Download Follow-up Care, Surveillance Protocol, and Secondary Prevention

Evidence-Based Series 26-2 Version 2
A Quality Initiative of the
Program in Evidence-based Care (PEBC), Cancer Care Ontario
Follow-up Care, Surveillance Protocol, and Secondary
Prevention Measures for Survivors of Colorectal Cancer
Members of the Colorectal Cancer Survivorship Group
Report Date: March 15 2016
This Evidence-based Series (EBS) was assessed in 2014 and endorsed by the
Colorectal Cancer Survivorship Group on March 10, 2016. The PEBC has a
formal and standardize process to ensure the currency of each document
(PEBC Assessment & Review Protocol)
EBS 26-2 is comprised of three sections
and is available on the CCO Website
Section 1: Guideline Recommendations
Section 2: Evidentiary Base
Section 3: EBS Development Methods and External Review Process
For information about the PEBC and the most current version of all reports, please visit the
CCO website at http://www.cancercare.on.ca/ or contact the PEBC office at:
Phone: 905-527-4322 ext. 42822 Fax: 905 526-6775 E-mail: [email protected]
Guideline Citation (Vancouver Style): Members of the Colorectal Cancer Survivorship Group. Follow-up
care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer.
Toronto (ON): Cancer Care Ontario; 2012 Feb 3. Program in Evidence-based Care Evidence-Based Series
No.: 26-2 Version 2.
EBS 26-2
Evidence-Based Series 26-2 Version 2: Section 1
A Quality Initiative of the
Program in Evidence-based Care (PEBC), Cancer Care Ontario
Follow-up Care, Surveillance Protocol, and Secondary
Prevention Measures for Survivors of Colorectal Cancer:
Guideline Recommendations
C. Earle, R. Annis, J. Sussman, A.E. Haynes, and A. Vafaei
Report Date: February 3, 2012
QUESTIONS
In colorectal cancer (CRC) survivors (adult patients who have completed primary
treatment for stage II or III CRC and who are without evidence of disease):
1. Which evaluations (e.g., colonoscopy, computed tomography [CT], carcinoembryonic
antigen [CEA], liver function, complete blood count [CBC], chest x-ray, history,
physical exam) should be performed for surveillance for recurrence of cancer?
2. What is a reasonable frequency of these evaluations for surveillance?
3. Which symptoms and/or signs potentially signify a recurrence of CRC and warrant
investigation?
4. What are the common and/or significant long-term and late effects of CRC treatment?
5. On what secondary prevention measures should CRC survivors be counselled?
6. Are there preferred models of follow-up care in Ontario, i.e., should patient follow-up
be done by a medical oncologist, radiation oncologist, surgeon, advanced practice
nurse, physician assistant, or primary care provider (e.g., family physician, nurse
practitioner, family practice nurse)?
OBJECTIVES
The Program in Evidence-based Care (PEBC) of Cancer Care Ontario (CCO) undertook
this survey of practice guidelines in order to create a reasonable, specific follow-up protocol
for survivors of CRC, with two purposes: (i) to facilitate different models of survivorship care
by having a guidance document with which any clinician (e.g., non-specialist physician,
advanced practice nurse) would be able to provide follow-up care to survivors of CRC and (ii)
to allow standards for overuse and underuse to be developed, against which practice could be
measured and reported.
TARGET POPULATION
CRC survivors: adult patients who have completed primary treatment for stage II or III
disease and are without evidence of disease. Whether these recommendations are
extrapolated to stage I patients is left to the discretion of the healthcare provider.
Section 1: Guideline Recommendations
Page 1
EBS 26-2
INTENDED USERS
This guideline is targeted for:
1. Clinicians (e.g., medical oncologist, radiation oncologist, surgeon, advanced practice
nurse, physician assistant, primary care provider [family physician, nurse practitioner,
family practice nurse]) involved in the delivery of care for CRC survivors.
2. Patients and family of patients who have survived CRC.
3. Healthcare organizations and system leaders responsible for offering, monitoring, or
providing resources for CRC survivorship protocols.
RECOMMENDATIONS AND KEY EVIDENCE
Eleven existing guidelines on follow-up protocols for CRC survivors addressed research
questions 1-5 (1-12) (Appendix 1, Section 1). The authors evaluated these guidelines with the
AGREE II (13) tool. In addition, the website of the Standards and Guidelines Evidence (SAGE)
Inventory
of
Cancer
Guidelines
(available
from:
http://www.cancerguidelines.ca/Guidelines/inventory/index.php) was searched for a record
of each included guideline, because AGREE II evaluations are conducted and reported for all
guidelines in the inventory. AGREE II evaluations were available for all eleven included
guidelines, and the scores for each of the evaluations across different domains are
summarized in Section 2, Appendix 2. The clinical authors confirmed that these guidelines
are still valid and in use by clinicians. For research question 6, one randomized controlled
trial (14) was identified that evaluated follow-up care of CRC cancer survivors.
The recommendations from each of the identified guidelines (Section 1, Appendix 2)
are consistent across all the guidelines. The consensus of the Colorectal Cancer Survivorship
Working Group (Section 1, Appendix 3) was that all the included guidelines were of sufficient
quality to inform the development of Ontario-specific recommendations. However, the PEBC
(6), American Society of Clinical Oncology (ASCO) (8), Cancer Council Australia and Australian
Cancer Network (9), New Zealand Guidelines Group (11), and National Comprehensive Cancer
Network (NCCN) (2,3) practice guidelines were considered to be of higher quality than those
remaining.
The recommendations and specific protocol below are based on the expert opinion of the
authors, interpretation of the available evidence (described in Section 2 of this
document), and feedback obtained from care providers across Ontario through an
extensive review process (described in Section 3 of this document).
The recommended evaluations and intervals for the routine surveillance of CRC survivors
are summarized in Table 1. These recommendations reflect the range of acceptable
testing reported in the source documents, the opinion of the authors, and the views
obtained through the review process.
1.
Which evaluations should be performed for CRC survivors for surveillance for
recurrence of cancer?
2. How often should CRC survivors undergo evaluation for surveillance?
Section 1: Guideline Recommendations
Page 2
EBS 26-2
RECOMMENDATIONS
A medical history and physical examination along with the CEA laboratory test should be
performed every six months for five years.
Key Evidence
The ASCO guideline (8) recommends a history and physical examination every three to
six months for the first three years and then every six months for two more years. After the
fifth year, the schedule for further examinations is at the discretion of the physician. ASCO
also recommends postoperative serum CEA testing every three months in patients with stage
II or III disease, for at least three years. The recommended schedule of the NCCN (4,5) and
Australian (9) guidelines for physical examinations for up to five years is similar to that of
ASCO, except that the frequency decreases after two years, and both recommend testing CEA
in every physical examination session. The updated PEBC guideline recommends testing
serum CEA and a physical examination when the patient is symptomatic or every six months in
the first three years and then yearly for up to at least five years (6). The European Society
for Medical Oncology (ESMO) has different guidelines for rectal (2) and colon cancers (3). For
colon cancer, the recommendations are similar to those of ASCO and NCCN: physical
examination and CEA testing every six months for three years and then every six to 12 months
for years four and five; rectal cancer survivors are only recommended to undergo physical
examination every six months for two years.
Qualifying Statements

A CBC and other routine blood work, aside from a CEA, are not recommended for routine
surveillance.

A Fecal Occult Blood Test (FOBT) is not recommended for routine surveillance.
Abdominal and chest CT scans are recommended annually for three years. A pelvic CT
scan is also recommended on the same schedule if the primary tumour was located in the
rectum.
Key Evidence
 The ASCO (8) and NCCN (4,5) guidelines recommend performing a CT scan of the abdomen
every year for three years for colon cancer survivors. The ESMO guideline
recommendations are similar but with shorter start dates to the intervals: every six to 12
months for the first three years. The Australian (9) guideline recommends a liver CT for
CRC survivors but provides no schedule.
 ASCO (8) recommends a chest CT annually for three years. ESMO (3) suggests a chest CT
scan every six to 12 months for the first three years in colon cancer survivors who are at
higher risk of recurrence and imaging the lungs at one and three years after surgery for
rectal cancer survivors.
 NCCN recommends a pelvic CT scan only for rectal cancer (5). ASCO (8) states that pelvic
CT scans can be considered for survivors of rectal cancer.
Section 1: Guideline Recommendations
Page 3
EBS 26-2
Qualifying Statement
 If local resources and/or patient preference preclude the use of CT, an ultrasound (US)
can be substituted for the CT of the abdomen and pelvis and a chest x-ray can be
substituted for the chest CT. Every six to 12 months for three years and then yearly
for years four and five is a reasonable schedule for these tests.
Key Evidence
The PEBC (6) guideline recommends a liver US every six months for the first three years and
then yearly for a total of at least five years. The EMSO guideline (3) suggests that a contrastenhanced US could substitute for an abdominal CT.
A surveillance colonoscopy should be performed approximately one year after the initial
surgery. The frequency of subsequent surveillance colonoscopies should be dictated by
the findings of the previous one, but they generally should be performed every five years
if the findings of the previous one are normal.
Key Evidence
The NCCN guideline (4,5) recommends a colonoscopy at one year, and thereafter as clinically
indicated. The PEBC (6) guideline recommends a colonoscopy yearly as long as polyps are
found; if no polyps are present, the colonoscopy is to be repeated every three to five years.
The remaining guidelines recommend similar approaches: The ASCO (8), Australian (9),
American Cancer Society (ACS) (7), and ESMO (2,3) guidelines recommend a colonoscopy at
three years after surgery and then every five years if the results are normal.
Qualifying Statement
 If a complete colonoscopy was not performed in the course of diagnosis and staging
(e.g., due to obstruction) the included guidelines consistently state that one should be
done within six months of completing primary therapy.
Table 1. Recommended evaluations and intervals for routine surveillance of CRC cancer
survivors.
Evaluation
Recommendation
Physical
examination,
history, and CEA
A medical history and
physical examination
along with the laboratory
test of CEA should be
performed.
Abdominal
imaging
Abdominal CT scanning is
recommended.
Section 1: Guideline Recommendations
Recommended frequency
Every 6 months for 5 years.
Under-use*
Years 1 – 5:
<1 within 12
months
Over-use*
Years 1 – 5:
>4 CEAs within 12
months
5+ Years: > 0
Annually for 3 years.
Years 1 – 3:
< 1 CT within
12 months
Or, < 1 U/S
within 12
months
Years 1 – 5:
> 2 CTs within 12
months
Or, > 4 U/S within
12 months
5+ Years: > 0
Page 4
EBS 26-2
Pelvic imaging
Pelvic CT scan is
recommended if the
primary tumour was
located in the rectum.
Annually for 3 years.
Years 1 – 3:
< 1 CT within
12 months
Years 1 – 5:
> 2 CTs within 12
months
Or > 0 if not
pelvic
5+ Years: > 0
Chest imaging
Colonoscopy
Chest CT scanning is
recommended.
Surveillance colonoscopy
is recommended.A
Annually for 3 years.
At 1 year following surgery; the
frequency of subsequent
surveillance colonoscopies
should be dictated by the
findings of the previous one, but
generally should be performed
every 5 years, if the findings of
the previous one are normal.
Years 1 – 3:
< 1 CT within
12 months
Or < 1 CXR
within 12
months
< 1 within 3
years, then < 1
every 5 years
Years 1 – 5:
> 2 CTs within 12
months
Or > 4 CXRs within
12 months
5+ Years: > 0
> 1 per year
Notes: CEA=carcinoembryonic antigen; CT=computed tomography; CXR=chest x-ray; U/S=ultrasound.
A
For rectal cancer patients who are considered at high risk of local recurrence by the treating physician, sigmoidoscopy may be
considered at intervals less than 5 years.
*Measured from completion of primary therapy, i.e., the end of adjuvant treatment if given, or surgery when no adjuvant
treatment is given, and with +/- 3 month leeway.
UPDATE 2016
This document was assessed in accordance with the PEBC Document Assessment and Review
Protocol. At that time, the clinical experts expressed some concerns about a footnote in Table 1
in Section 1, Section 2 and Section 3 that states that “Patients with rectal cancer who have not
received pelvic radiation should receive a rectosigmoidoscopy every 6 months for 2-5 years. There
was concern that this particular statement was not consistent with current clinical practice as local
recurrence rates are quite low and imaging with CT and MRI are quite good. It was suggested to
change the footnote to “for rectal cancer patients who are considered at high risk of local
recurrence by the treating physician, sigmoidoscopy may consider at intervals less than 5 years”.
Members of the Colorectal Cancer Survivorship Group endorsed the change and the
recommendations found in Section 1 (Clinical Practice Guideline) on March 8, 2016.
Section 1: Guideline Recommendations
Page 5
EBS 26-2
3. Which symptoms/signs potentially signify a recurrence of CRC and warrant
investigation?
RECOMMENDATION
In the expert opinion of the authors, any new and persistent or worsening symptom
warrants the consideration of a recurrence, especially:




Abdominal pain, particularly in the right upper quadrant or flank (liver area).
Dry cough.
Vague constitutional symptoms such as:
o Fatigue.
o Nausea.
Unexplained weight loss.

Signs and/or symptoms specific to rectal cancer
o Pelvic pain.
o Sciatica.
o Difficulty with urination or defecation.

There are no signs of symptoms specific to colon cancer that would not also apply to
rectal cancer.
Table 2 provides an estimate of the percentage of patients with recurrence at five
years by site of recurrence.

Table 2. Sites of recurrent disease.
Site of Recurrence
*
Liver
Lung
Peritoneal
Retroperitoneal
Peripheral Lymph Nodes
Other (brain, bones)
Loco-regional
Second or metachronous CRC cancer
Percent of Patients with Recurrence at 5 Years by
Site of Initial Tumour*
Colon
35
20
20
15
2
<5
15
3
Rectum
30
30
20
5†
7†
<5
35 †
3
Data modified from Galandiuk et al1. The median time to recurrence is significantly shorter for stage C versus B and
for lesions that originally had perforation or adhesion/invasion of surrounding structures (p<0.01).
†
Indicates significant differences (p<0.05).
1
Galandiuk S, Wieand HS, Moertel CG, Cha SS, Fitzgibbons RJ Jr, Pemberton JH, et al. Patterns of recurrence after
curative resection of carcinoma of the colon and rectum. Surg Gynecol Obstet. 1992;174:27-32.
Section 1: Guideline Recommendations
Page 6
EBS 26-2
4. What are the common and/or significant long-term and late effects of CRC treatment?
RECOMMENDATION
In the expert opinion of the authors, common long-term or late effects of treatment for
CRC may include the following:




General
o Fatigue
o Distress (e.g., anxiety, depression)
Related to surgery
o Frequent and/or urgent bowel movements or loose bowels—often improves over first few
years.
o Gas and/or bloating.
o Incisional hernia.
o Increased risk of bowel obstruction.
o In patients who received ostomy—lifestyle adjustment will be required.
Related to medication
o Peripheral neuropathy (associated with treatment using oxaliplatin).
o “Chemo-brain,” including difficulty with short-term memory and the ability to
concentrate.
Related to radiation
o Localized skin changes (i.e., colour, texture, and loss of hair).
o Rectal ulceration and/or bleeding (radiation colitis).
o Anal dysfunction (incontinence).
o Bowel obstruction (from unintended small bowel scarring).
o Infertility.
o Sexuality dysfunction (e.g., vaginal dryness, erectile dysfunction, retrograde ejaculation).
o Second primary cancers in the radiation field (typically about seven years after
radiotherapy).
o Bone fracture (e.g., sacral region).
5. On what secondary prevention measures should CRC survivors be counselled?
RECOMMENDATION
Despite the lack of high-quality evidence on secondary prevention in CRC survivors, the
following counselling goals would be reasonable based on lower levels of evidence and the
expert opinion of the authors:




Maintain an ideal body weight.
Engage in a physically active lifestyle.
Eat a healthy diet.
There are insufficient data to make a firm recommendation regarding the role of
acetylsalicylic acid (ASA) in the secondary prevention of CRC.
6. Is there a preferred model of follow-up care in Ontario?
A response to question 6 was added in October 2012, after the completion of PEBC EvidenceBased Series (EBS) 26-1: Models of Care for Cancer Survivorship. The recommendation and
the evidentiary base used to inform the recommendation were taken from EBS 26-1.
Section 1: Guideline Recommendations
Page 7
EBS 26-2
RECOMMENDATION
The most common practice for follow-up care in Ontario involves specialist-coordinated
care within an institution. Emerging evidence suggests that, for CRC cancer survivors who
have completed all their treatment, discharge from specialist-led care to communitybased family physician-coordinated or institution-based nurse-coordinated care is a
reasonable option.
Key Evidence
 The evidence suggests that when colon cancer survivors were followed by a communitybased family physician, there were no significant differences for rates of recurrence;
time-to-detection of recurrence; death rates; or physical, psychosocial or quality-of-life
components compared to survivors who were followed by an institutional-based specialist
(14). This finding can reasonably be applied to both colon and rectal cancer populations
as the follow-up care trajectories are very similar.
 The working group was unable to find comparative studies investigating the role of nursecoordinated follow-up of CRC cancer survivors. The recommendation that CRC cancer
survivors may be followed by nurses is based on the success of nurse-coordinated followup of breast cancer survivors (15,16) and on the similarity in the follow-up care trajectory
between CRC and breast cancers, in settings where guideline recommended visits and
testing can be organized by physicians or nurses within the institutional setting.
RELATED GUIDELINE
 PEBC EBS 2-9 Version 2: Follow-up of patients with curatively resected colorectal cancer.
Singh S, Tey R, reviewers. Toronto (ON): Cancer Care Ontario; 2011 Sep 15 [Endorsed 2010
Jun 16]. Program in Evidence-based Care Evidence-Based Series No.: 2-9 Version 2.
Available from:
http://www.cancercare.on.ca/toolbox/qualityguidelines/diseasesite/gastro-ebs/
 PEBC EBS 26-1: Sussman J, Souter LH, Grunfeld E, Howell D, Gage C, Keller-Olaman S,
Brouwers M. Models of care for cancer survivorship. Toronto (ON): Cancer Care Ontario;
2012 Oct [Pending public availability]. Program in Evidence-based Care Evidence-Based
Series No.: 26-1.
Funding
The PEBC is a provincial initiative of Cancer Care Ontario supported by the Ontario Ministry of Health
and Long-Term Care. All work produced by the PEBC is editorially independent from the Ontario
Ministry of Health and Long-Term Care.
Updating
All PEBC documents are maintained and updated
as described in the PEBC Document Assessment and Review Protocol at
http://www.cancercare.on.ca/.
Copyright
This report is copyrighted by Cancer Care Ontario; the report and the illustrations herein may not be
reproduced without the express written permission of Cancer Care Ontario. Cancer Care Ontario
reserves the right at any time, and at its sole discretion, to change or revoke this authorization.
Section 1: Guideline Recommendations
Page 8
EBS 26-2
Disclaimer
Care has been taken in the preparation of the information contained in this report. Nonetheless, any
person seeking to apply or consult the report is expected to use independent medical judgment in the
context of individual clinical circumstances or seek out the supervision of a qualified clinician. Cancer
Care Ontario makes no representation or guarantees of any kind whatsoever regarding the report
content or use or application and disclaims any responsibility for its application or use in any way.
Contact Information
For information about the PEBC and the most current version of all reports,
please visit the CCO web site at http://www.cancercare.on.ca/ or contact the PEBC office at:
Phone: 905-527-4322 ext. 42822 Fax: 905 526-6775 E-mail: [email protected]
Section 1: Guideline Recommendations
Page 9
EBS 26-2
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Cairns SR, Scholefield JH, Steele RJ, Dunlop MG, Thomas HJW, Evans GD, et al.
Guidelines for colorectal cancer screening and surveillance in moderate and high risk
groups (update from 2002). Gut. 2010 May 1, 2010;59(5):666-89.
Glimelius B, Pahlman L, Cervantes A, Group EGW. Rectal cancer: ESMO clinical practice
guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010 May;21 Suppl 5:v82-6.
Labianca R, Nordlinger B, Beretta GD, Brouquet A, Cervantes A, Group EGW. Primary
colon cancer: ESMO clinical practice guidelines for diagnosis, adjuvant treatment and
follow-up. Ann Oncol. 2010 May;21 Suppl 5:v70-7.
National Comprehensive Cancer Network (NCCN) Colon Cancer Panel. NCCN clinical
practice guidelines in oncology. Colon Cancer V.3.2010. National Comprehensive Cancer
Network;
2010
[cited
2010
Jun
21].
Available
from:
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
National Comprehensive Cancer Network (NCCN) Rectal Cancer Panel. NCCN clinical
practice guidelines in oncology. Rectal cancer V.3.2010. National Comprehensive Cancer
Network;
2010
[cited
2010
Jun
21].
Available
from:
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Figueredo A, Rumble RB, Maroun J, Earle CC, Cummings B, McLeod R, et al. Follow-up of
patients with curatively resected colorectal cancer [Internet]. Singh S, Tey R, reviewers
[2010]. Toronto (ON): Cancer Care Ontario; 2004 [endorsed 2010 Jun 16; cited 2010 Jun
21].
Practice
Guideline
Report
No.:
1-24.
Available
from:
http://www.cancercare.on.ca/toolbox/qualityguidelines/diseasesite/gastro-ebs/.
Rex DK, Kahi CJ, Levin B, Smith RA, Bond JH, Brooks D, et al. Guidelines for colonoscopy
surveillance after cancer resection: a consensus update by the American Cancer Society
and US Multi-Society Task Force on Colorectal Cancer. CA Cancer J Clin. 2006 MayJun;56(3):160-7; quiz 85-6.
Desch CE, Benson AB, 3rd, Somerfield MR, Flynn PJ, Krause C, Loprinzi CL, et al.
Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology
practice guideline.[Erratum appears in J Clin Oncol. 2006 Mar 1;24(7):1224]. J Clin Oncol.
2005 Nov 20;23(33):8512-9.
Australian Cancer Network Colorectal Cancer Guidelines Revision Committee. Guidelines
for the prevention, early detection and management of colorectal cancer. Sydney: The
Cancer Council Australia and Australian Cancer Network; 2005 [cited 2010 Jun 21].
Available from: http://www.nhmrc.gov.au/publications/synopses/cp106/cp106syn.htm.
Anthony T, Simmang C, Hyman N, Buie D, Kim D, Cataldo P, et al. Practice parameters
for the surveillance and follow-up of patients with colon and rectal cancer. Dis Colon
Rectum. 2004 Jun;47(6):807-17.
New Zealand Guidelines Group. Surveillance and management of groups at increased risk
of colorectal cancer. Wellington, New Zealand: New Zealand Guidelines Group; 2004
[cited 2010 Jun 21]. Available from:
http://www.nzgg.org.nz/guidelines/dsp_guideline_popup.cfm?&guidelineID=48.
Figueredo A, Rumble RB, Maroun J, Earle CC, Cummings B, McLeod R, et al. Follow-up of
patients with curatively resected colorectal cancer: a practice guideline. BMC Cancer.
2003 Oct 6;3:26.
Brouwers M, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II:
Advancing guideline development, reporting and evaluation in healthcare. CMAJ.
2010;182(18):E839-42.
Section 1: Guideline Recommendations
Page 10
EBS 26-2
14. Wattchow DA, Weller DP, Esterman A, Pilotto LS, McGorm K, Hammett Z, et al. General
practice vs surgical-based follow-up for patients with colon cancer: randomised
controlled trial. Br J Cancer. 2006;94(8):1116-21.
15. Beaver K, Tysver-Robinson D, Campbell M, Twomey M, Williamson S, Hindley A, et al.
Comparing hospital and telephone follow-up after treatment for breast cancer:
randomised equivalence trial. BMJ. 2009;338:a3147.
16. Kimman ML, Dirksen CD, Voogd AC, Falger P, Gijsen BC, Thuring M, et al. Economic
evaluation of four follow-up strategies after curative treatment for breast cancer: results
of an RCT. Eur J Cancer. 2011;47(8):1175-85.
Section 1: Guideline Recommendations
Page 11
EBS 26-2
APPENDICES: SECTION 1
Appendix 1. List of included guidelines.
GUIDELINE YEAR
REFERENCE
ASCO
2005
American
Cancer
Society
2006
NCCN
2010
PEBC
2004
PEBC EBS 2-9 version 2: Follow-up of patients with curatively resected
(UPDATE colorectal cancer.
2010)
http://cancercare.on.ca/common/pages/UserFile.aspx?fileId=14014
AUSTRALIA 2005
NHMRC
ESMO
2010
BSG/
ACGBI
SPTF/
ASCRS
NZGG
2010
Colorectal Cancer Surveillance: 2005 Update of an American Society of
Clinical Oncology Practice Guideline. Desch, et al. J Clin Oncol.
2005;23:8512-9.
Guidelines for colonoscopy surveillance after cancer resection: a
consensus update by the American Cancer Society and US Multi-Society
Task Force on Colorectal Cancer. CA Cancer J Clin. 2006;56(3):160-6.
Colon Cancer:
http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf
p. 36-8
Rectal Cancer:
http://www.nccn.org/professionals/physician_gls/PDF/rectal.pdf
p.32-4
The Cancer Council of Australia Document approved by the National
Health and Medical Research Council Clinical Practice Guidelines for
the Prevention, Early Detection and Management of Colorectal Cancer;
Chapter 17: Follow up after curative resection for Colorectal Cancer:
http://www.nhmrc.gov.au/publications/synopses/cp106/cp106divided
.htm#a17
Rectal cancer: ESMO clinical practice guidelines for diagnosis,
treatment and follow-up. Ann Oncol. 2010;21 Suppl 5:v82–v86.
Primary colon cancer: ESMO clinical practice guidelines for diagnosis,
adjuvant treatment and follow-up. Ann Oncol. 2010;21 Suppl 5:v70–
v77.
Guidelines for colorectal cancer screening and surveillance in moderate
and high risk groups (update from 2002). Gut. 2010;59:666-90.
2004
Practice parameters for the surveillance and follow-up or patients with
colon and rectal cancer. Dis Colon Rectum. 2004;47(6):807-17.
2004
Surveillance and management of groups at increased risk of colorectal
cancer.
http://www.nzgg.org.nz/guidelines/0048/040624_FINAL_Full_for_Web
_Colorectal_Guideline1.pdf
Notes: ACGBI= Association of Coloproctology for Great Britain and Ireland; ASCRS=American Society of Colon and
Rectal Surgeons; BSG=British Society of Gastroenterology; NZGG=New Zealand Guidelines Group; SPTF=Standards
Practice Task Force.
Section 1: Guideline Recommendations
Page 12
EBS 26-2
Appendix 2. Summary of recommendations from identified guidelines.
ASCO 2005
ACS 2006
Stage II or III
Stage I-III
NCCN
2010*
Stage I-III
Evaluation
PEBC 2010
Stage IIb-III
(I-III for
colonoscopy)
Australia
2005
“curatively
resected”
ESMO 2010*
Stage not
specified
BSG/ACGBI
2010
ASCRS/
SPTF 2004
Stage not
specified
Stage not
specified
Physical
exam/History
Q 3-6 m first 3 y, Q
6m to 5 y, then at
the discretion of the
physician
Q 3-6m for 2
y, then Q 6 m
for total of 5 y
Q 6 m first 3 y,
then yearly for at
least 5 y
Q 3-6m for 2 y,
then Q 6m-1y
thereafter
Rectal: Q 6 m for
2y
Colon: Q3-6m for
3 y then Q6-12m
in years 4-5
At least 3
times per year
for first 2
years
CEA
Q 3 m for at least 3
y
Q 3-6m for 2
y, then Q 6 m
for total of 5 y
Q 6 m x 3y, then
yearly for at least
5y
Q 3-6 m in
conjunction
with clinical
review
Colon: Q3-6 m for
3 y then Q6-12 m
at years 4 & 5
At least 3
times per year
for first 2
years
CT: Annually
for 3-5y
Ultrasound: Q 6 m
first 3 y, then
yearly for at least
5y
Abdominal
imaging
CT: Annually for 3 y
Pelvic CT
Consider for rectal
cancer patients
Chest imaging
CT: Annually for 3 y
CXR: not
recommended
Colonoscopy
At 3 y, if normal
then Q 5 y
CT: within 2 y
after surgery
Stage not
specified
Q 6 m for 2 y, then
yearly for a total of
3-5 y
Routine use
not
recommended
Rectal, CT: 1 and
3 y after surgery
CT
recommended,
no schedule
Annually for
3-5y
At 1 y, if
normal, then
at 3 y; again,
if normal, at 5
yA
CT
recommended,
no schedule
Colon: CT or
contrast enhanced
ultrasound, Q 612m for first 3 y
NZGG 2004
CT: Annually
for 3-5y
CXR: Q 6 m first
3y, then yearly for
at least 5 y
CT
recommended,
no schedule
Rectal : Lung
imaging at 1 & 3
y after surgery
Colon: CT Q 6-12
m first 3 y
At 1 y then as
clinically
indicated
Yearly as long as
polyps are found;
if no polyps
present, repeat
every 3-5 years.
3 to 5 y after
the initial
operation and
then at Q3-5 y
intervals
Rectal: Q5yB
Colon: at year 1,
then Q3-5 y
CXR:
insufficient
evidence to
recommend
for or against
5 y after surgery
then Q5 y
intervals
3 y after
surgery then
Q3 y
3-5 y after surgery
then at Q 3-5 y
intervals
Q 6 m for 5 y for
Rectal, anterior
rectal cancer
Rectal Q 6 m for 2 y
Rectoresection: Q3Rectal: Q 6 m for
patients who
then yearly for at
6m
then
Q
6m2
y
sigmoidoscopy
haven’t received
total of 5 y
1y thereafter
pelvic radiation
Notes: ACGBI=Association of Coloproctology for Great Britain and Ireland; ACS=American Cancer Society; ASCO=American Society of Clinical Oncology; ASCRS=American Society of
Colon and Rectal Surgeons; BSG=British Society of Gastroenterology; CT=computed tomography; CXR=chest x-ray; ESMO=European Society for Medical Oncology; m=months;
NCCN=National Comprehensive Cancer Network; NZGG=New Zealand Guidelines Group; PEBC=Program in Evidence-based Care; Q=every; SPTF=The Standards Practice Task Force;
y=year(s).
*Both NCCN and ESMO published two separate guidelines: one on rectal cancer and another on colon cancer.
A
Patients who did not have colonoscopy as part of initial diagnostic work-up should have a colonoscopy within 3-6 months of surgery.
B
Patients who did not have colonoscopy as part of initial diagnostic work-up should have a colonoscopy within 1 year of surgery.
Section 1: Guideline Recommendations
Page 13
EBS 26-2
Appendix 3. Members of the Working Group.
Dr. Craig Earle*………………..… Medical oncologist, Odette Cancer Centre at Sunnybrook Health
Sciences Centre; Senior Scientist, Institute for Clinical
Evaluative Sciences.
Dr. Rob Annis……………………….. Family physician, Southwest Regional Primary Care Lead,
Cancer Care Ontario.
Dr. Jonathan Sussman………….. Radiation oncologist, Juravinski Cancer Centre.
Mr. Adam Haynes…………………. Research coordinator, Program in Evidence-based Care, Cancer
Care Ontario.
Mr. Afshin Vafaei................Research coordinator, Program in Evidence-based Care, Cancer
Care Ontario.
*Lead author.
Section 1: Guideline Recommendations
Page 14