Evidence
Alert

Intensive routine follow-up after bowel cancer treatment may not be necessary

More intensive follow-up strategies for patients who have surgery to cure bowel cancer do not result in an overall survival benefit when compared with less intensive follow-up. More intensive strategies include increased frequency of clinic visits, blood tests and scans.

This Cochrane review did find that those people followed up intensively had more frequent surgery to try and cure a recurrence, but this did not translate into a measurable benefit in survival. This suggests that people do not need a more intensive regime, which may be more expensive for health services and burdensome for patients.

This was the fourth update of this Cochrane review. It did not change the conclusions from the last update in 2016, but the four new studies that were included (with an additional 6,238 participants) now strengthen confidence in the conclusions.

 

Why was this study needed?

Colorectal, or bowel cancer, is cancer of the colon or rectum. It is the fourth most common cancer in the UK, with about 42,000 people diagnosed each year. For about two-thirds of patients, the cancer is curable with surgery and sometimes chemotherapy.

It is common practice to follow patients up for several years, to check whether the cancer has returned. However, there is considerable uncertainty over whether patients benefit from being seen more often and what tests should be used. Follow-up can be expensive, inconvenient, and cause anxiety, and some tests can have side effects.

This study aimed to answer these questions by assessing the effect of a variety of follow-up programmes on overall survival, cancer-specific and relapse-free survival, and quality of life. It also investigated the harms and costs of follow-up.

 

What did this study do?

This update of a Cochrane systematic review included four new trials since the last update in 2016, giving nineteen trials with 13,216 participants. Participants had all had surgery to remove tumours in the colon or rectum. The included studies were all randomised controlled trials, comparing different follow-up strategies. Follow-up included clinic visits and examinations, CT scans, and carcinoembryonic antigen (CEA) blood tests.

More intensive strategies were defined as an increased frequency of these visits and investigations, compared to no follow-up, or less frequent investigations. The study also compared follow-up settings, and usual follow-up to follow-up with additional support materials. The individual tests were evaluated in a sub-group analysis.

The trials took place in Europe, Australia and China, with two carried out in the UK. The quality of evidence for the important outcomes was reliable.

 

What did it find?

  • For overall deaths, intensive follow-up made no significant difference compared with less intensive follow-up (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.80 to 1.04). The average effect was 24 fewer deaths per 1,000 patients. But the true effect could be between 60 fewer and 9 more deaths per 1,000 patients.
  • For colorectal cancer-specific deaths, the use of intensive versus less intensive follow-up made little or no difference (HR 0.93, 95% CI 0.81 to 1.07).
  • More people had salvage surgery, with curative intent, when followed up intensively (risk ratio 1.98, 95% CI 1.53 to 2.56).
  • Intensive follow-up probably made little or no difference to quality of life, anxiety or depression but data was not available for meta-analysis.
  • No benefit was found from the use of particular tests such as the CEA blood test or CT scans and harms or costs could not be estimated.

 

What does current guidance say on this issue?

The NICE 2020 guideline on the diagnosis and management of colorectal cancer recommends that patients are offered regular surveillance, with both CT scans of the chest, abdomen and pelvis and CEA blood tests in the first three years.

It no longer specifies how frequent these tests should be. However, the guideline committee noted that previously standard care was considered to be a minimum of two CTs of the chest, abdomen and pelvis, as well as six-monthly blood tests during these three years.

Regular follow-up should be stopped when the patient and healthcare professional have discussed and agreed that the likely benefits no longer outweigh the risks of further tests, or if the patient cannot tolerate further treatments.

 

What are the implications?

This research suggests that we still are not sure which follow-up strategy is best, but a less intensive regime appears adequate. The new NICE guidance does not specify the number or frequency of CTs or CEA blood tests because of remaining uncertainty around the most clinically and cost-effective regime. This means there is likely to be wide variation depending on clinician and patient preferences.

 

Citation and Funding

Jeffery M, Hickey BE and Hider PN. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev. 2019;(9):CD002200.

The review was supported by Cochrane Colorectal Cancer group, New Zealand Health Technology Assessment and Princess Alexandra Hospital Cancer Collaborative Group, Australia.

 

Bibliography

Cancer Research UK. Bowel cancer. London: Cancer Research UK; reviewed 2018.

NHS website. Bowel cancer. London: Department of Health and Social Care; 2016.

NICE. Colorectal cancer. NG151. London: National Institute for Health and Care Excellence; 2020.

NICE. Colorectal cancer (update). Evidence review E1. Follow-up to detect recurrence after treatment for non-metastatic colorectal cancer. London: National Institute for Health and Care Excellence; 2020.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Commentaries

Expert commentary

Conventional thought has been that more intensive follow-up increases early detection of relapse thereby improving survival outcomes in early-stage colorectal cancer. This has been challenged by finding no improvement in survival with more intensive follow-up in patients treated with curative intent. Despite an increase in salvage surgery (curative intent) following relapse detection, this did not translate to improved survival. Practice still varies considerably from centre to centre, and this review reassures clinicians against the requirement for intensive follow-up.

Although there was no effect on overall quality of life with more frequent follow-up, it is important to determine if the increase in salvage surgery and earlier detection of recurrences improve patients’ symptom burden and global health.

Further evidence is required regarding the cost and benefits of less frequent follow-up and the risk of harm from frequent imaging/intervention. This will guide clinicians and standardise practice; however, follow-up strategy should be tailored according to individual patient needs.

Dr Nalinie Joharatnam-Hogan, Clinical Research Fellow, MRC Clinical Trials Unit, UCL, London

Dr Khurum Khan, Professor and Consultant Medical Oncologist, Gastrointestinal Oncology Service, Cancer of Unknown Primary Service, University College London Hospital, UCL Cancer Institute and North Middlesex University Hospital

The commentators declare no conflicting interests

Expert commentary

The benefits of intensive follow-up after curative resection of colorectal cancer have been debated for many years. These benefits do not extend to the population level. The challenge for the clinician is to balance the hopes and expectations of individual cancer patients against the issues of cost and resource use.

Intensive follow-up results in less than a 10% chance of patients undergoing salvage surgery, but that represents the only chance of cure in the setting of recurrent disease. At least intensive follow-up is not associated with loss of quality of life or harm.

Professor James Hill, Consultant General and Colorectal Surgeon, Manchester University NHS Foundation Trust

The commentator declares no conflicting interests