Mechanisms of improved survival from intensive followup in colorectal cancer: a hypothesis

Abstract

A meta-analysis of six randomised trials demonstrated that intensive followup in colorectal cancer was associated with an absolute reduction in all-cause 5-year mortality of 10% (95% confidence interval (CI): 4 -16) -however, only two percent (95% CI: 0 -5) was attributable to cure from salvage re-operations. We postulate that other factors, such as increased psychological well-being and/or altered lifestyle, and/or improved treatment of coincidental disease may contribute to the remaining lives saved, and form important future research questions. Approximately two-thirds of patients presenting with colorectal cancer undergo resection with curative intent, and most subsequently enter protocols for long-term followup (Kievit, 2002). The rationale for surveillance is three-fold: psychological support, facilitation of audit, and an opportunity for the early detection and treatment of recurrent disease, with potential improvement in survival. Recently, the authors (Renehan et al, 2002b) reported a meta-analysis of five randomised trials and demonstrated a significant improvement in all-cause 5-year mortality in patients followed intensively. A Cochrane review (Jeffery et al, 2002) independently found similar results, and, subsequently, a sixth randomised trial reported additional results supporting these conclusions (Secco et al, 2002). These data offer the first direct evidence that intensive followup improves survival, but fall short of evaluating the mechanisms underlying the observed survival benefit. This study updates and extends our previous metaanalysis to explore the survival mechanisms associated with intensive followup. MATERIALS AND METHODSThe search strategy, inclusion and exclusion criteria, data extraction, and study quality assessment have been published elsewhere (Renehan et al, 2002b(Renehan et al, , 2004, with further details at www.christie.man.ac.uk/profinfo/departments/surgery/default. htm. The key features were:Updated search strategy (to December 2003) using Cochrane methodology.Inclusion criteria were: randomised controlled trial; patients with colorectal cancer treated surgically with curative intent; randomisation at or shortly after surgery, and availability of 5-year survival data. Data were extracted independently by two investigators (AGR, MPS). Important components of methodological quality, namely adequacy of concealment of patients' allocation to treatment groups, double-blinding, and withdrawals, were assessed. Statistical analysisMeta-analyses were performed at two levels. First, comparisons of events (e.g. all-cause deaths) for intensive vs conventional followup were performed and pooled estimates expressed as risk ratios (RR) and 95% confidence intervals (95% CIs). Second, estimates of the proportion of overall lives gained, and lives gained through to salvage re-operation, were calculated using absolute risk differences (and 95% CIs) (Deeks and Altman, 2001). The difference between these estimates was taken as an estimate of the gain in lives attributable to nonsalvage-related ...

Follow-Up After Curative Resection of Colorectal Cancer: A Meta-Analysis

“…More importantly, psychologic support and reassurance from regular medical follow-up might have a significant role. 20 This was evidenced by the improved outcome in response to increased psychologic support to patients with breast cancer 41 and gastrointestinal cancer. 42 In a Danish trial, 25 a small but significant improvement of health-related quality of life with intensive follow-up was found.…”

Towards a personalised approach to aftercare: a review of cancer follow-up in the UK

“…➢ All but one review [9] concluded that providing intensive (i.e. long-term) follow-up for colorectal cancer improves survival, with three concluding that it was slightly more effective than minimal follow-up [10][11][12]. All studies found intensive follow-up to be more costly than minimal followup; the incremental cost-effectiveness ratio varied from US $4,926 per life year saved to US $25, 926, respectively.…”

Contrast-enhanced MRI and PET-CT in the evaluation of patients with suspected local recurrence of rectal carcinoma

“…Until 2002, no significant benefits on long-term survival had been proved for patients undergoing intensive follow-up and, although effective for early diagnosis of recurrence and curative reoperation, most proposed schedules did not offer a worthwhile cost-benefit ratio [3]. On the other hand, three recent meta-analyses comparing the results of low-intensity and high-intensity surveillance programmes for all patients after curative-intent surgery demonstrated the survival benefit of intensive follow-up with a reduction of absolute mortality of 10% [4][5][6][7]. Furthermore, in 2002, Secco et al [3] demonstrated that a risk-adapted follow-up tailored to the different risk categories of patients resulted in improved targeting of curative reoperation and overall survival.…”

“…Fino al 2002 non sono stati dimostrati significativi benefici sulla sopravvivenza a lungo termine in pazienti sottoposti a follow-up intensivo e la maggior parte degli studi proposti, nonostante l'efficacia nella diagnosi precoce di recidiva ed una seconda possibilità di intervento chirurgico curativo, non offrivano un rapporto costo-beneficio accettabile [3]. Tre recenti metanalisi, confrontando i risultati di programmi di sorveglianza a bassa intensità e ad alta intensità per pazienti con CCR sottoposti ad intervento curativo, hanno tuttavia dimostrato un miglioramento della sopravvivenza nel follow-up intensivo con una riduzione del 10% della mortalità assoluta [4][5][6][7]. Inoltre, nel 2002 Secco et al [3] hanno dimostrato che un follow-up adattato al rischio di recidiva, basato cioè su diverse categorie di rischio dei pazienti, permette un significativo aumento della sopravvivenza totale e l'individuazione di un maggior numero di casi trattabili con un secondo intervento curativo.…”