Should colonoscopy be performed one year out from colorectal cancer resection? Newcastle NHS Trust Alexandra Kent, Philip Thompson, Prof Alan Horgan, Mr Paul Hainsworth
ACPGBI: Guidelines for the Management of Colorectal Cancer Staging investigation for potentially curable colorectal cancer • Complete visualisation of colon required either pre- or post-operatively. • If complete colonic imaging is not possible before surgery, it is important this is done within six months, or as soon as possible after closure of a temporary ileostomy.
ACPGBI Guidelines Colonoscopic follow-up • If such a policy is pursued, it is recommended that a “clean” colon should be examined by colonoscopy at 5 yearly intervals. • Patients should be counselled about the potential complications of colonoscopy. ACPGBI. Guidelines for the management of colorectal cancer 3rd edition 2007.
NICE guidelines (2004) • Patients who did not have a complete colonoscopy pre-op should be offered colonoscopy within 6 months of discharge. • MDTs in each network should agree follow up guidelines. • 5 yearly intervals for patients with a ‘clean’ colon. NICE. Guidance on cancer services. Improving outcomes in colorectal cancer. 2004.
NICE guidelines (2011) • Offer a surveillance colonoscopy at 1 year after initial treatment. If this is normal consider colonoscopy at 5 years. • Two Systematic reviews - potential benefit in identifying recurrence of disease at an earlier stage - Low-moderate evidence base. NICE. CG131 Colorectal cancer - the diagnosis and management of colorectal cancer 2011 Jeffery M, Hickey BE, Hider PN. Follow-up strategies for patients treated for non-metastatic colorectal cancer (Review), The Cochrane Library 2007, Issue 4 Tiandra J, Chan MK..Follow-up after curative resection of colorectal cancer: a meta-analysis. Dis Colon Rectum. 2007 Nov;50(11):1783-99
Newcastle Colorectal MDT Guidelines Patients undergoing curative resection. • Complete colonoscopy pre-operatively or within 6 months of discharge • Surveillance colonoscopy at 1 year
AimsTo assess compliance with local guidelines in patients undergoing curative colorectal cancer resection: • Complete colonoscopy pre-op or within 6 months • Follow up colonoscopy at one year • Incidence of synchronous / metachronous lesions • Record interventions resulting from colonoscopy
Method • Colorectal cancer resections 2008-2012 PJH/AFH (total=347) • Sub-set selected commencing 2008 • Retrospective electronic chart review • Endoscopy database • Endoscopic outcomes recorded
Sample • 115 patients • 53 female, 62 male • Age range 39-92, median 71 • Dukes A 23; B 33; C39; D20.
Resections performed Other: - 1 pelvic exanteration and 1 enbloc resection
60/ 88 patients had surveillance colonoscopy 28 eligible patients did not have colonoscopies Reasons for failure to perform 1 year follow up colonoscopy
Timing of ‘1 year’ colonoscopy Range 6-30 months post-op
Incidence of metachronous lesions at ‘1 year’ scope (n=60) • Normal 35 • Polyps 24 • 1 patient had a TEMS procedure, local reoccurrence at 17 months on colonoscopy - anterior resection
Interventions and complicationsresulting from colonoscopy • 24 patients cleared of polyps • 1 vasovagal episode - delayed discharge
Conclusion • Failure to establish clean colon within 6 months • 1 year colonoscopy performed in 68% range 6 - 30 months • Significant incidence of lesions leading to interventions in 24 • Low complication rate from colonoscopy
DiscussionShould colonoscopy be performed one year out from colorectal cancer resection? Benefits • Ensures clean colon in patients missed by pre-op/ 6month colonoscopy. • Acknowledged aversion to removing polyps by surgeons when suspected cancer discovered • Drawbacks • Cost • Invasive Procedure • Limitations • Small study size • Missing data