Cosa dicono le linee guida

Dr.ssa Foltran Luisa

Oncologia medica Pordenone

CARCINOMA DEL COLON-RETTO: COSA DICONO LE LINEE GUIDA

Convegno Regionale AIOM FVG, Palmanova, 14 Maggio 2016

COLORECTAL CANCER FOLLOW-UP

 Objectives

 Intensive follow-up versus minimal follow-up

 Guidelines

AIOM

ESMO

ASCO

 Survivorship care plans

 Open issues

 Third group of long-term cancer survivors

 Median age: 72 years

 Life expectancy of 70-year old healthy individual

 8 years for men

 14 years for women

 5-year survival after surgery:

 stage I (T1,T2 N0 M0): 85-95%

 stage II (T3, T4 N0 M0): 60-80%

 stage III (any T, N1-N2, M0): 30-60%

 Sites of recurrent disease

 Liver > Lung > Peritoneal

EARLY COLORECTAL CANCER

Recurrence rate by stage and time from random assignment.

Daniel J. Sargent et al. JCO 2007;25:4569-4574

73% of stage II and 82% of stage III colon cancer recurrences are diagnosed within 3 years

Kaplan-Meier plots of overall survival (OS) in treatment arm versus

control arm for (A) all patients, (B) stage II patients, and (C) stage III patients.

Daniel Sargent et al. JCO 2009;27:872-877

MAIN OBJECTIVES OF FOLLOW-UP

Early detect asymptomatic recurrences and second primary tumours

Increase curative surgery at recurrence

Improve overall survival

INTENSIVE FOLLOW-UP VERSUS MINIMAL FOLLOW-UP

RANDOMIZED CONTROLLED CLINICAL TRIALS AND 7 META-ANALYSES

Early colorectal cancer patients stage I-III, disease-free after curative surgery and treatment

(Pita-Fernandez S, et al. Ann Oncol 2015)

INTENSIVE FOLLOW-UP

• Improves OS (HR 0.75); estimated gain 7-13%

• Increases detection of asymptomatic recurrences (RR 2.6)

• Increases curative surgery at recurrences (RR 2.0)

• Improves OS after recurrence (RR 2.1)

• Anticipate detection of recurrence (5-8 months)

WEAKNESSES OF STUDIES

HETEROGENEITY

 Follow-up strategies (types and frequency of tests, setting)

 Study populations

 Study design

UNDERPOWERED

UNBLINDED

LONG TIME-FRAME (1983-2006)

OUTDATED APPROACHES

NO IMPACT ON CANCER-SPECIFIC SURVIVAL

INTENSIVE FOLLOW-UP VERSUS MINIMAL FOLLOW-UP

COLORECTAL CANCER FOLLOW-UP: MAIN RECOMMENDATIONS

TARGET

POPULATION

FOLLOW-UP

DURATION

FREQUENCY

OF VISITS

TESTS

CT scan of chest and abdomen Colonscopy

Pelvic CT and recto-sigmoidoscopy for rectal cancer

VISIT CEA RADIOLOGICAL IMAGING

ENDOSCOPIC

IMAGING ^Comments Q 4-6 MONTHS

first 3 years, Q 6 MONTHS to

5 year

Rectal exhamination if rectal cancer

Q 3-4 MONTHS first 3 years, Q 6 MONTHS to

5 year

Repeat CEA at 6-8 weeks from surgery,

if pre-operative elevated

CT scan of chest and abdomen Q 6-12 MONTHS

for 3-5 years, depending on risk

Pelvic CT or MRI Q 6-12 MONTHS first 2 years, then annually to 5 year depending on risk

Abdominal ultrasound may substitute CT

scan if logistic problems or patient

not suitable for surgery

Colonscopy at 1 year, then at 3 year, and Q 5 years (depending on age

and comorbidity)

Recto-sigmoidoscopy Q 6 MONTHS first 2

years

Colonscopy at 6-8 months from surgery if incomplete

preoperative

STAGE I:

endoscopic follow-up only

STAGE IV NED:

CT of chest and abdomen Q 3-6 months first 2 YEARS,

then Q 6-12 months to 5

year

Not recommended:

Other lab tests, chest X-Ray,

CT-PET

COLORECTAL CANCER FOLLOW-UP: AIOM GUIDELINES

VISIT CEA RADIOLOGICAL IMAGING

ENDOSCOPIC

IMAGING ^Comments

Q 3-6 MONTHS first 3 years,

then Q 6-12 MONTHS

to 5 year

Q 6 MONTHS First 2 years

Q 3-6 MONTHS first 3 years,

then Q 6-12 MONTHS

to 5 year

Not

recommended

CT scan of chest and abdomen Q 6-12 MONTHS

first 3 years

CEUS could substitute for abdominal CT scan

Not

recommended

Colonscopy at year 1, and Q 3-5 years

Colonscopy Q 5 years

Colorectal cancer stage not

specified

COLON

COLORECTAL CANCER FOLLOW-UP: ESMO GUIDELINES

RECTAL CANCER

VISIT CEA RADIOLOGICAL IMAGING

ENDOSCOPIC

IMAGING ^Comments

Q 3-6 MONTHS for

5 years

Q 3-6 MONTHS for

5 years

CT scan of chest and abdomen

ANNUALLY for 3 years CT scan Q 6-12

MONTHS for 3 years

if high risk Pelvic CT ANNUALLY for 3-5 years (depending of rectal cancer risk)

Colonscopy at year 1 then if normal Q 5

years

Recto-sigmoidoscopy Q 6 MONTHS

for 2-5 years, for rectal cancer not

treated with pelvic radiation

ALL STAGE II and III

STAGE I AND IV:

no

recommendations

No follow-up if patient not fit for

surgery or sistemic treatment

COLORECTAL CANCER FOLLOW-UP: ASCO GUIDELINES

COLON

CANCER

Q 4-6 MONTHS FIRST 3 YEARS

THEN Q 6 MONTHS

Q 3-4 MONTHS FIRST 3 YEARS

THEN Q 6 MONTHS

Q 6-12 MONTHS FOR 3-5 YEARS

DEPENDING ON RISK

AT YEAR 1, then at YEAR 3,

and Q 5 YEARS

STAGE II - III

Indications STADIO I E IV

Q 3-6 MONTHS FIRST 3 YEARS

THEN Q 6-12 MONTHS

Q 3-6 MONTHS FIRST 3 YEARS

THEN Q 6-12 MONTHS

Q 6-12 MONTHS FIRST 3 YEARS

AT YEAR 1 THEN Q 3-5 YEARS

STAGE NOT SPECIFIED

Q 3-6 MONTHS FOR 5 YEARS

Q 3-6 MONTHS FOR 5 YEARS

Q 12 MONTHS (Q 6-12 MONTHS IF HIGH

RISK) FIRST 3 YEARS

AT YEAR 1 THEN Q 5 YEARS

STAGE II - III

COMPARING GUIDELINES: COLON CANCER

RECTAL

CANCER

PELVIC CT SCAN

RECTO-

SIGMOIDOSCOPY

Q 6-12 MONTHS FIRST 2 YEARS, THEN ANNUALLY

TO YEAR 5, DEPENDING ON

RISK

Q 6 MONTHS FIRST 2 YEARS

Q 6 MONTHS FIRST 2 YEARS

NOT RECOMMENDED

NOT RECOMMENDED

NOT RECOMMENDED (COLONSCOPY Q 5

YEARS)

ANNUALLY FOR 3-5 YEARS,

DEPENDING ON RISK

Q 6 MONTHS FOR 2-5 YEARS,

ONLY IF NOT IRRADIATED

COMPARING GUIDELINES: RECTAL CANCER

SURVIVORSHIP CARE PLANS (1)

Integration between primary care physician and oncologist

MONITOR LONG-TERM AND LATE EFFECTS OF TREATMENT

 Cronic diarrhea; bloating; incisional hernia

 Incontinence

 Radiation colitis

 Sexual disfunction

 Peripheral neuropathy

REHABILITATION INTERVENTIONS

PSYCOSOCIAL SUPPORT

SURVEILLANCE FOR SECOND CANCERS

SURVIVORSHIP CARE PLANS (2)

 SECONDARY PREVENTION

COLORECTAL CANCER FOLLOW-UP: OPEN ISSUES

 STAGE I

 AIOM: endoscopic follow-up (COST trial: CEA + imaging -> benefit <1%)

 STAGE IV NED

 AIOM: frequent CT scanning

 QUALITY OF LIFE

 SETTING (Primary care vs Specialist)

 COST-EFFECTIVENESS