Κυριακή, 20 Μαρτίου 2016

AVOID TOO MUCH SURVEILLANCE IN EARLY COLORECTAL CANCER

Why do we follow up patients? In terms of colorectal cancer, my particular field of interest, it's with the hope that we'll be able to detect disease in the early stage in recurrence, so that we could offer salvage treatments of some sort, resection of hepatic metastases, ablation of pulmonary metastases. We're managing metastatic disease, in a collective multidisciplinary sense, much more aggressively.
The secondary endpoints would be, I guess, reassuring patients, and following up patients in terms of the natural history of the disease, or [participation in] trials. Dr Rosati and colleagues have reported recently in Annals of Oncology[1] a trial of minimal vs intensive surveillance or follow-up for patients with early-stage colorectal cancer. Over a period of around 7 or 8 years, they randomly assigned 1200 patients [to minimal or intensive surveillance]. They had excellent follow-up, extending beyond 5 years, for the majority of their patients. They compared a minimal regime—which consisted of office visits, carcinoembryonic antigen (CEA) levels, a couple of colonoscopies, and a couple of hepatic ultrasounds—to a more intensive arm in which CEA plus cancer antigen 19-9 (CA 19-9) levels were measured, and blood biochemistry was assessed. In the intensive arm, the number of ultrasounds was increased, chest x-rays increased fourfold, and the number of colonoscopies was increased by two- to threefold. So it was a much more intensive regime.
At the end of the follow-up period, they reported no impact in the overall survival at all for those patients who were followed intensively compared with those with a minimal follow-up regime. What does this mean?
It means that we could save resources. There are some data, particularly from breast cancer,[2,3]indicating that levels of anxiety of patients who are not followed up largely abate within a year of their surgery. The most anxiety about recurrence is within that early period, and subsequently those anxieties tend to fade away. Therefore, the hypothesis about patient reassurance is a relatively bogus one.
We divert resources by pushing money into following up patients that doesn't yield a major benefit in terms of survival. We might be diverting further resources from front-line therapy that could mean access to drugs and new techniques, but it costs money, with little return in benefit. And, therefore, we could ask: What's the relative value of it?
This is an interesting study. It's moderately consistent with other, smaller studies in the field which struggle to show any major benefits from intensive follow-up.[4-6] What we tend to do in Oxford is a CT scan, in which we look at the chest, abdomen, and pelvis at 1 year, at the anniversary of the initial operation, and we do a colonoscopy at 3 years. Only those patients who have received intensive chemotherapy do we see more regularly.
If we look at the national guidelines from professional societies, I think there's overkill in follow-up. On the basis of virtually no evidence of benefit at all, they recommend too intensive a follow-up regime.
So, I think this is useful information, a well-conducted study by a notable Italian group. I'd be really interested if you'd have a look at it and post any comments or queries you would like to make. But in the meantime, thanks for listening. Medscapers, over and out.

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