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© 2000 American Society for Clinical Oncology
2000 Update of American Society of Clinical Oncology Colorectal Cancer Surveillance GuidelinesFrom the American Society of Clinical Oncology, Alexandria, VA. Address reprint requests to American Society of Clinical Oncology, 1900 Duke St, Suite 200, Alexandria, VA 22314; email guidelines{at}asco.org THE AMERICAN SOCIETY of Clinical Oncology (ASCO) published evidence-based clinical practice guidelines on colorectal cancer surveillance in 1999.1 ASCO guidelines are updated at intervals by a subset of the original expert panel. For the 2000 update, the expert panel cochairs completed the review and analysis of data published since 1994. Computerized literature searches of MEDLINE and CancerLit were performed. The searches of the English-language literature from 1997 to 2000 combined the terms colon neoplasms and rectal neoplasms with the term surveillance. The set of articles yielded from this initial search was combined in turn with each of the tests or procedures addressed in the original guideline (eg, history and physical examination, liver function test, carcinoembryonic antigen). The searches were limited to human-only studies and clinical trials. The cochairs held a teleconference to consider the evidence for each of the 1999 recommendations. The guideline update was circulated in draft form to the full expert panel for review and approval. Each guideline from the 1999 guideline is listed below; followed by the 2000 update and then by the 2000 recommendation, if applicable.* GUIDELINES
1.
1999 Guideline. (Note: Adopted from the ASCO Clinical Practice Guidelines for the Use of Tumor Markers in Breast and Colon Cancer.).
If resection of liver metastases is clinically indicated, it is recommended that postoperative serum carcinoembryonic antigen (CEA) testing be performed every 2 to 3 months in patients with stage II or III disease for 2000 Update. A study from the Eastern Cooperative Oncology Group followed patients on the INT 0089 trial after surgical resection for high-risk stage B2 and C colon carcinoma.2 For the 421 patients who developed recurrent disease, investigators tried to determine which tests were the most effective and cost-effective in detecting metastases. Follow-up testing was done by protocol guidelines. Ninety-six of the 421 patients with recurrent disease underwent surgical resection with curative intent. For the subgroup of resectable patients, the first test to detect recurrence was the CEA test (n = 30), chest x-ray (n = 12), colonoscopy (n = 14), and other tests (n = 40). The physician’s examination was unsuccessful in finding resectable disease. The CEA test was the most cost-effective approach to detecting potentially resectable metastases from colon cancer. Another study followed patients with a specified testing strategy after curative colorectal surgery. In this study, 64% of recurrences were detected first by CEA testing, far more than the other tests in the battery.3 2000 Recommendation. No change.
2. 1999 Guideline. No data directly address the contribution of the history and physical examination to outcomes of colorectal cancer surveillance. However, it is the consensus of the expert panel to suggest that a clinical history and pertinent physical examination should be performed every 3 to 6 months for the first 3 years and annually thereafter. 2000 Update. Several articles confirm the general impression that routine doctor visits for a physical examination have little impact on finding resectable recurrences from colorectal cancer.2,3 However, there are no mechanisms in the health care system that permit the ordering and interpretation of any of the recommended tests without physician coordination. Therefore, the panel recommends periodic physician visits to obtain a history of symptoms, coordinate tests, and counsel patients as needed. 2000 Recommendation. Clinical history, test coordination, and patient counseling should be performed by the physician every 3 to 6 months for the first 3 years and annually thereafter.
3. 1999 Guideline. The data are sufficient to suggest against the regular monitoring of any liver function tests after primary therapy for colon and rectal cancer. 2000 Update. None. 2000 Recommendation. No change.
4. 1999 Guideline. The data are sufficient to recommend against periodic fecal occult blood testing in surveillance for colorectal cancer recurrence. 2000 Update. Few studies of colorectal cancer follow-up require or suggest fecal occult blood testing. The usefulness of this test is more established as a screening tool for primary cancer. 2000 Recommendation. No change.
5. 1999 Guideline. The data are sufficient to recommend against routine computed tomography (CT) scanning in colorectal cancer follow-up. 2000 Update. Studies continue to show that CT, ultrasonography, and magnetic resonance imaging are useful in the work-up of suspected metastatic colorectal cancer.4 Thirty-five percent of Medicare beneficiaries underwent multiple abdominal CT scanning after resection.5 However, no studies show that CT increases the proportion of patients eligible for resection. A recent cohort study examining whether compliance with follow-up affects resectability found that the CT scan is the first positive test in 11% of patients, far fewer than CEA testing.3 2000 Recommendation. No change.
6. 1999 Guideline. (Note: There was no consensus among panel members on this guideline. One dissenting vote is noted here.). Data are sufficient to suggest against routine yearly chest x-rays in colorectal cancer follow-up. Chest radiographs may be ordered to diagnose abnormalities prompted by an elevated CEA test or for patients who have symptoms suggestive of a pulmonary metastasis. 2000 Update. The Eastern Cooperative Oncology Group postsurgical surveillance cost analysis of colon cancer patients on INT 0089 (see Guideline 1, Carcinoembryonic Antigen, above) concluded that routine chest x-rays identified 12 (0.9%) of 1,356 patients with potentially curable disease.2 These results were comparable to those in other series and do not warrant any change in surveillance recommendations. 2000 Recommendation. No change.
7. 1999 Guideline. All patients should have a colonoscopy for the pre- or perioperative documentation of a cancer- and polyp-free colon. The data are sufficient to recommend colonoscopy every 3 to 5 years to detect new cancers and polyps. Routine annual colonoscopies are not recommended for all patients. The follow-up schema for colorectal screening guidelines, devised for patients with adenomatous polyps by the World Health Organization panel, is recommended. 2000 Update. None. 2000 Recommendation. No change.
8. 1999 Guideline. Combined chemotherapy and pelvic radiation represent the standard treatment for patients with stage II and stage III rectal cancer. For patients who have not received pelvic radiation, either because they could not for medical reasons or because they refused such treatment, direct imaging of the rectum at periodic intervals is suggested. For patients who have received pelvic radiation, direct imaging of the rectum (except for colonoscopy at 3 to 5 years) is not suggested. All patients with rectal cancer should have a colonoscopy for the pre- or perioperative documentation of a cancer- and polyp-free colon. 2000 Update. One study tested an aggressive surveillance program after curative surgery for locally recurrent rectal cancer.6 In this study, 62 patients underwent frequent endorectal ultrasound, CEA testing, digital examination, colonoscopy, and pelvic CT scanning. All local recurrences were detected by endorectal ultrasound. Unfortunately, there is no evidence that these patients received pre- or postoperative chemotherapy and radiation. Their 18% local-regional recurrence rate is higher than expected after combined-modality treatment. Large, randomized clinical trials confirm an expected recurrence rate of less than 10% for those patients treated with chemotherapy and radiation.7 These data do not demonstrate that direct or indirect imaging after combined-modality treatment influences survival or resectability. 2000 Recommendation. No change.
9. 1999 Guideline. Data are sufficient to suggest against routine pelvic imaging in asymptomatic patients who have received surgical resection and radiation for rectal cancer. 2000 Update. None. 2000 Recommendation. No change.
10. 1999 Guideline. The expert panel suggests against routine monitoring of the complete blood count for colorectal cancer surveillance. 2000 Update. None. 2000 Recommendation. No change. RESEARCH ISSUES New surveillance methods are needed to detect colorectal recurrences when resection or systemic treatment may prolong survival. The panel considered magnetic resonance imaging and positron emission tomography as tools requiring further study.8 Positron emission tomography seems promising in detecting liver metastases and distinguishing postoperative from neoplastic pelvic changes.9 The panel continues to recommend that studies be designed to determine whether any of the available imaging tests can increase the proportion of patients undergoing successful resection of metastatic disease over and above serial CEA monitoring.
NOTES Adopted on August 2, 2000, by the American Society of Clinical Oncology.
* The American Society of Clinical Oncology considers adherence to these guidelines to be voluntary. The ultimate determination regarding their application is to be made by the physician in light of each patient’s individual circumstances. In addition, these guidelines describe administration of therapies in clinical practice; they cannot be assumed to apply to interventions performed in the context of clinical trials, given that such clinical studies are designed to test innovative and novel therapies for this symptom in which better treatment is of paramount importance. In that guideline development involves a review and synthesis of the latest literature, a practice guideline also serves to identify important questions for further research and those settings in which investigational therapy should be considered. REFERENCES
1.
American Society of Clinical Oncology: Recommended colorectal cancer surveillance guidelines by the American Society of Clinical Oncology. J Clin Oncol 17: 1312-1321, 1999 2. Graham RA, Wang S, Catalano PJ, et al: Postsurgical surveillance of colon cancer: Preliminary cost analysis of physician examination, carcinoembryonic antigen testing, chest x-ray and colonoscopy. Ann Surg 228: 59-63, 1998[Medline] 3. Castells A, Bessa X, Daniels M, et al: Value of postoperative surveillance after radical surgery for colorectal cancer. Dis Colon Rectum 41: 714-724, 1998[Medline] 4. Lassau N, Leclere J, Elias D, et al: Role de l’imagerie dans la surveillance abdomino-pelvienne apres resection des cancers colorectaux. J Chir 134: 51-58, 1997 5. Cooper GS, Yuan Z, Chak A, et al: Geographic and patient variation among Medicare beneficiaries in the use of follow-up testing after surgery for nonmetastatic colorectal carcinoma. Cancer 85: 2124-2131, 1999[Medline] 6. Rotondano G, Esposito P, Pellecchia L, et al: Early detection of locally recurrent rectal cancer by endosonography. Br J Radiol 70: 567-571, 1997[Abstract]
7.
Tepper JE, O’Connell MJ, Petroni GR, et al: Adjuvant postoperative fluorouracil-modulated chemotherapy combined with pelvic radiation therapy for rectal cancer: Initial results of Intergroup 0014. J Clin Oncol 15: 2030-2039, 1997 8. Valk PI, Abella-Columna E, Haseman MK, et al: Whole-body PET imaging with [18F] fluorodeoxyglucose in management of recurrent colorectal cancer. Arch Surg 134:503-511, discussion 511-513, 1999 9. Takeuchi O, Saito N, Koda K, et al: Clinical assessment of positron emission tomography for the diagnosis of local recurrence in colorectal cancer. Br J Surg 86: 932-937, 1999[Medline] Submitted August 22, 2000; accepted August 22, 2000. This article has been cited by other articles:
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Copyright © 2000 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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2 years after diagnosis. An elevated CEA level, if confirmed by retesting, warrants further evaluation for metastatic disease but does not justify the institution of systemic therapy for presumed metastatic disease. 
