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Patients who have undergone resections for cure are followed closely to look for evidence of symptomatic or asymptomatic tumor recurrence that may be amenable to curative resection in a small number of patients The optimal cost-effective strategy is not clear Two randomized trials reported that intense follow-up with yearly colonoscopy, abdominal CT, and chest radiography did not improve overall outcome compared with most standard follow-up protocols Patients should be evaluated every 3 6 months for 3 5 years with history, physical examination, and CEA determinations Patients who had a complete preoperative colonoscopy should undergo another colonoscopy 1 year after surgical resection Patients who did not undergo full colonoscopy preoperatively should undergo colonoscopy within 3 6 months postoperatively to exclude other synchronous colorectal neoplasms and 1 year thereafter Thereafter, surveillance colonoscopy should be performed every 3 5 years to look for metachronous polyps or cancer Because of the high incidence of local tumor recurrence in patients with rectal cancer, sigmoidoscopy should be performed every 3 6 months for 3 years New onset of symptoms or a rising CEA warrants investigation with chest and abdominal CT to look for recurrent or metastatic disease that may be amenable to therapy For patients with a rising CEA with unrevealing CT imaging, a PET scan is more sensitive for the detection of occult metastatic disease
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The stage of disease at presentation is the most important determinant of long-term survival: stage I, > 90%; stage II, 70 80%; stage III with fewer than four positive lymph nodes, 67%; stage III with more than four positive lymph nodes, 33%; and stage IV, 5 7% For each stage, rectal cancers have a worse prognosis For those patients whose disease progresses despite therapy, meticulous efforts at palliative care are essential (see 5)
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Compared with colon cancer, rectal cancer has lower longterm survival rates and significantly higher rates of local tumor recurrence (25%) due to the difficulty of achieving adequate surgical resection margins Combination therapy with fluorouracil and radiation has been shown to improve the disease-free survival rate and to decrease pelvic recurrence and is recommended for all patients with stage II and stage III
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Colorectal cancer is ideal for screening because it is a common disease affecting 6% of men and women that is fatal in almost
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50% of cases yet is curable if detected at an earlier stage Furthermore, the vast majority of cases arise from benign adenomas that progress over many years to cancer, and removal of adenomas has been shown to prevent the vast majority of cancers Colorectal cancer screening has now been endorsed by the United States Preventive Services Task Force, the Agency for Health Care Policy and Research, the American Cancer Society, and every professional gastroenterology and colorectal surgery society Although there is continued debate about the optimal cost-effective means of providing population screening, there is unanimous consent that screening of some kind should be offered to every patient over the age of 50 years Several analyses suggest that the cost of screening is approximately $25,000 per year of life saved for all recommended screening strategies, which is well below the range of $40,000 $50,000 per year generally considered to be cost-effective A number of options for screening are available and reimbursed by third-party payers and by Medicare The recommendations of a multidisciplinary consensus panel are listed in Table 39 5 for patients at average risk of developing colorectal cancer Patients with first-degree relatives with colorectal cancer are at increased risk, and for these individuals more intensive screening recommendations are recommended Recommendations for screening in families with inherited cancer syndromes or inflammatory bowel disease are provided in 14 The advantages and disadvantages of the various options are discussed below It is important for primary care providers to understand the relative merits of various options and to discuss them with their patients Despite growing awareness of the importance of screening on the part of medical professionals and the public,
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