gene
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100. Il'yasova D, Hodgson ME, Marti
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133. Meyskens FL, Jr., Gerner EW. D
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CHAPTER 3 POPULATION SCREENING FOR
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studies also demonstrate that age i
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• symptoms • family medical his
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Should screening be recommended? Gu
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Box 3.3 Screening Pathway used in t
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References 1. Young GP, Levin B, Ro
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33. Alexander F, Weller D. Evaluati
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CHAPTER 4 COMMUNICATION WITH THE PA
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4.6 Coordination of care Treatment
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• assistance with and care of chi
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17. National Breast Cancer Centre,
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CHAPTER 5 THE PATIENT WITH SYMPTOMS
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considered (see 8.1.5). Double cont
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58 The prevention, early detection
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diagnoses prove difficult to confir
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What recommendations are there for
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References 1. Woolf CM. A genetic s
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34. Australian Health Technology Ad
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CHAPTER 7 HIGH-RISK FAMILIAL COLORE
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offered predictive genetic testing.
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endoscopically uncontrollable numbe
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mutation carriers. 52 There is also
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standard for consideration of MSI a
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added to transvaginal ultrasound. 8
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category 2, see Chapter 6) but may
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What screening is recommended for e
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References 1. Vasen HF, Griffioen G
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33. Giardiello FM, Hamilton SR, Kru
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international criteria for the dete
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96. Burt RW, Jass JR. Hyperplastic
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8.1.2 Sigmoidoscopy: rigid versus f
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For radiological imaging of the lar
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8.2.3 Staging for distant metastase
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The feelings and fears of the patie
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18. Rex DK, Cutler CS, Lemmel GT et
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52. Liu SK, Church JM, Lavery IC, F
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strong family history of Colorectal
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A screening interval of 4-6 years i
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BRAF mutation, particularly when mu
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18. Jass JR, Young J, Leggett BA. E
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52. Jass JR, Young J, Leggett BA. H
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What is the role of the stomal ther
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What happens if a blood transfusion
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References 1. Bass EM, Del Pino A,
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32. The National Working Party on t
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CHAPTER 11 ELECTIVE SURGERY FOR COL
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Total or subtotal colectomy may be
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11.12 Self-expanding metal stents f
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18. Gall FP, Tonak J, Altendorf A.
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etween 1993 and 1999. The local rec
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When should local excision of recta
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What factors influence sphincter pr
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It has been demonstrated that there
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References 1. Smith TJ, Hillner BE,
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36. Vernava AM, III, Moran M, Rothe
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69. Pimentel JM, Duarte A, Gregorio
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Page 181 and 182: A clinical diagnosis of large bowel
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Study Country Comparator/ screening
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Study Country Study questions Concl
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Three United States studies investi
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Table 22.6 Results of studies inves
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22.9 Treatments 22.9.1 Surgery Seve
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Table 22.10 Results of studies inve
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Table 22.11 Summary of findings fro
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References 1. Australian Institute
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32. Nakama, H., B. Zhang, and A.S.
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65. Sieg, A., et al., Screening for
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97. Durand-Zaleski, I., et al., Eco
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Cost effectiveness 289
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References 1. National Health and M
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Appendices
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“Zorbas et al 2 Multidisciplinary
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a pathologist-molecular biologist o
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References 1. Australian Cancer Net
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Chapter 2 — Primary prevention an
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Three Cochrane systematic reviews w
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Dates 1 January 1998 to June 2004 S
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Dates Update of 1999 document from
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Search terms MeSH terms were ‘col
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Chapter 20 — The role of systemic
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Search terms Colorectal Cancer, soc
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However, in some cases it was also
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Professor James St John Gastro ente
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Working party on emergency surgery
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Dr Russel Stitz Surgeon, Royal Bris
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14. Dr Michael Izard Radiation Onco
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Mrs Avis Mcphee Consumer (June 9 an
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DVT deep venous thrombosis ECOG Eur
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TNM tumour, node, metastasis stagin
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Chemotherapy The use of drugs (whic
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Malignant Cancerous Malignant cells
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with a specific disease might survi
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