In the Journals

New guidelines urge colonoscopy surveillance after CRC resection

The U.S. Multi-Society Task Force on Colorectal Cancer has released updated recommendations on the use of endoscopy in patients after colorectal cancer resection, which emphasize the importance of colonoscopic surveillance in these patients to prevent metachronous cancer or diagnose recurrent and metachronous cancers at a curable stage.

“The U.S. Multi-Society Task Force has developed recommendations that update and replace the guidelines published in 2006,” Charles J. Kahi, MD, from the Richard L. Roudebush VA Medical Center and Indiana University School of Medicine in Indianapolis, told Healio Gastroenterology. “The document is based on a critical review of the recent literature regarding the role of colonoscopy, flexible sigmoidoscopy, endoscopic ultrasound, fecal testing and CT colonography in the surveillance of patients after surgical resection of colorectal cancer. The recommendations address the appropriate use and timing of colonoscopy for perioperative clearing and detection of metachronous neoplasms, considerations for the detection of local recurrence in the case of rectal cancer, and the role of CT colonography and fecal tests.”

Charles J. Kahi

The most recent data show postoperative colonoscopy is associated with lower overall mortality, but not cancer-specific mortality, so its value is mainly in perioperative clearing and preventing metachronous colon cancer, the task force wrote. The prevalence of synchronous cancers is 0.7% to about 7% in patients with CRC.

The task force recommends that patients with CRC undergo perioperative clearing with colonoscopy before surgery or within 3 to 6 months after surgery if there is a malignant obstruction. Surveillance colonoscopy should then occur 1, 4 and 9 years after surgery or perioperative colonoscopy, and then “at 5-year intervals until the benefit of continued surveillance is outweighed by diminishing life expectancy.”

These recommendations do not apply to patients with Lynch syndrome, and guidelines for polyp surveillance intervals should be followed if neoplastic polyps are detected, they wrote.

Additional local surveillance with flexible sigmoidoscopy or endoscopic ultrasound every 3 to 6 months for the first 2 to 3 years after surgery is recommended for surveillance of patients with rectal cancer, as they have an increased risk for local recurrence vs. those with colon cancer.

Regarding possible alternatives and adjuncts to colonoscopy, the task force recommends that in patients for whom complete colonoscopy is not possible due to obstructive CRC, CT colonography is the best alternative to exclude synchronous neoplasms. If CT colonography is not available, double-contrast barium enema is an acceptable alternative, they wrote. Finally, the task force does not support the routine use of fecal immunohistochemical tests or fecal DNA tests for surveillance after CRC resection due to insufficient evidence. – by Adam Leitenberger

Disclosure: The researchers report no relevant financial disclosures. 

The U.S. Multi-Society Task Force on Colorectal Cancer has released updated recommendations on the use of endoscopy in patients after colorectal cancer resection, which emphasize the importance of colonoscopic surveillance in these patients to prevent metachronous cancer or diagnose recurrent and metachronous cancers at a curable stage.

“The U.S. Multi-Society Task Force has developed recommendations that update and replace the guidelines published in 2006,” Charles J. Kahi, MD, from the Richard L. Roudebush VA Medical Center and Indiana University School of Medicine in Indianapolis, told Healio Gastroenterology. “The document is based on a critical review of the recent literature regarding the role of colonoscopy, flexible sigmoidoscopy, endoscopic ultrasound, fecal testing and CT colonography in the surveillance of patients after surgical resection of colorectal cancer. The recommendations address the appropriate use and timing of colonoscopy for perioperative clearing and detection of metachronous neoplasms, considerations for the detection of local recurrence in the case of rectal cancer, and the role of CT colonography and fecal tests.”

Charles J. Kahi

The most recent data show postoperative colonoscopy is associated with lower overall mortality, but not cancer-specific mortality, so its value is mainly in perioperative clearing and preventing metachronous colon cancer, the task force wrote. The prevalence of synchronous cancers is 0.7% to about 7% in patients with CRC.

The task force recommends that patients with CRC undergo perioperative clearing with colonoscopy before surgery or within 3 to 6 months after surgery if there is a malignant obstruction. Surveillance colonoscopy should then occur 1, 4 and 9 years after surgery or perioperative colonoscopy, and then “at 5-year intervals until the benefit of continued surveillance is outweighed by diminishing life expectancy.”

These recommendations do not apply to patients with Lynch syndrome, and guidelines for polyp surveillance intervals should be followed if neoplastic polyps are detected, they wrote.

Additional local surveillance with flexible sigmoidoscopy or endoscopic ultrasound every 3 to 6 months for the first 2 to 3 years after surgery is recommended for surveillance of patients with rectal cancer, as they have an increased risk for local recurrence vs. those with colon cancer.

Regarding possible alternatives and adjuncts to colonoscopy, the task force recommends that in patients for whom complete colonoscopy is not possible due to obstructive CRC, CT colonography is the best alternative to exclude synchronous neoplasms. If CT colonography is not available, double-contrast barium enema is an acceptable alternative, they wrote. Finally, the task force does not support the routine use of fecal immunohistochemical tests or fecal DNA tests for surveillance after CRC resection due to insufficient evidence. – by Adam Leitenberger

Disclosure: The researchers report no relevant financial disclosures. 

    Perspective
    Douglas G. Adler

    Douglas G. Adler

    The new multi-society guideline on colonoscopy surveillance after colorectal cancer resection will very likely prove to be a valuable document for the coming years. Most gastroenterologists are very well informed with regards to surveillance in patients with a prior history of polyps; less so in patients with a prior history of CRC.

    Many patients with a history of CRC are often primarily followed by their oncologists (and often not referred back to the gastroenterologist who discovered the cancer in the first place via a screening colonoscopy). It seems likely that many oncologists were making recommendations for subsequent colonoscopy on a case by case basis. This guideline lays out a well thought out plan for follow-up colonoscopy in this setting.

    The authors recommend that patients with CRC undergo a colonoscopy perioperatively, or within 3-6 months in patients who have an obstructing cancer at the time of presentation. In most patients, excepting some patients with rectal cancer or those with high risk syndromes, the guideline recommends colonoscopy 1 year after surgery, followed by another 3 years later (thus 4 years after surgery), followed by another 5 years later (thus 9 years after surgery), and then every five years thereafter until the end of the surveillance period as decided by the patient and their physicians.

    Of note, the guideline does not recommend fecal DNA or FIT testing for surveillance after CRC resection, and leans heavily on colonoscopy as the main modality for surveillance, recognizing that some patients will undergo CT colonoscopy or barium enema for those who cannot undergo colonoscopy.

    I suspect that these recommendations will be closely studied in coming years to see if adherence to these guidelines further reduces mortality rates from recurrent CRC.

    • Douglas G. Adler, MD, FACG, AGAF, FASGE
    • Professor of Medicine Division of Gastroenterology and Hepatology Department of Internal Medicine University of Utah School of Medicine Director of Therapeutic Endoscopy Huntsman Cancer Institute Healio Gastroenterology Peer Perspective Board Member

    Disclosures: Adler reports no relevant financial disclosures.