Association of Coloproctology of Great Britain &amp; Ireland (<scp>ACPGBI</scp>): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) – Follow Up, Lifestyle and Survivorship

Abstract

The role of follow up after curative treatment for colorectal cancer continues to evolve. The potential benefits of follow up for patients and Colorectal MDTs are Previous meta-analyses of randomized controlled trials of follow up after curative colorectal cancer resection have shown survival benefit in patients undergoing ‘intensive’ follow up, with odds ratio of 0.73 (95% CI 0.59–0.91) and 0.74 (95% CI: 0.59–0.93) respectively over ‘less intensive’ follow up (Jeffery et al., 2007; Tjandra & Chan, 2007). There was a reduction in the time to recurrence and more curative surgical procedures performed in the intensively followed up arm but there is no consensus as to what constitutes ‘intensive’ follow up. A more recent meta-analysis has found that although intensive monitoring resulted in earlier detection of recurrent disease by a median of 10 months, this did not confer any survival advantage over ‘less intensive’ monitoring protocols (Mokhles et al., 2016). Evidence suggests that serum carcinoembryonic antigen (CEA) and CT imaging are the two investigations that have significant potential to detect treatable metastatic recurrence in patients with colorectal cancer. Due to significant heterogeneity in these trials, this guideline is unable to recommend the optimal frequency and duration of follow up investigations. The FACS trial reported that in patients who had undergone curative surgery for primary colorectal cancer, intensive CT imaging (CT of the chest, abdomen, and pelvis every 6 months for 2 years, then annually for 3 years) or CEA screening (serum CEA every 3 months for 2 years, then every 6 months for 3 years) each provided an improved rate of detected recurrence treatable with curative intent compared with minimal follow-up; there was no additional advantage in combining CEA and CT (Primrose et al., 2014). Complete visualization of the colon is recommended prior to curative resection to detect synchronous cancers and adenomas. This can be achieved with optical colonoscopy or CT colonography in most patients. In patients who have undergone emergency resection, the remaining colon and rectum should be visualized within 6 months of surgery. Subsequent colonoscopic surveillance should be performed in accordance with British Society of Gastroenterology guidelines (Cairns et al., 2010). The 2011 NICE guidelines recommend commencing follow-up 4–6 weeks after potentially curative surgery (National Institute for Health and Care Excellence, 2011). The follow-up should consist of; Re-investigation should be instituted if there are any clinical, radiological, or biochemical suspicion of recurrent disease. Regular follow-up should cease when the patient and healthcare professionals agree that likely benefits are outweighed by the risks of investigation or the patient cannot tolerate further treatment. A minimum of two CT scans of the chest, abdomen and pelvis are recommended within the first 3 years of resection. Recommendation grade B Regular serum CEA (every 6 months in the first 3 years) could be used in addition to CT with local consensus. Recommendation grade C A ‘clean’ colon should be confirmed by colonoscopy or CTC at 1 year and subsequently at 5 yearly intervals. Recommendation grade C Follow up should cease in elderly or unfit patients by mutual agreement. Recommendation grade D Follow up may be more important in those with social isolation as survival after cancer treatment is worse in those who are unmarried (Nilsen et al., 2008), or those with comorbidities. Thus, cancer-specific mortality is increased in patients with diabetes and colon cancer (Isomura et al., 2006). Patients’ preference is for follow up, but by whom, and where, may depend on local circumstances (Al Chalabi et al., 2014; McFarlane et al., 2012). All patients should have access to appropriate support throughout the period of follow up. Recommendation grade C Audit of clinical outcomes underpins clinical governance. As hospital-specific and surgeon-specific outcome data on colorectal cancer in England and Wales become available in the public domain, accurate, relevant and timely acquisition of data has become a pre-requisite. Audit allows clinicians and MDTs to measure and compare their individual and unit outcomes. These audit data provide units and individuals with information to improve their practice. Colorectal MDTs should be resourced to provide accurate and timely entry of data to NBOCAP. Recommendation grade D Population-based studies have demonstrated risk reduction in colorectal cancer through regular moderate physical activity (Howard et al., 2008; Isomura et al., 2006; Larsson et al., 2006; Nilsen et al., 2008). A meta-analysis reported that engaging in high levels of physical activity prior to the diagnosis of colorectal cancer was associated with a 25% lower cancer-specific mortality compared to those with low levels activities. In addition, survivors who were involved in high levels of physical activity during and after treatment for colorectal cancer lowers the risk of recurrence (Meyerhardt et al., 2006) and mortality (Schmid & Leitzmann, 2014) (Meyerhardt et al., 2006). There is no consensus regarding the optimal level of physical activity required to achieve these benefits but the Chief Medical Officers from England, Scotland, Wales and Northern Ireland have published recommendations on the frequency and intensity of physical activity required to maintain a healthy lifestyle (Department of Health, 2011). Meyerhardt et al. 2007, reported that those on the highest quintile of a Western dietary pattern had an over 2-fold increased risk of colorectal cancer recurrence and mortality to those on the lowest quintile (Meyerhardt et al., 2007). McCullough et al. suggested that ongoing high consumption of red and processed meat before, and after, the diagnosis of colorectal cancer was associated with a 79% increased risk of cancer specific mortality (McCullough et al., 2013). High carbohydrate intake including sugar-sweetened beverages is associated with an increased risk of disease recurrence and mortality (Meyerhardt et al., 2012) (Fuchs et al., 2014). Patients should be encouraged to limit the consumption of red meat, processed meat and refined carbohydrates and observe a low carbohydrate diet. Recommendation grade C Advice on physical activity, weight management and diet should be available for cancer survivors during and after treatment. Recommendation grade C The journey for cancer survivors begins at the point of diagnosis and continues beyond the completion of treatment. Survivors may develop a recurrence, a second cancer, metastases or suffer the long-term physical, emotional and psychological effects of cancer treatment. Provision of care for survivors should include cancer surveillance, intervention for consequences of treatment and health promotion. The National Cancer Survivorship Initiative (NCSI) was set up in 2007 and is a partnership between NHS England and Macmillan Cancer Support. This alliance aims to provide cancer survivors with the necessary care and support to lead healthy and active lives. Further information about how NCSI aims to provide such care and support can be found in the ‘Living with and beyond cancer: Taking action to improve outcomes’ document drawn up in 2013 (Department of Health, 2013). Key areas where interventions can make a significant difference in survivorship include: A tailored follow-up plan to meet the needs of individuals and stratified according to oncological risk is desirable. This plan may need to be modified during the follow up process, depending on the presence of any ongoing symptoms or toxicities. The Treatment Summary should be generated by the cancer MDT to clarify the individualized follow up plan for the patient and primary care team. Patients who are unlikely to be fit for further invasive therapies could be discharged from secondary care with mutual agreement. Cancer survivors should have access to information and support from the point of diagnosis. Recommendation grade D Individualized care planning, treatment and follow up plan should be developed for cancer survivors according to their needs, stage of their disease and co-morbidities. These should be communicated with patients and primary care. Recommendation grade D None of the authors have any conflicts of interest to declare.