Should colonoscopy be performed one year out from colorectal cancer resection?

Alexandra Kent, Philip Thompson, Prof Alan Horgan, Mr Paul Hainsworth

Newcastle NHS Trust

ACPGBI: Guidelines for the Management of Colorectal Cancer

Staging investigation for potentially curable colorectal cancer

•Complete visualisation of colon required either pre- or post-operatively.

•If complete colonic imaging is not possible before surgery, it is important this is done within six months, or as soon as possible after closure of a temporary ileostomy.

ACPGBI Guidelines

Colonoscopic follow-up

• If such a policy is pursued, it is recommended that a “clean” colon should be examined by colonoscopy at 5 yearly intervals.

•Patients should be counselled about the potential complications of colonoscopy.

ACPGBI. Guidelines for the management of colorectal cancer 3rd edition 2007.

• Patients who did not have a complete colonoscopy pre-op should be offered colonoscopy within 6 months of discharge.

•MDTs in each network should agree follow up guidelines.

• 5 yearly intervals for patients with a ‘clean’ colon.

NICE guidelines (2004)

NICE. Guidance on cancer services. Improving outcomes in colorectal cancer. 2004.

NICE guidelines (2011)

•Offer a surveillance colonoscopy at 1 year after initial treatment. If this is normal consider colonoscopy at 5 years.

•Two Systematic reviews - potential benefit in identifying recurrence of disease at an earlier stage - Low-moderate evidence base.

NICE. CG131 Colorectal cancer - the diagnosis and management of colorectal cancer 2011

Jeffery M, Hickey BE, Hider PN. Follow-up strategies for patients treated for non-metastatic colorectal cancer (Review), The Cochrane Library 2007, Issue 4

Tiandra J, Chan MK..Follow-up after curative resection of colorectal cancer: a meta-analysis. Dis Colon Rectum. 2007 Nov;50(11):1783-99

Patients undergoing curative resection.

• Complete colonoscopy pre-operatively or within 6 months of discharge

• Surveillance colonoscopy at 1 year

Newcastle Colorectal MDT Guidelines

AimsTo assess compliance with local guidelines in patients undergoing curative colorectal cancer resection:•Complete colonoscopy pre-op or within 6 months

•Follow up colonoscopy at one year

• Incidence of synchronous / metachronous lesions

•Record interventions resulting from colonoscopy

• Colorectal cancer resections 2008-2012 PJH/AFH (total=347)

• Sub-set selected commencing 2008

• Retrospective electronic chart review

• Endoscopy database

• Endoscopic outcomes recorded

Method

Sample

•115 patients

•53 female, 62 male

•Age range 39-92, median 71

•Dukes A 23; B 33; C39; D20.

Other: - 1 pelvic exanteration and 1 enbloc resection

Colonic resection 53

Anterior resection 38

AP resection + Hartmann’s

16

Local excision 6

Other 2

Resections performed

Complete colonoscopy pre-op or by 6 months

Completion colonoscopy

Patients eligible for 1 year follow up colonoscopy

Deceased12

Eligible patients88

Metastatic disease12

Panproctocolectomy3

115 patients

Reasons for failure to perform

1 year follow up colonoscopy

Patient refused 6

Lost to follow up 5

Alt. surveillance 7

Private patient 4

Awaiting 5

Frailty 1

•60/ 88 patients had surveillance colonoscopy

•28 eligible patients did not have colonoscopies

Timing of ‘1 year’ colonoscopy

Range 6-30 months post-op

Incidence of metachronous lesions at ‘1 year’ scope

(n=60)

•Normal 35

•Polyps 24

•1 patient had a TEMS procedure, local reoccurrence at 17 months on colonoscopy - anterior resection

Interventions and complications

resulting from colonoscopy

•24 patients cleared of polyps

•1 vasovagal episode - delayed discharge

Surveillance Polyps (24 patients)

Conclusion

•Failure to establish clean colon within 6 months

•1 year colonoscopy performed in 68% range 6 - 30 months

•Significant incidence of lesions leading to interventions in 24

•Low complication rate from colonoscopy

DiscussionShould colonoscopy be performed one year out from colorectal cancer resection?

Benefits

• Ensures clean colon in patients missed by pre-op/ 6month colonoscopy.

• Acknowledged aversion to removing polyps by surgeons when suspected cancer discovered

Drawbacks

• Cost• Invasive Procedure

Limitations Small study size Missing data