Follow-Up Strategy After Primary and Early Diagnosis

  • Aldo InfantinoEmail author
  • Andrea Lauretta
Part of the Updates in Surgery book series (UPDATESSURG)


Recurrent disease following colorectal cancer surgery will occur in about 30–50% of patients when considering both locoregional relapse and distant metastasis [1]. Rectal cancer is associated more frequently with local failure than is colon cancer due to its distinctive behavior of spreading to the pelvis through the lymphatic and venous system. However, the introduction of total mesorectal excision (TME) and the association of neoadjuvant radiochemotherapy have dramatically reduced the local relapse rate to 6% [2]. Anastomotic recurrence is recorded in 5–15% of patients [3], even though it should be considered that the recurrent disease most often begins extraluminally, especially in the presacral area, and less frequently in the anastomotic area [4]. Curative treatment of recurrence is possible, and this improves prognosis and overall survival. However, salvage surgery in patient with pelvic recurrence can be performed only in 30–40% of cases, with morbidity and mortality rates, respectively, up to 44% and 6% [5, 6, 7, 8]. Given the high risk of recurrence, both locoregional and distant, and the dismal prognosis of patient with disease relapse, the importance of follow-up programs for early recurrent cancer detection is clear.


National Comprehensive Cancer Network National Comprehensive Cancer Network Salvage Surgery Anastomotic Recurrence Colorectal Cancer Recurrence 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Bohm B, Schwenk W, Hucke HP, Stock W (1993) Does methodic long-term follow-up affect survival after curative resection of colorectal carcinoma? Dis Colon Rectum 36:280–286CrossRefPubMedGoogle Scholar
  2. 2.
    Kapiteijn E, Marijnen CAM, Nagtegaal ID (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. New Engl J Med 345:638–646CrossRefPubMedGoogle Scholar
  3. 3.
    Heald RJ, Ryall RD (1986). Recurrence and survival after total mesorectal excision and rectal cancer. Lancet 1:1479–1482CrossRefPubMedGoogle Scholar
  4. 4.
    Steele SR, Chang GJ, Hendren S et al (2015) Practice guidelines for the surveillance of patients after curative treatment of colon and rectal cancer. Dis Colon Rectum 58:713-725CrossRefPubMedGoogle Scholar
  5. 5.
    Lopez-Kostner F, Fazio VW, Vignali A et al (2001) Local recurrent rectal cancer. Predictors and success of salvage surgery. Dis Colon Rectum 44:173–178CrossRefPubMedGoogle Scholar
  6. 6.
    Suzuki K, Dozois RR, Devine RM et al (1996) Curative reoperations for locally recurrent rectal cancer. Dis Colon Rectum 39:730–736CrossRefPubMedGoogle Scholar
  7. 7.
    Ogunbiyi OA, McKenna K, Bimbaum EH et al (1997) Aggressive surgical management of recurrent rectal cancer – is it worthwhile? Dis Colon Rectum 40:150–155CrossRefPubMedGoogle Scholar
  8. 8.
    Gagliardi G, Hawley PR, Hershman MJ, Arnott SJ (1995) Prognostic factors in surgery for local recurrence of rectal cancer. Br J Surg 82:1401–1405CrossRefPubMedGoogle Scholar
  9. 9.
    Meyerhardt JA, Mayer RJ (2003) Follow-up strategies after curative resection of colorectal cancer. Seminars in Oncol 30:349–360CrossRefGoogle Scholar
  10. 10.
    Renehan AG, Egger M, Saunders MP et al (2002) Impact on survival of intensive follow-up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 324:813CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Tjandra JJ, Chan MK (2007) Follow-up after curative resection of colorectal cancer: a meta-analysis. Dis Colon Rectum 50:1783–1799CrossRefPubMedGoogle Scholar
  12. 12.
    Jeffery M, Hickey BE, Hider PN (2007) Follow-up strategies for patients treated for non-metastaticcolorectal cancer. Cochrane Database Syst Rev 2007;1:CD002200.Google Scholar
  13. 13.
    Mirnezami A, Mirnezami R, Chandrakumaran K et al (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak. Ann Surg 253:890–899CrossRefPubMedGoogle Scholar
  14. 14.
    Obrand DI, Gordon PH (1997) Incidence and patterns of recurrence following curative resection for colorectal carcinoma. Dis Colon Rectum 40:15–24CrossRefPubMedGoogle Scholar
  15. 15.
    Phillips RK, Hittinger R, Blesovsky L et al (1984) Local recurrence following curative surgery for larger bowel cancer: the overall picture. Br J Surg 71:12–16CrossRefPubMedGoogle Scholar
  16. 16.
    Heald RJ, Moran BJ, Ryall RD et al (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg 133:894–899CrossRefPubMedGoogle Scholar
  17. 17.
    Baca B, Beart RW Jr, Etzioni DA (2011) Surveillance after colorectal cancer resection: a systematic review. Dis Colon Rectum 54:1036–1048CrossRefPubMedGoogle Scholar
  18. 18.
    Meyerhardt JA, Mangu PB, Flynn PJ et al (2013) Follow-up care, surveillance protocol, and secondary prevention measures for survivor of colonrectal cancer: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol 31:4465–4470CrossRefPubMedGoogle Scholar
  19. 19.
    Glimelius B, Oliveira J (2009) Rectal cancer: ESMO clinical reccomendations for diagnosis, treatment and follow-up. Ann Oncol 20:54–56CrossRefPubMedGoogle Scholar
  20. 20.
    Guidelines for the management of colorectal cancer 3rd edition (2007). Available at: http:// Accessed February 26, 2015Google Scholar
  21. 21.
    NCCN clinical practice guidelines in oncology (NCCN guidelines). Rectal Cancer. Version 2.2015 Available at: Accessed February 26, 2015Google Scholar
  22. 22.
    Kjeldsen BJ, Kronborg O, Fenger C, Jorgensen OD (1997) A prospective randomized study of follow-up after radical surgery for colorectal cancer. Br J Surg 84:666–669CrossRefPubMedGoogle Scholar
  23. 23.
    Graham RA, Wang S, Catalano PJ, Haller DG (1998) Postsurgical surveillance of colon cancer: preliminary cost analysis of physician examination, carcinoembryonic antigen testing, chest x-ray, and colonoscopy. Ann Surg 228:59–63CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Goldberg RM, Fleming TR, Tangen CM et al (1998) Surgery for recurrent colon cancer: strategies for identifying resectable recurrence and success rates after resection. Eastern Cooperative Oncology Group, the North Central Cancer Treatment Group, and the Southwest Oncology Group. Ann Intern Med 129:27–35CrossRefPubMedGoogle Scholar
  25. 25.
    Bruinvels DJ, Stiggelbout AM, Kievit J et al (1994) Follow-up of patients with colorectal cancer. A meta-analysis. Ann Surg 219:174–182CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Kjeldsen BJ, Kronborg O, Fenger C et al (1997) The pattern of recurrent colorectal cancer in a prospective randomised study and the characteristics of diagnostic tests. Int J Colorectal Dis 12:329–334CrossRefPubMedGoogle Scholar
  27. 27.
    Mayer RJ, Garnick MB, Steele GD Jr, Zamcheck N (1978) Carcinoembryonic antigen (CEA) as a monitor of chemotherapy in disseminated colorectal cancer. Cancer 42(3 Suppl):1428–1433CrossRefPubMedGoogle Scholar
  28. 28.
    Glover C, Douse P, Kane P et al (2002) Accuracy of investigations for asymptomatic colorectal liver metastases. Dis Colon Rectum 45:476–484CrossRefPubMedGoogle Scholar
  29. 29.
    Sugarbaker PH, Gianola FJ, Dwyer A et al (1987) A simplified plan for follow-up of patients with colon and rectal cancer supported by prospective studies of laboratory and radiologic test results. Surgery 102:79–87PubMedGoogle Scholar
  30. 30.
    Wanebo HJ, Llaneras M, Martin T et al (1989) Prospective monitoring trial for carcinoma of colon and rectum after surgical resection. Surg Gynecol Obstet 169:479–487PubMedGoogle Scholar
  31. 31.
    Minton JP, Hoehn JL, Gerber DM et al (1985) Results of a 400-patient carcinoembryonic antigen second-look colorectal cancer study. Cancer 55:1284–1290CrossRefPubMedGoogle Scholar
  32. 32.
    Tate H (1982) Plasma CEA in the post-surgical monitoring of colorectal carcinoma. Br J Cancer 46:323–330CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Boey J, Cheung HC, Lai CK et al (1984) A prospective evaluation of serum carcinoembryonic antigen (CEA) levels in the management of colorectal carcinoma. World J Surg 8:279–286CrossRefPubMedGoogle Scholar
  34. 34.
    Moertel CG, Fleming TR, Macdonald JS et al (1993) An evaluation of the carcinoembryonic antigen (CEA) test for monitoring patients with resected colon cancer. JAMA 270:943–947CrossRefPubMedGoogle Scholar
  35. 35.
    McCall JL, Black RB, Rich CA et al (1994) The value of serum carcinoembryonic antigen in predicting recurrent disease following curative resection of colorectal cancer. Dis Colon Rectum 37:875–881CrossRefPubMedGoogle Scholar
  36. 36.
    Wang JY, Tang R, Chiang JM (1994) Value of carcinoembryonic antigen in the management of colorectal cancer. Dis Colon Rectum 37:272–277CrossRefPubMedGoogle Scholar
  37. 37.
    Hine KR, Dykes PW (1984) Serum CEA testing in the postoperative surveillance of colorectal carcinoma. Br J Cancer 49:689–693CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Martin EW Jr, Cooperman M, Carey LC et al (1980) Sixty second-look procedures indicated primarily by rise in serial carcinoembryonic antigen. J Surg Res 28:389–394CrossRefPubMedGoogle Scholar
  39. 39.
    Primrose JN, Perera R, Gray A et al; FACS Trial Investigators (2014) Effect of 3 to 5 years of scheduled CEA and CT follow-up to detect recurrence of colorectal cancer: the FACS randomized clinical trial. JAMA 311:263–270CrossRefPubMedGoogle Scholar
  40. 40.
    Maas M, Rutten IJ, Nelemans PJ et al (2011) What is the most accurate whole-body imaging modality for assessment of local and distant recurrent disease in colorectal cancer? A metaanalysis: imaging for recurrent colorectal cancer. Eur J Nucl Med Mol Imaging 38:1560–1571CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Graffner H, Hultberg B, Johansson B et al (1985) Detection of recurrent cancer of the colon and rectum. J Surg Oncol 28:156–159CrossRefPubMedGoogle Scholar
  42. 42.
    Ohlsson B, Breland U, Ekberg H et al (1995) Follow-up after curative surgery for colorectal carcinoma. Randomized comparison with no follow-up. Dis Colon Rectum 38:619–626CrossRefPubMedGoogle Scholar
  43. 43.
    Schoemaker D, Black R, Giles L, Toouli J (1998) Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients. Gastroenterology 114:7–14CrossRefPubMedGoogle Scholar
  44. 44.
    Rodríguez-Moranta F, Saló J, Arcusa A et al (2006) Postoperative surveillance in patients with colorectal cancer who have undergone curative resection: a prospective, multicenter, randomized, controlled trial. J Clin Oncol 24:386–393CrossRefPubMedGoogle Scholar
  45. 45.
    McCormack PM, Ginsberg RJ (1998) Current management of colorectal metastases to lung. Chest Surg Clin N Am 8:119–126PubMedGoogle Scholar
  46. 46.
    Manfredi S, Bouvier AM, Lepage C et al (2006) Incidence and patterns of recurrence after resection for cure of colonic cancer in a well defined population. Br J Surg 93:1115–1122CrossRefPubMedGoogle Scholar
  47. 47.
    Kobayashi H, Mochizuki H, Sugihara K et al (2007) Characteristics of recurrence and surveillance tools after curative resection for colorectal cancer: a multicenter study. Surgery 141:67–75CrossRefPubMedGoogle Scholar
  48. 48.
    Makela JT, Laitinen SO, Kairaluoma MI (1995) Five-year follow- up after radical surgery for colorectal cancer. Results of a prospective randomized trial. Arch Surg 130:1062–1067CrossRefPubMedGoogle Scholar
  49. 49.
    Mc Call JL, Cox MR, Wattchow DA (1995) Analysis of local recurrence rates after surgery alone for rectal cancer. Int J Colorectal Dis 10:126–132CrossRefGoogle Scholar
  50. 50.
    Chen F, Stuart M (1994) Colonoscopic follow-up of colorectal carcinoma. Dis Colon Rectum 37:568–572CrossRefPubMedGoogle Scholar
  51. 51.
    Secco GB, Fardelli R, Gianquinto D et al (2002) Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial. Eur J Surg Oncol 28:418–423CrossRefPubMedGoogle Scholar
  52. 52.
    Grossmann EM, Johnson FE, Virgo KS et al (2004) Follow-up of colorectal cancer patients after resection with curative intent-the GILDA trial. Surg Oncol 13:119–124CrossRefPubMedGoogle Scholar
  53. 53.
    Wang T, Cui Y, Huang WS et al (2009) The role of postoperative colonoscopic surveillance after radical surgery for colorectal cancer: a prospective, randomized clinical study. Gastrointest Endosc 69(3 Pt 2):609–615CrossRefPubMedGoogle Scholar
  54. 54.
    de Anda EH, Lee SH, Finne CO et al (2004) Endorectal ultrasound in the follow-up of rectal cancer patients treated by local excision or radical surgery. Dis Colon Rectum 47:818–824CrossRefPubMedGoogle Scholar
  55. 55.
    Lu YY, Chen JH, Chien CR et al (2013) Use of FDG-PET or PET/CT to detect recurrent colorectal cancer in patients with elevated CEA: a systematic review and meta-analysis. Int J Colorectal Dis 28:1039–1047CrossRefPubMedGoogle Scholar
  56. 56.
    Sanli Y, Kuyumcu S, Ozkan ZG et al (2012) The utility of FDGPET/CT as an effective tool for detecting recurrent colorectal cancer regardless of serum CEA levels. Ann Nucl Med 26:551–558CrossRefPubMedGoogle Scholar
  57. 57.
    Pietra N, Sarli L, Costi R (1998) Role of follow-up in management of local recurrences of colorectal cancer. Dis Colon Rectum 41:1127–1133CrossRefPubMedGoogle Scholar
  58. 58.
    Figueredo A, Rumble RB, Maroun J et al (2003) Follow-up of patients with curatively resected colorectal cancer: a practice guideline. BMC Cancer 3:26CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Renehan AG, O_Dwyer ST, Whynes DK (2004) Cost effectiveness analysis of intensive versus conventional follow up after curative resection for colorectal cancer. BMJ 328:81–84CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Renehan AG, Egger M, Saunders MP, O_Dwyer ST (2005) Mechanisms of improved survival from intensive follow-up in colorectal cancer: a hypothesis. Br J Cancer 92:430–433PubMedPubMedCentralGoogle Scholar
  61. 61.
    Virgo KS, Vernava AM, Longo WE et al (1995) Cost of patient follow-up after potentially curative colorectal cancer treatment. JAMA 273:1837–1841CrossRefPubMedGoogle Scholar
  62. 62.
    Kievit J, Bruinvels DJ (1995) Detection of recurrence after surgery for colorectal cancer. Eur J Cancer Am 31:1222–1225CrossRefGoogle Scholar
  63. 63.
    Onaitis MW, Noone RB, Fields R et al (2001) Complete response to neoadjuvant chemoradiation for rectal cancer does not influence survival. Ann Surg Oncol 8:801–806CrossRefPubMedGoogle Scholar
  64. 64.
    García-Aguilar J, Hernandez de Anda E, Sirivongs P et al (2003) A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excision. Dis Colon Rectum 46:298–304CrossRefPubMedGoogle Scholar
  65. 65.
    Bedrosian I, Rodriguez-Bigas MA, Feig B et al (2004) Predicting the node-negative mesorectum after preoperative chemoradiation for locally advanced rectal carcinoma. J Gastrointest Surg 8:56–62CrossRefPubMedGoogle Scholar
  66. 66.
    Chan AKP, Wong A, Jenken D et al (2005) Posttreatment TNM staging is a prognostic indicator of survival and recurrence in tethered or fixed rectal carcinoma after preoperative chemotherapy and radiotherapy. Int J Radiat Oncol Biol Phys 61:665–677CrossRefPubMedGoogle Scholar
  67. 67.
    Guillem JG, Chessin DB, Cohen AM et al (2005) Long-term oncologic outcome following preoperative combined modality therapy and total mesorectal excision of locally advanced rectal cancer. Ann Surg 241:829–836CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Stipa F, Chessin DB, Shia J et al (2006) A pathologic complete response of rectal cancer to preoperative combined-modality therapy results in improved oncological outcome compared with those who achieve no downstaging on the basis of preoperative endorectal ultrasonography. Ann Surg Oncol 13:1047–1053CrossRefPubMedGoogle Scholar
  69. 69.
    Kuo L-J, Liu M-C, Jian JJ-M et al (2007) Is final TNM staging a predictor for survival in locally advanced rectal cancer after preoperative chemoradiation therapy? Ann Surg Oncol 14:2766–2772CrossRefPubMedGoogle Scholar
  70. 70.
    Martin ST, Heneghan HM, Winter DC (2012) Systematic review and meta-analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer. Br J Surg 99:918–928CrossRefPubMedGoogle Scholar
  71. 71.
    Habr-Gama A, Perez RO, Nadalin W et al (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 240:711–717PubMedPubMedCentralGoogle Scholar
  72. 72.
    Habr-Gama A, Perez RO, Guilherme P et al (2011) Nonperative approach to rectal cancer: a critical evaluation. Semin Radiat Oncol 21:234–239CrossRefPubMedGoogle Scholar
  73. 73.
    Smith JD, Ruby JA, Goodman KA et al (2012) Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy. Ann Surg 256:965–972CrossRefPubMedGoogle Scholar
  74. 74.
    Maas M, Beets-Tan Rg, Lambregts DM et al (2011) Wait and see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol 29:4633–4640CrossRefPubMedGoogle Scholar
  75. 75.
    Rossi BM, Nakagawa WT, Novaes PE et al (1998) Radiation and chemotherapy instead of surgery for low infiltrative rectal adenocarcinoma: a prospective trial. Ann Surg Oncol 5:113–118CrossRefPubMedGoogle Scholar
  76. 76.
    Nakagawa WT, Rossi BM, Ferreira FO et al (2002) Chemoradiation instead of surgery to treat mid and low rectal tumors: is it safe? Ann Surg Oncol 9:568–573CrossRefPubMedGoogle Scholar
  77. 77.
    Habr-Gama, Perez RO (2014) Immediate surgery or clinical follow-up after a complete clinical response? Recent Results Cancer Res 203:203–210CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2016

Authors and Affiliations

  1. 1.General Surgery UnitSanta Maria dei Battuti HospitalSan Vito al Tagliamento, PordenoneItaly

Personalised recommendations