SAGES - Position Statements and Guidelines

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Guidelines for Colonoscopy Surveillance after Cancer Resection

Practice patterns differ widely in the follow-up colonoscopic surveillance of patients with colorectal cancer. Available data indicate that a substantial portion of the post-cancer resection cohort receives colonoscopy surveillance at one of two opposite (both inappropriate) extremes: On the one hand, many patients do not undergo surveillance. On the other hand, many receive surveillance exams that are too frequent; patients with hereditary nonpolyposis colorectal cancer may account for some, but not all, of these. The results suggest that uniform surveillance guidelines and systematic reminders to post-resection patients about the need for surveillance are sorely needed, as are new methods for educating practitioners who overuse surveillance exams.

A recent guideline has been published by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer. (1)

1. Patients with rectal and colon cancer should undergo high-quality perioperative clearing, by means of preoperative colonoscopy. In the event of an obstructing tumour various methods may be used including CT colonoscopy, on-table colonoscopy or double-contrast barium enema. If a colonoscopy is not possible prior to surgery, it may be delayed until 3-6 months after surgery, provided no unresectable metastases were found at surgery.
2. Patients undergoing curative resection should undergo colonoscopy at 1 year after surgery, or after the clearing colonoscopy if it was delayed until after surgery.
3. If the 1-year colonoscopy is normal, the interval before the next examination should be 3 years. If that colonoscopy is normal, the interval before the next examination should be 5 years.
4. Following the 1-year colonoscopy the interval before the next examination may be shortened in hereditary non-polyposis colorectal cancer (HNPCC) is suspected, or if adenoma findings warrant earlier colonoscopy.
5. In the follow-up of rectal cancer following low anterior resection, rectal inspection may be performed 3-6 monthly, with either rigid or flexible proctoscopy. These examinations are independent of the colonoscopic examinations described above for the detection of metachronous disease.


All patients undergoing curative-intent surgery should be considered for surveillance colonoscopy. Patients with unresectable Stage 1V are generally excluded, as they will not derive benefit from surveillance.
The goals of surveillance are two-fold: the detection of metachronous lesions, and detection of early recurrence of the primary tumour at a stage that will allow curative treatment. Annual or more frequent colonoscopic surveillance has not been shown to prolong survival. The reason for this phenomenon is that few intra-luminal recurrences occur, with most being associated with intra-abdominal or pelvic disease that is unresectable for cure. The primary goal of colonoscopy after surgery is the detection of metachronous disease.

Reference

1. Guidelines for Colonoscopy Surveillance after Cancer Resection: A Consensus Update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer. Rex DK, Kahi CJ, Levin B et al. CA Cancer J Clin 2006; 56:160-167