Colorectal cancer

The purpose of follow-up is to:

• Monitor for the presence of treatment-related complications

• Detect recurrence at the primary site

• Detect and remove metachronous colorectal polyps

• Monitor for potentially recurrent metastatic disease.

National Comprehensive Cancer Network (NCCN) guidelines

The NCCN makes the following recommendations regarding monitoring:[129]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: rectal cancer [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx [139]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: colon cancer [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

All patients

Colonoscopy should be performed at 1 year post surgery, and then again at 3 years and 5 years if with each subsequent colonoscopy no advanced adenoma is detected.

Colonoscopy should be repeated again at a 1 year interval if an advanced adenoma is detected.

Stage 2-3 cancers

In addition to colonoscopies, a history and physical every 3-6 months for the first 2 years, and then every 6 months until 5 years post-treatment.​

Carcinoembryonic antigen (CEA) testing every 3-6 months for 2 years and then every 6 months for a total of 5 years post-treatment. CT chest, abdomen, and pelvis every 6-12 months for 5 years.

Stage 4 cancers

In addition to colonoscopies, a history and physical examination every 3-6 months for 2 years, then every 6 months for a total of 5 years. CEA testing every 3-6 months for 2 years and then every 6 months for a total of 5 years post-treatment. CT chest, abdomen, and pelvis every 3-6 months for 2 years, then every 6 months for a total of 5 years.

US Multi-Society Task Force (MSTF) on colorectal cancer

The US MSTF on colorectal cancer provides recommendations for follow-up after colonoscopy and polypectomy. The recommended follow-up times are based on risk stratification of the detected polyps.[129]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: rectal cancer [internet publication]. https://www.nccn.org/professionals/physician_gls/default.aspx

Average risk adults with normal colonoscopy or adenomas; intervals for surveillance colonoscopy:

• 1-2 tubular adenomas <10 mm: 10 years

• 3-4 adenomas <10 mm: 7-10 years

• 5-10 adenomas <10 mm: 3 years

• Adenoma with tubulovillous or villous histology: 3 years

• Adenoma with high grade dysplasia: 3 years

• >10 adenomas on single examination: 1 year

• Piecemeal resection of adenoma ≥20 mm: 6 months

Average risk adults with serrated polyps; intervals for surveillance colonoscopy:

• ≤20 hyperplastic polyps in rectum or sigmoid colon <10 mm: 10 years

• ≤20 hyper plastic polyps proximal to sigmoid colon <10 mm: 10 years

• 1-2 serrated polyps <10 mm: 5-10 years

• 3-4 serrated polyps <10 mm: 3-5 years

• 5-10 serrated polyps <10 mm: 3 years

• Serrated polyps ≥10 mm: 3 years

• Serrated polyp with dysplasia: 3 years

• Hyperplastic polyps ≥10 mm: 3-5 years

• Traditional serrated adenoma: 3 years

• Piecemeal resection serrated polyp ≥20 mm: 6 months

European Society of Gastrointestinal Endoscopy (ESGE)

The ESGE recommends endoscopic surveillance of patients post-polypectomy as follows:[391]Hassan C, Antonelli G, Dumonceau JM, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2020. Endoscopy. 2020 Aug;52(8):687-700. https://www.doi.org/10.1055/a-1185-3109 http://www.ncbi.nlm.nih.gov/pubmed/32572858?tool=bestpractice.com

• Patients with complete removal of 1-4 <10 mm adenomas with low grade dysplasia, irrespective of villous components, or any serrated polyp <10 mm without dysplasia, do not require endoscopic surveillance and should return to described recommended screening

• Surveillance colonoscopy after 3 years for patients with complete removal of at least 1 adenoma ≥10 mm or with high grade dysplasia, or ≥5 adenomas, or any serrated polyp ≥10 mm or with dysplasia

• 3- to 6-month early repeat colonoscopy following piecemeal endoscopic resection of polyps ≥20 mm

• Patients with 10 or more adenomas should be referred for genetic counselling.

The American Gastroenterological Association (AGA) has issued following Best Practice Advice statements on post-polypectomy surveillance based on published literature and expert opinion:[60]Issaka RB, Chan AT, Gupta S. AGA clinical practice update on risk stratification for colorectal cancer screening and post-polypectomy surveillance: expert review. Gastroenterology. 2023 Nov;165(5):1280-91. https://www.gastrojournal.org/article/S0016-5085(23)04771-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/37737817?tool=bestpractice.com

• For individuals aged >75 years, post-polypectomy surveillance decisions should be individualised, taking into account risks, benefits, and comorbidities

• All risk stratification tools for post-polypectomy surveillance derived from research should be examined for real-world effectiveness and cost-effectiveness in diverse populations before implementation.