ASCO updates colorectal cancer surveillance practice guidelines

An Expert Panel from the American Society of Clinical Oncology (ASCO) reviewed and updated practice guidelines for follow-up surveillance after treatment for colorectal cancer. The new guidelines were published online ahead of print on October 31, 2005 in the [*Journal of Clinical Oncology*](http://www.jco.org/cgi/reprint/JCO.2005.04.0063v1).

The guidelines were last updated in 2000. New recommendations embody research published since 1999, including three recent meta-analyses of randomized studies comparing *low-intensity* and *high-intensity* plans for post-treatment surveillance. The Panel also considered pooled information from clinical trials for treatment of colon or rectal cancer.

In light of evidence showing benefit of more intensive treatment follow-up, the panel changed several guideline recommendations.

One significant change is the **recommendation *for* an annual CT scan of the chest and abdomen for 3 years** for patients at high risk of recurrence who could be candidates for surgery to cure metastatic cancer. In addition, **pelvic CT scan** should be considered for rectal cancer patients, particularly those who did not undergo radiation. Previous guidelines recommended *against* such scans. Yearly chest x-rays are *not recommended* in either the new or old guidelines.

The panel added a new category to the guidelines in 2005: *Laboratory-Derived Prognostic and Predictive Factors*. This relates to molecular and cellular markers that may predict response to chemotherapy or influence prognosis. However, the Expert Panel decided that evidence was not yet strong enough to include them in the guidelines:

“Until prospective data are available, use of molecular or cellular markers should not influence the surveillance strategy”.

Briefly, the guidelines recommend:

+ **history and physical examination** every 3 to 6 months for the first 3 years, every 6 months during years 4 and 5, and subsequently at the discretion of the physician
+ **carcinoembryonic antigen** blood test every 3 months postoperatively for at least 3 years after diagnosis, if the patient is a candidate for surgery or systemic therapy should cancer recur
+ **annual computed tomography (CT)** of the chest and abdomen for 3 years
after primary therapy for patients who are at higher risk of recurrence and who could be
candidates for curative-intent surgery
+ **pelvic CT scan** for *rectal cancer* surveillance, especially for patients with several poor prognostic factors, including those have not been treated with radiation
+ **colonoscopy at 3 years** after operative treatment, and, if results are normal, every
5 years thereafter
+ **flexible protosigmoidoscopy** every 6 months for 5 years for *rectal cancer* patients who have not been treated with pelvic radiation
+ **Chest x-rays, CBCs, and liver function tests** are *not recommended*
+ **molecular or cellular markers** should *not influence* the surveillance strategy based on available evidence

Recommendations for colonoscopy mirror those of the American Gastroenterological Association — a colonoscopy at 3 years and then, if normal, then every five years thereafter. Patients with high-risk genetic syndromes should have colonoscopies according to the AGA schedule.

Panel members included:

+ Al B. Benson, MD, Co-Chair — Northwestern University Medical School
+ Christopher Desch, MD, Co-Chair — Virginia Cancer Institute
+ Patrick J. Flynn, MD — Minnesota Oncology Hematology P. A.
+ Carol Krause — Health Systems Research (Patient Representative)
+ Charles L. Loprinzi, MD — Mayo Clinic
+ Bruce D. Minsky, MD — Memorial Sloan-Kettering Cancer Center
+ Nicholas J. Petrelli, MD — Helen F. Graham Cancer Center
+ David Pfister, MD — Memorial Sloan-Kettering Cancer Center
+ Katherine S. Virgo, PhD — Saint Louis University Health Science Center
.
**UPDATE** Although originally published early online, the new Guidelines are now available in the November 20, 2005 edition of the [*Journal of Clinical Oncology](http://www.jco.org/cgi/reprint/23/33/8512)