CARCINOMA DEL COLON-RETTO: COSA DICONO LE LINEE GUIDA. Dr.ssa Foltran Luisa Oncologia medica Pordenone

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1 CARCINOMA DEL COLON-RETTO: COSA DICONO LE LINEE GUIDA Dr.ssa Foltran Luisa Oncologia medica Pordenone Convegno Regionale AIOM FVG, Palmanova, 14 Maggio 2016

2 COLORECTAL CANCER FOLLOW-UP Objectives Intensive follow-up versus minimal follow-up Guidelines AIOM ESMO ASCO Survivorship care plans Open issues

3 EARLY COLORECTAL CANCER 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

4 Recurrence rate by stage and time from random assignment. 73% of stage II and 82% of stage III colon cancer recurrences are diagnosed within 3 years Daniel J. Sargent et al. JCO 2007;25:

5 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:

6 MAIN OBJECTIVES OF FOLLOW-UP Early detect asymptomatic recurrences and second primary tumours Increase curative surgery at recurrence Improve overall survival

7 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)

8 INTENSIVE FOLLOW-UP VERSUS MINIMAL FOLLOW-UP WEAKNESSES OF STUDIES HETEROGENEITY Follow-up strategies (types and frequency of tests, setting) Study populations Study design UNDERPOWERED UNBLINDED LONG TIME-FRAME ( ) OUTDATED APPROACHES NO IMPACT ON CANCER-SPECIFIC SURVIVAL

9 COLORECTAL CANCER FOLLOW-UP: MAIN RECOMMENDATIONS TARGET POPULATION Colorectal cancer stage II e III FOLLOW-UP DURATION 5 YEARS FREQUENCY OF VISITS Q 3-6 MONTHS first 3 years, Q 6 months at year 4 and 5 TESTS CEA CT scan of chest and abdomen Colonscopy Pelvic CT and recto-sigmoidoscopy for rectal cancer

10 COLORECTAL CANCER FOLLOW-UP: AIOM GUIDELINES VISIT CEA RADIOLOGICAL IMAGING ENDOSCOPIC IMAGING Comments Q 4-6 MONTHS first 3 years, Q 6 MONTHS to 5 year Q 3-4 MONTHS first 3 years, Q 6 MONTHS to 5 year 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 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 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 Rectal exhamination if rectal cancer Repeat CEA at 6-8 weeks from surgery, if pre-operative elevated depending on risk Abdominal ultrasound may substitute CT scan if logistic problems or patient not suitable for surgery Colonscopy at 6-8 months from surgery if incomplete preoperative Not recommended: Other lab tests, chest X-Ray, CT-PET

11 COLORECTAL CANCER FOLLOW-UP: ESMO GUIDELINES VISIT CEA RADIOLOGICAL IMAGING ENDOSCOPIC IMAGING Comments COLON Q 3-6 MONTHS first 3 years, then Q 6-12 MONTHS Q 3-6 MONTHS first 3 years, then Q 6-12 MONTHS CT scan of chest and abdomen Q 6-12 MONTHS first 3 years Colonscopy at year 1, and Q 3-5 years Colorectal cancer stage not specified to 5 year to 5 year CEUS could substitute for abdominal CT scan RECTAL CANCER Q 6 MONTHS First 2 years Not recommended Not recommended Colonscopy Q 5 years

12 COLORECTAL CANCER FOLLOW-UP: ASCO GUIDELINES 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 Colonscopy at year 1 then if normal Q 5 years ALL STAGE II and III STAGE I AND IV: no recommendations for 3 years if high risk Pelvic CT ANNUALLY for 3-5 years (depending of rectal cancer risk) Recto-sigmoidoscopy Q 6 MONTHS for 2-5 years, for rectal cancer not treated with pelvic radiation No follow-up if patient not fit for surgery or sistemic treatment

13 COMPARING GUIDELINES: COLON CANCER COLON CANCER VISIT CEA CT SCAN COLONSCOPY Comments Q 6-12 MONTHS STAGE II - III Q 4-6 MONTHS FIRST 3 YEARS Q 3-4 MONTHS FIRST 3 YEARS FOR 3-5 YEARS AT YEAR 1, THEN Q 6 MONTHS THEN Q 6 MONTHS DEPENDING ON RISK then at YEAR 3, and Q 5 YEARS Indications STADIO I E IV Q 3-6 MONTHS FIRST 3 YEARS Q 3-6 MONTHS FIRST 3 YEARS Q 6-12 MONTHS FIRST 3 YEARS AT YEAR 1 THEN Q 3-5 YEARS STAGE NOT SPECIFIED THEN Q 6-12 MONTHS THEN Q 6-12 MONTHS Q 3-6 MONTHS FOR 5 YEARS Q 3-6 MONTHS FOR 5 YEARS Q 12 MONTHS (Q 6-12 MONTHS IF HIGH RISK) AT YEAR 1 THEN Q 5 YEARS STAGE II - III FIRST 3 YEARS

14 COMPARING GUIDELINES: RECTAL CANCER RECTAL CANCER VISIT CEA 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

15 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

16 SURVIVORSHIP CARE PLANS (2) SECONDARY PREVENTION

17 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