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Long Term Survivorship Care

Staying vigilant: recurrence monitoring for colorectal cancer

 

Care for people diagnosed with colorectal cancer (CRC) doesn’t end when active treatment has finished. Your health care team will continue to check to ensure the cancer has not returned, manage side effects, and monitor your overall health. This is called follow-up care, and it includes the important practice of recurrence monitoring or surveillance.

Unfortunately, cancer can return after treatment for a few reasons. In some cases, the tumor was not completely removed during surgery and residual tumor cells were able to re-grow. It’s also possible some cells were able to survive chemotherapy. It is also possible that cancer cells had already spread in the body, even before surgery or chemotherapy treatment.

The goal of follow-up care is to detect whether the cancer has returned as early as possible, even before symptoms present. Early detection through recurrence monitoring increases the chance that the cancer can be treated and cured.

The odds for cancer recurrence increase if the initial tumor was diagnosed at an advance stage, however early detection and treatment of a recurrent tumor may improve patient survival.

In addition to recurrence monitoring, your follow-up care may also include regular physical examinations, medical tests, or both. Doctors want to keep track of your recovery in the months and years ahead.

Key messages

  • The primary goal of follow-up care for colorectal cancer is early detection of cancer that has returned after treatment.

  • Follow-up care for colorectal cancer includes regular physical examinations, carcinoembryonic antigen (CEA) tests, computed tomography (CT) scans, and colonoscopy or rectosigmoidoscopy.

  • Talk with your doctor about your risk of the cancer returning and an appropriate follow-up care schedule for you.

Recommendations for follow-up care


  • The recommendations for follow-up care included on this page are intended for people who had stage II to stage IV colorectal cancer and are now NED (no evidence of disease). It is less certain what testing should be done for people who had stage I colorectal cancer, as this stage has a lower risk of recurrence.  

  • If you had surgery for metastatic (cancer that has spread) colorectal cancer, it is important to talk with your doctor about follow-up care specifically for you, as no standardized follow-up care schedule for this stage of colorectal cancer exists.  

  • It is also important to remember that these follow-up care recommendations are for people who had colorectal cancer that was not inherited.

  • The recommended tests and schedule of testing are based on your risk of recurrence and your overall health.

  • In general, you will visit your doctor and receive follow-up screening more often earlier in your recovery. Eighty percent of recurrences are found in the first two to three years after surgery, and 95 percent of recurrences are found within five years.

In addition to regular physical examinations every three to six months, the following tests are recommended to watch for a colorectal cancer recurrence:

CEA test

This is a blood test that detects the levels of CEA protein. High levels of CEA may indicate that a cancer has spread to other parts of the body. CEA testing is recommended every three to six months for five years.

COLVERA™ - Circulating tumor DNA (ctDNA) test

This is a doctor-prescribed blood test designed to identify small fragments of DNA, known as ctDNA, which may leak from a tumor into the bloodstream. The presence of ctDNA may indicate residual disease after a patient has undergone surgery or recurrent colorectal cancer after a patient has completed primary treatment. If this test, known as COLVERA, shows a positive result, your doctor may order additional tests such as CT or PET scans to determine whether the cancer has returned.

Colonoscopy

This test lets a doctor look for polyps or second cancers in the entire rectum and colon with a colonoscope (a flexible, lighted tube). You should expect to receive a colonoscopy one year after surgery. How often you need this test depends on the results of your previous test. For example, if polyps are found, you may need to have another colonoscopy sooner. However, in general, this test will be performed every five years.

Computed tomography (CT) scan

A CT scan creates a three-dimensional image of the inside of the body with an x-ray machine. CT scans of the abdomen and chest are recommended each year for three years. If you have a high risk of recurrence, your doctor may recommend CT scans every six to 12 months for the first three years. If you had rectal cancer, a pelvic CT scan may also be recommended, but how often you need this test depends on your risk of recurrence.

Endoscopic Ultrasound (EUS)

A test that utilizes sound waves transmitted from a probe to detect abnormalities in the colon and rectal wall.  The ultrasound imaging provides a highly detailed visualization of all the bowel wall layers, the surrounding structures, as well as the size and location of the recurred lesion. This procedure is useful in combination with other imaging methods.

Proctosigmoidoscopy

In this procedures, a sigmoidoscope (a flexible, lighted tube) is inserted into a patient’s rectum to check for polyps, cancer, and other abnormalities. If you had rectal cancer, but did not have radiation therapy to the pelvis, this test is recommended every six months. Although it depends on your risk of recurrence, rectosigmoidoscopy may be recommended even if you had radiation therapy for rectal cancer.

Pros and Cons


 

Method

Pros

Cons

CEA

(For patients who had stage II, stage III, and high-risk stage I colorectal cancer, every three to six months in the first three years, and then every six months.)

  • An easy blood test

  • Relatively inexpensive

  • Recommended by the NCCN, ASCO and ASCRS guidelines

  • Sensitivity for detection of very early metastasis is relatively low

  • If positive, needs to be confirmed by imaging (CT scans or colonoscopy)

COLVERA (ctDNA)

(For patients who had all stages of colorectal cancer.)

  • A blood test identifying ctDNA in patients post-treatment for early detection of residual and recurrent colorectal cancer

  • Relatively inexpensive

  • Can be ordered with or without CEA

 

  • Currently not in guidelines

  • If positive, needs to be confirmed by imaging (CT, PET scans or colonoscopy)

Colonoscopy

(One year after surgery for patients who had colorectal cancer at all stages, and every three to five years afterward.)

  • High sensitivity

  • Ability to remove polyps during the procedure

  • Reviews the whole colon

  • Recommended by the NCCN, ASCO and ASCRS guidelines

  • Proved to provide clinical benefit to patients

  • Expensive

  • Complex bowel preparation prior to the exam

 

CT Scan

(For patients who had stage II, stage III, and stage IV colorectal cancer, as well as high-risk stage I, at least once a year in the first five years following surgery.)

  • Detect new lesions throughout the body including sites of metastasis

  • Proved to provide clinical benefit to patients

  • Recommended by the NCCN, ASCO and ASCRS guidelines

  • Complex bowel preparation prior to the exam

  • Cannot remove polyps during the exam

  • High radiation exposure that prevents frequent utilization

  • Detects both benign and cancerous lesions

ProctosigmoidoscopyWith or without endoscopic ultrasound (EUS)

For rectal cancer patients who either undergone curative resection or local resection. At least every 6 months in the first 3-5 years

  • Detect new local and distal lesions following rectal cancer resection.

  • EUS adds a higher level of sensitivity for  detection of recurrent disease earlier than other convention imaging.

 

General follow-up care schedule


First year after treatment

  • Physical examination and CEA testing every three to six months

  • Abdominal and chest CT scan each year (every six to 12 months for patients with a high risk of recurrence)

  • For patients with rectal cancer, pelvic CT scan every six to 12 months

  • Colonoscopy one year after surgery

  • Rectosigmoidoscopy every six months for patients with rectal cancer who did not have radiation therapy to the pelvis.

Second year after treatment

  • Physical examination and CEA testing every three to six months

  • CT scan each year (every six to 12 months for patients with a high risk of recurrence)

  • For patients with rectal cancer, pelvic CT scan every six to 12 months

  • Rectosigmoidoscopy every six months for patients with rectal cancer who did not have radiation therapy to the pelvis

Third year after treatment

  • Physical examination and CEA testing every three to six months

  • CT scan each year (every six to 12 months for patients with a high risk of recurrence)

  • For patients with rectal cancer, pelvic CT scan every six to 12 months

  • Rectosigmoidoscopy every six months for patients with rectal cancer who did not have radiation therapy to the pelvis

Fourth year after treatment

  • Physical examination and CEA testing every three to six months

  • For patients with rectal cancer, pelvic CT scan each year

  • Rectosigmoidoscopy every six months for patients with rectal cancer who did not have radiation therapy to the pelvis

Fifth year after treatment

  • Physical examination and CEA testing every three to six months

  • For patients with rectal cancer, pelvic CT scan each year

  • Rectosigmoidoscopy every six months for patients with rectal cancer who did not have radiation therapy to the pelvis

What this means for patients


  • Regularly scheduled follow-up care helps increase the likelihood of finding a treatable recurrence.

  • Discussing your risk of recurrence is important as you are nearing the end of your cancer treatment.

  • Web-based prediction tools are available to help your doctor better estimate your risk of recurrence.

  • Knowing this information helps your doctor develop an appropriate follow-up care plan.

  • Talk with your doctor about your risk of recurrence and how it affects your schedule of follow-up care.

  • Many people who have finished treatment for colorectal cancer receive their follow-up care through their primary care doctor.  

  • Maintain a healthy weight, exercising, not smoking, eating a balanced diet, and having recommended cancer screening tests.

  • Talk with your doctor to develop a plan that is best for your needs. Your oncologist can provide you and your primary care doctor a written treatment summary, as well as recommendations for your follow-up care.

The recommendations on this page are based on literature from the American Society of Clinical Oncology and American Society of Colon and Rectal Surgeons

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