Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer

doi:10.1067/mge.2000.106685

Gastrointestinal Endoscopy

Volume 52, Issue 1, July 2000, Pages 33-38

Presented in part at the American Society for Gastrointestinal Endoscopy, New Orleans, Louisiana, May 20, 1998 (Gastrointest Endosc 1998;47:AB96).

https://doi.org/10.1067/mge.2000.106685 Get rights and content

Abstract

Background: Endoscopic examinations of the colon are often recommended for surveillance following colorectal cancer resection. The actual use and outcome of this testing are not known. Methods: Five thousand seven hundred sixteen patients 65 years of age or older with local or regional stage colorectal cancer diagnosed in 1991 were identified through the Surveillance Epidemiology and End Results registry. All inpatient and outpatient Medicare claims from 6 months after diagnosis through the end of 1994 were examined to determine use of endoscopic procedures. Results: One or more colonoscopies were performed in 51%, with an average of 2.9 procedures performed among those tested; sigmoidoscopy was performed in 17%. The rate of colonoscopy was highest during the initial 18 months. Polypectomy was performed in 21% of all patients, and subsequent primary colorectal tumors were diagnosed in 1.3%. Factors associated with colonoscopy and sigmoidoscopy use included younger age, survival through follow-up, and geographic region; sigmoidoscopy was also more common in relation to rectal cancers. Conclusions: There is variability in the use of endoscopic procedures following potentially curative resection for colorectal cancer, with patient-related factors and local practice patterns accounting for the variation. Further studies are needed to elicit the reasons for lack of follow-up and adherence to practice guidelines. (Gastrointest Endosc 2000;52:33-8.)

Section snippets

Patients and data sources

The cohort for the study was obtained from a unique merged Medicare–SEER database that was developed jointly by the National Cancer Institute and Health Care Finance Administration (HCFA) to conduct cancer-related health services research.¹⁰ As previously described, the joint database includes all patients older than 64 years who were diagnosed with cancer and resided in one of the 9 SEER areas in the program in 1991 (Atlanta, Detroit, Seattle–Puget Sound, San Francisco– Oakland, Connecticut,

RESULTS

A total of 5716 patients with colorectal cancer were identified. The mean age was 74.8 ± 7.0 years, 51% were women and 6% were black. The cancers were local stage and regional stage in 50% each and were located in the colon in 75% and rectum in 25%. Survival through the end of 1994 was 74%. Among the 1465 patients who died, 962 of deaths (66%) were attributed to colorectal cancer and 503 (34%) attributed to other causes.

Subsequent primary tumors were diagnosed in 73 patients (1.3%) (61 colon,

DISCUSSION

Patients are considered at increased risk for development of adenomatous polyps and additional primary tumors, as well as local recurrence of the original cancer, during the time interval following potentially curative treatment of colorectal cancer. Thus, the routine use of colonoscopy or sigmoidoscopy is generally recommended. However, there is little consensus about the intensity of such follow-up, and there are few data about the relative yield of this strategy. In a cohort of more than

Acknowledgements

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are solely the responsibility of the authors. We acknowledge the efforts of the Applied Research Branch, Division of Cancer Prevention and Population Science, NCI; the Office of Information Services and the Office of Strategic Planning, HCFA; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology and End Results (SEER) Program tumor registries in the creation of the

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Cited by (33)

Colorectal cancer and race: Understanding the differences in outcomes between African Americans and whites
2005, Medical Clinics of North America
Citation Excerpt :
At least among the elderly population, this does not seem to be the case. In an analysis of over 5000 elderly patients in the SEER-Medicare database diagnosed with local or regional disease who underwent curative surgical treatment for their colon cancer, Cooper et al [53] did not find a difference between African Americans and whites in the use of follow-up colonoscopy or sigmoidoscopy in the 3 years following surgery. With the exceptions noted previously, there seems to be agreement that even after controlling for all known prognostic factors, African Americans who have CRC have a higher mortality rate compared with whites.
Computed tomographic colonography compared with colonoscopy in patients at increased risk for colorectal cancer
2004, Gastroenterology
$Background & Aims :$ To date, computed tomographic (CT) colonography has been compared with an imperfect test, colonoscopy, and has been mainly assessed in patients with positive screening test results or symptoms. Therefore, the available data may not apply to screening of patients with a personal or family history of colorectal polyps or cancer (increased risk). We prospectively investigated the ability of CT colonography to identify individuals with large (≥10 mm) colorectal polyps in consecutive patients at increased risk for colorectal cancer. $Methods :$ A total of 249 consecutive patients at increased risk for colorectal cancer underwent CT colonography before colonoscopy. Two reviewers interpreted CT colonography examinations independently. Sensitivity, specificity, and predictive values were determined after meticulous matching of CT colonography with colonoscopy. Unexplained large false-positive findings were verified with a second-look colonoscopy. $Results :$ In total, 31 patients (12%) had 48 large polyps at colonoscopy. This included 8 patients with 8 large polyps that were overlooked initially and detected at the second-look colonoscopy. In 6 of 8 patients, the missed polyp was the only large lesion. With CT colonography, 84% of patients (26/31) with large polyp(s) were identified, paired for a specificity of 92% (200–201/218). Positive and negative predictive values were 59%–60% (26/43–44) and 98% (200–201/205–206), respectively. CT colonography detected 75%–77% (36–37/48) of large polyps, with 9 of the missed lesions being flat. $Conclusions :$ CT colonography and colonoscopy have a similar ability to identify individuals with large polyps in patients at increased risk for colorectal cancer. The large proportion of missed flat lesions warrants further study.
Clinical and sociodemographic factors associated with colon surveillance among patients with a history of colorectal cancer
2004, Gastrointestinal Endoscopy
Substantial variability in the use of colon surveillance among colorectal cancer survivors has been reported. This study sought to examine trends in the use of colon surveillance among patients who have had colorectal cancer and to investigate factors associated with utilization.
Health maintenance organization enrollees with a diagnosis of local or regional colon or rectal cancer between January 1993 and December 1999 were studied. Receipt of a colon examination by colonoscopy or by flexible sigmoidoscopy, together with barium contrast radiography of the colon was determined from automated clinical records, and rates of colon surveillance were estimated by using survival analysis.
A total of 1002 patients with a diagnosis of colorectal cancer met inclusion criteria for the study. Colon examinations were performed in 61% of patients within 18 months of diagnosis and in 80% of patients within 5 years of diagnosis. The median time from diagnosis to first colon surveillance examination (14 months) was unchanged over the study period, but the interval between first and second surveillance examinations increased by 17 months (p<0.001). Patients over 80 years of age (relative risk = 0.32; 95% CI[0.22, 0.45]) and those with rectal cancer (relative risk = 0.80; 95% CI[0.66, 0.97]) were less likely to undergo surveillance. Higher socioeconomic status (relative risk = 1.29; 95% CI[1.03, 1.61]) and being married (relative risk = 1.27; 95% CI[1.05, 1.53]) were associated with greater utilization. There was lower utilization among African American patients (relative risk = 0.70; p = 0.14) and increased utilization among other minorities (relative risk = 1.47; p = 0.06).
There is substantial variability in the use of colon examination for surveillance in patients with a history of colorectal cancer, and clinical and sociodemographic factors appear to influence the likelihood of surveillance.
Colonoscopy Surveillance After Colorectal Cancer: the Optimal Interval for Follow-Up
2020, Journal of Gastrointestinal Cancer
Adherence to postresection colorectal cancer surveillance at National Cancer Institute-designated Comprehensive Cancer Centers
2018, Cancer Medicine
Health status, use of healthcare, and socio-economic implications of cancer survivorship in Portugal: results from the Fourth National Health Survey
2014, Journal of Cancer Survivorship

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^☆: Supported in part by a Case Western Reserve University Pepper Center Pilot Project Grant #AG-10418 from the National Institute of Aging (G.S.C.) and a Clinical Research Training Grant for Junior Faculty from the American Cancer Society (G.S.C.).

^☆☆: Reprint requests: Gregory S. Cooper, MD, Division of Gastroenterology, University Hospitals of Cleveland, 11100 Euclid Ave., Cleveland, OH 44106.

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Original ArticlesPatterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer☆,☆☆

Abstract

Section snippets

Patients and data sources

RESULTS

DISCUSSION

Acknowledgements

Gastroenterology

Gastrointest Endosc

Gastroenterology

Cancer statistics, 1999

Ca Cancer J Clin

American Cancer Society guidelines for screening and surveillance for early detection of colorectal polyps and cancer: update 1997

CA Cancer J Clin

The utility of follow up testing after curative cancer therapy

J Gen Intern Med

Cost of patient follow up after potentially curative colorectal cancer treatment

JAMA

Practice parameters for the detection of colorectal neoplasms

Dis Colon Rectum

Current follow up strategies after resection of colon cancer: results of a survey of members of the American Society of Colon and Rectal Surgeons

Dis Colon Rectum

Does methodic long term follow up affect survival after curative resection of colorectal carcinoma?

Dis Colon Rectum

Follow up of patients with colorectal cancer: a meta-analysis

Ann Surg

Potential for cancer related health services research using a linked Medicare-tumor registry database

Med Care

Cumulative incidence of metachronous colorectal cancer

Dis Colon Rectum

Original Articles
Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer☆,☆☆