Follow-Up after Surgery

Patients who have undergone resections for cure are followed closely to look for evidence of symptomatic or asymptomatic tumor recurrence that may be amenable to curative resection in a small number of patients. The optimal cost-effective strategy is not clear. Two randomized trials reported that intense follow-up with yearly colonoscopy, abdominal CT, and chest radiography did not improve overall outcome compared with most standard follow-up protocols. Patients should be evaluated every 3-6 months for 3-5 years with history, physical examination, and CEA determinations.

Patients who had a complete preoperative colonoscopy should undergo another colonoscopy 1 year after surgical resection. Patients who did not undergo full colonoscopy preoperatively should undergo colonoscopy within 3-6 months postoperatively to exclude other synchronous colorectal neoplasms and 1 year thereafter.

Thereafter, surveillance colonoscopy should be performed every 3-5 years to look for metachronous polyps or cancer. Because of the high incidence of local tumor recurrence in patients with rectal cancer, sigmoidoscopy should be performed every 3-6 months for 3 years. New onset of symptoms or a rising CEA warrants investigation with chest and abdominal CT to look for recurrent or metastatic disease that may be amenable to therapy. For patients with a rising CEA with unrevealing CT imaging, a PET scan is more sensitive for the detection of occult metastatic disease.

Prognosis

The stage of disease at presentation is the most important determinant of long-term survival: stage I, > 90%; stage II, 70-80%; stage III with fewer than four positive lymph nodes, 67%; stage III with more than four positive lymph nodes, 33%; and stage IV, 5-7%. For each stage, rectal cancers have a worse prognosis. For those patients whose disease progresses despite therapy, meticulous efforts at palliative care are essential.

Rebecca A. Barnetson and Malcolm G. Dunlop
Colon Cancer Genetics Group, University of Edinburgh, School of Molecular and Clinical Medicine and MRC Human Genetics Unit, Western General Hospital, Edinburgh, U.K.

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