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Follow-up of GI Cancers. Dr. Marianne Taylor BC Cancer Agency – CSI November 29, 2003. Introduction. Purposes of follow-up Colorectal cancer Gastric cancer Esophageal cancer Pancreas cancer. Colorectal Cancer - Surveillance.
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Follow-up of GI Cancers Dr. Marianne Taylor BC Cancer Agency – CSI November 29, 2003
Introduction • Purposes of follow-up • Colorectal cancer • Gastric cancer • Esophageal cancer • Pancreas cancer
Colorectal Cancer - Surveillance • Primary goal is to discover isolated recurrence in lung, liver or bowel that is potentially curable with surgery • ?Secondary goals – • Prevent second primary • Support patient • Start metastatic therapy earlier?? • Look for side effects of therapy
Colorectal Cancer – Surveillance • Resectable liver metastases – 5yr survival 25-30% • Resectable lung metastases – 5 yr survival 25-30% • Isolated rectal recurrence – 20% 5 yr. Survival (Tepper et al. J Clin Oncol. 2003)
Colorectal Cancer – Surveillance • Risk of a second primary • Cancer risk 5.3% in five years (Togashi et al. Dis Colon Rectum 2000) • Risk of polyps is higher • Polypectomy can prevent development of cancer (National Polyp Study)
Levels of Evidence • Meta-analysis and good RCT (high power) • At least one well designed trial or RCT with low power • Well designed but quasi-experimental trials cohort, case-control studies • Comparative and case studies • From case reports and clinical examples
ASCO & BCCA Guidelines • History and physical exam every 3-6 months x 3yrs then annually • BCCA- every 3mos x 3yrs then annually • Level V • CEA – only if surgery will be considered • Q2-3 months for 2yrs • BCCA guideline –q3mos. X 3 yrs • Level II J. Clin Oncol – 20:3586 2000
ASCO & BCCA Guidelines • Colonoscopy – pre or post-op then q3-5 yrs (level I) • Ba enema & sigmoidoscopy • Liver function testing – NR (level IV) • FOBT – NR (level II) • CT scan – NR (level II) • CXR – NR (level II) J. Clin Oncol – 20:3586 2000
ASCO & BCCA Guidelines • Proctosigmoidoscopy – only if no XRT • No interval suggested (level IV) • If XRT colonoscopy as usual • Pelvic imaging – NR (level IV) • CBC – NR (level IV) J. Clin Oncol – 20:3586 2000
ASCO & BCCA Guidelines Summary: • Do: • History and physical • CEA • Colonoscopy • Investigate symptoms/signs as appropriate
ASCO & BCCA Guidelines Summary • Don’t do: • CBC, liver tests, FOBT • Proctosigmoidoscopy unless no prior XRT • Pelvic imaging/ CT scan • CXR
Gastric Cancer • Very early cancers (musosa or submucosa +/- nodes) might benefit from follow-up gastroscopy ( 6 &18 mos then 2-3 yr. Intervals) • No evidence to support any follow-up in those with more advanced disease • Clinical follow-up only with investigations directed by symptoms/signs
Esophageal Cancer • No evidence to support imaging/gastroscopy/BW • Symptomatic follow-up only • High propensity in XRT patients for benign strictures – so consider early referral for dilatation
Pancreas Cancer • After curative surgery – clinical follow-up only • Keep in mind that surgery only cures 10-20% • Have low index of suspicion for symptoms/signs – good palliative therapy is available
Summary - GI Follow-up More intensive follow-up helpful: • Colorectal • Anal canal carcinoma
Summary - GI Follow-up Clinical follow-up only: • Stomach • Esophagus • Pancreas