Colon Adenocarcinoma Follow-up

  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: Jules E Harris, MD   more...
 
Updated: Dec 23, 2011
 

Further Outpatient Care

Pooled analysis form several large adjuvant trials reported that 85% of colon cancer recurrences occur within 3 years from after resection of primary tumor. Therefore, patients with resected colon cancer (stage II and III) should undergo regular surveillance for at least 5 years following resection. An update of American Society of Clinical Oncology (2005) recommends physical examinations every 3-6 months for the first 3 years, every 6 months during years 4 and 5, and subsequently at the discretion of physician and based on individual risk assessment.

Serum CEA level should be checked every 3 months in patients with stage II or III disease for at least 3 years and every 6 months in years 4 and 5. Computerized tomography (CT) of the chest and abdomen should be performed annually for at least 3 years after resection of primary tumor. All patients with colon cancer should have preoperative or postoperative colonoscopy to document absence of additional primary colon tumors or polyps. In the absence of high-risk pathology on the first colonoscopy or increased susceptibility for colon cancer, follow-up colonoscopy should be performed at 3 years after surgery and then, if normal, once every 5 years thereafter.

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Deterrence/Prevention

Colorectal cancer prevention strategies are based on our understanding of colorectal carcinogenesis and availability of pharmacologic agents that are effective yet minimally toxic. The efficacy of these agents is usually first tested in high-risk populations.

Celecoxib (Celebrex), a selective cyclooxygenase-2 inhibitor was first tested in patients with familial adenomatous polyposis (FAP). Celecoxib was effective in decreasing the number and size of polyps on serial colonoscopies, which was the primary surrogate endpoint for this trial. The drug was approved for FAP patients, although it remains to be seen if this intervention translates to reduced cancer incidence and prolonged survival.

Other NSAIDs, such as sulindac and nonselective cyclooxygenase inhibitors were tested in lower risk populations. Enthusiasm for cyclooxygenase-2 inhibitors as chemopreventive agents has dampened because of a high incidence of cardiovascular toxicity (rofecoxib) in trial patients. An aspirin prevention trial suggested a benefit in terms of polyp prevention with low-dose (81 mg) aspirin.

Although aspirin use has been proven to decrease colon cancer risk, this association may vary among population subgroups. However, body mass index, physical activity, and plasma C-peptide levels were shown to not have a significant impact on aspirin’s effect on colon cancer risk.[60]

Some recent trials focused on combined inhibition of polyamine production and cyclooxygenase inhibition. A recent report from a large randomized trial of a combination of sulindac and dimethylformamine (DMFO), an inhibitor of ornithine decarboxylase (ODC), described a dramatic effect of this combination in reducing polyp recurrence in patients with prior history of colon polyps. Confirmatory trials are ongoing.[61]

Screening

The goal of colorectal cancer screening is to decrease mortality through diagnosis and treatment of precancerous lesions (adenomatous colon polyps) and early curable cancerous lesions. The evidence for the importance of early detection and removal of colorectal polyps in preventing development of invasive cancer is mostly indirect but has been corroborated by data from many trials.

In the United States, a Joint Guideline was developed by the American Cancer Society, US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. The Guideline lists appropriate screening procedures and their indications and frequency based on projected individual risks of developing colorectal cancer.

Their testing options for the early detection of colorectal cancer and adenomatous

polyps for asymptomatic adults aged 50 years and older can be summarized as follows:

  • Tests that detect adenomatous polyps and cancer
    • Flexible sigmoidoscopy every 5 years, or
    • Colonoscopy every 10 years, or
    • Double-contrast barium enema every 5 years, or
    • computed tomographic colonography every 5 years
  • Tests that primarily detect cancer
    • Annual guaiac-based fecal occult blood test with high test sensitivity for cancer, or
    • Annual fecal immunochemical test with high test sensitivity for cancer, or
    • Stool DNA test with high sensitivity for cancer, interval uncertain

For individuals who carry an increased or high risk of developing colorectal cancer such as persons with prior history of polyps, prior history of colorectal cancer, family history of colon cancer, or history of inflammatory bowel diseases screening should start at an earlier age and be more frequent and more stringent. Those genetically diagnosed or suspected of having hereditary familial syndromes such as HNPCC or FAP should be treated as having high risk of developing colon and rectal cancer and should adhere to a more intense surveillance protocol.[62]

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Prognosis

The approximate 5-year survival rate for colorectal cancer patients in the United States (all stages included) is 65%. Survival is inversely related to stage; patients with stage I have a 95% 5-year survival rate, and those with stage III have only a 60% survival rate. For patients with metastatic, stage IV disease, the 5-year survival rate is estimated at approximately 10% (see Staging).

A study by Chua et al found that approximately 1 in every 3 patients who undergo resection for colorectal liver metastases become actual 5-year survivors.[63] Of those, approximately half survive 10 years and are cured of colorectal liver metastases.

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Contributor Information and Disclosures
Author

Tomislav Dragovich, MD, PhD  Chief, Section of Hematology and Oncology, Banner M D Anderson Cancer Center

Tomislav Dragovich, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society of Clinical Oncology, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Coauthor(s)

Vassiliki L Tsikitis, MD  Assistant Professor of Surgery, Department of Surgery, Division of General and Gastrointestinal Surgery, Oregon Health and Science University School of Medicine

Vassiliki L Tsikitis, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, and Association of Women Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

from Memorial Sloan-Kettering - Philip Schulman, MD  Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center

from Memorial Sloan-Kettering - Philip Schulman, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD  Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research

Disclosure: GlobeImmune Salary Consulting

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Standard colectomies for adenocarcinoma of the colon.
Table 1. TNM Staging System for Colon Cancer
StagePrimary Tumor (T)Regional Lymph Node (N)Remote Metastasis (M)
Stage 0Carcinoma in situ (Tis)N0M0
Stage ITumor may invade submucosa (T1) or muscularis propria (T2)N0M0
Stage IITumor invades muscularis (T3) or adjacent organs or structures (T4)N0M0
Stage IIAT3N0M0
Stage IIBT4aN0M0
Stage IICT4bN0M0
Stage IIIAT1-4N1-2M0
Stage IIIBT1-4N1-2M0
Stage IIICT3-4N1-2M0
Stage IVAT1-4N1-3M1a
Stage IVBT1-4N1-3M1b
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