Guideline:
Practice parameters for the surveillance and followup of patients with colon and rectal cancer
Bibliographic Source(s)
- Anthony T Simmang C Hyman N Buie D Kim D Cataldo P Orsay C Church J Otchy D Cohen J Perry WB Dunn G Rafferty J Ellis CN Rakinic J Fleshner P Stahl T Gregorcyk S Ternent C Kilkenny JW 3rd Whiteford M. Practice parameters for the surveillance and follow-up of patients with colon and rectal cancer. Dis Colon Rectum 2004 Jun;47(6):807-17. [54 references] PubMed
Guideline Status
This is the current release of the guideline.
Guideline Category
Evaluation
Intended Users
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians
Guideline Objective(s)
To provide evidence-supported guidelines for colorectal cancer follow-up for physicians engaged in the care of patients with colorectal cancer
Target Population
Patients with colon and rectal cancer
Interventions and Practices Considered
Evaluation
- Offering follow-up to patients after resection for colorectal cancer
- Routine office visits as part of follow-up
- Carcinoembryonic antigen measurement (note: other tumor markers are considered experimental)
- Computed tomography (CT) scanning
- Periodic anastomotic evaluation
- Colonoscopy (complete visualization of colon)
- Timing of follow-up visits and follow-up interventions
Note: The following interventions were considered but not recommended routinely in the follow-up of patients with colon and rectal cancer: chest x-ray; serum hemoglobin; Hemoccult II; liver function tests; and routine use of hepatic imaging studies
Major Outcomes Considered
- Patient survival
- Cost-effectiveness of follow-up
- Predictive value of tests
- Quality of life
- Recurrence (local metastatic or secondary neoplasm)
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The source of the supporting literature was a Medline search (1966 through May 2002; parameters: human English language; search terms: colon cancer rectal cancer or colorectal neoplasm and surveillance or follow-up). This search resulted in 2599 articles. The titles of these articles were screened for relevance. Prospective randomized controlled trials meta-analyses and retrospective evaluations of randomized controlled trials were given preference in developing these guidelines when such information was available.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence
Level I: Evidence from properly conducted randomized controlled trials
Level II: Evidence from controlled trials without randomization
or
Cohort or case-control studies
or
Multiple time series dramatic uncontrolled experiments
Level III: Descriptive case series opinions of expert panels
Scale Used for Evidence Grading
Grade A: High-level (level I or II) well-performed studies with uniform interpretation and conclusions by the expert panel
Grade B: High-level well-performed studies with varying interpretations and conclusions by the expert panel
Grade C: Lower level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
Although several studies have attempted to address the issue of cost of follow-up cost effectiveness has not been examined in the context of a prospective randomized trial. Graham et al. reported on the cost per resectable recurrence identified using 1995 Medicare reimbursement costs. They found that carcinoembryonic antigen (CEA) was the cheapest option costing $5696 per recurrence; chest x-ray (CXR) cost $10078 and colonoscopy $45810 per recurrence. Similarly Virgo and colleagues reported on the potential variation in cost associated with follow-up as a function of the variability of follow-up intensity. Norum and Olsen performed a theoretical cost-effectiveness analysis based on the recommended Norwegian Gastrointestinal Cancer Groups preferred follow-up strategy. This analysis found that the program was cost effective over a wide range of assumptions. It is unclear whether this analysis is generalizable to other economic situations or other follow-up strategies.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
The rating schemes for the level and grade of the evidence are provided at the end of the "Major Recommendations" field.
Recommendations
- Offering follow-up for patients with completely resected colorectal cancer is justified (Evidence Level I; Grade B)
- Routine office visits should be part of a follow-up program for patients who have completed treatment for colon and rectal cancer (Level II Grade A)
- Serum hemoglobin Hemoccult II and liver function tests (hepatic enzymes tests) should not be routine components of a follow-up program (Level II Grade A)
- Carcinoembryonic antigen (CEA) should be used as a part of follow-up for colorectal cancer; the use of other tumor markers remains experimental (Level II Grade B)
- There is insufficient data to recommend for or against chest x-ray (CXR) as part of routine colorectal cancer follow-up (Level II Grade C)
- Routine use of hepatic imaging studies in the follow-up of colorectal cancer should not be performed (Level II Grade B)
- Periodic anastomotic evaluation is recommended for patients who have undergone resection/anastomosis or local excision of rectal cancer (Level III Grade B)
- Data concerning proper timing of office visits CEA and chest x-ray is insufficient to recommend one particular schedule of follow-up over another; however office visits and CEA evaluations should be performed at a minimum of three times per year for the first two years of follow-up (Level II Grade A)
- Complete visualization of the colon should be performed if practical in all patients being considered for colon or rectal cancer resection; posttreatment colonoscopy should be performed at three-year intervals (Level III Grade A)
Definitions:
Levels of Evidence
Level I: Evidence from properly conducted randomized controlled trials
Level II: Evidence from controlled trials without randomization
or
Cohort or case-control studies
or
Multiple time series dramatic uncontrolled experiments
Level III: Descriptive case series opinions of expert panels
Scale Used for Evidence Grading
Grade A: High-level (level I or II) well-performed studies with uniform interpretation and conclusions by the expert panel
Grade B: High-level well-performed studies with varying interpretations and conclusions by the expert panel
Grade C: Lower level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of evidence supporting each recommendation is identified and graded (see "Major Recommendations" section).
Potential Benefits
- Appropriate follow-up and surveillance of patients with colon and rectal cancer
- The potential benefits of follow-up after colon and rectal cancer include improved overall survival better monitoring of outcome identification of other treatable diseases found during follow-up and greater psychologic support.
Potential Harms
- There are potential negative physical financial and psychologic consequences of follow-up.
- Regardless of how often carcinoembryonic antigen (CEA) is checked or the cutoff used to separate normal and abnormal values once an elevation is identified expert opinion suggests that the first step should be confirmation of the elevation with a second level before embarking on a more intensive workup because false-positive elevations have been reported in 7 to 16 percent.
Qualifying Statements
- These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made rather that dictate a specific form of treatment. These guidelines are intended for the use of all practitioners health care workers and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
- The practice parameters set forth in this document have been developed from sources believed to be reliable. The American Society of Colon and Rectal Surgeons makes no warranty guarantee or representation whatsoever as to the absolute validity or sufficiency of any parameter included in this document and the Society assumes no responsibility for the use or misuse of the material contained here.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Bibliographic Source(s)
- Anthony T Simmang C Hyman N Buie D Kim D Cataldo P Orsay C Church J Otchy D Cohen J Perry WB Dunn G Rafferty J Ellis CN Rakinic J Fleshner P Stahl T Gregorcyk S Ternent C Kilkenny JW 3rd Whiteford M. Practice parameters for the surveillance and follow-up of patients with colon and rectal cancer. Dis Colon Rectum 2004 Jun;47(6):807-17. [54 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Society of Colon and Rectal Surgeons
Guideline Committee
The Standards Practice Task Force
Composition of Group that Authored the Guideline
Task Force Members: Thomas Anthony MD; Clifford Simmang MD; Neil Hyman MD; Donald Buie MD; Donald Kim MD; Peter Cataldo MD; Charles Orsay MD; James Church MD; Daniel Otchy MD; Jeffery Cohen MD; W. Brian Perry MD; Gary Dunn MD; Janice Rafferty MD; C. Neal Ellis MD; Jan Rakinic MD; Phillip Fleshner MD; Thomas Stahl MD; Sharon Gregorcyk MD; Charles Ternent MD; John W. Kilkenny III MD; Mark Whiteford MD
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Society of Colon and Rectal Surgeons Web site.
Print copies: Available from the American Society of Colon and Rectal Surgeons 85 W. Algonquin Rd. Suite 550 Arlington Heights IL 60005
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on October 19 2004.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.
Tools
No Quick Reference tools have been developed.