1. Follow-up of GI Cancers Dr. Marianne Taylor BC Cancer Agency – CSI November 29, 2003

2. Introduction Purposes of follow-up Colorectal cancer Gastric cancer Esophageal cancer Pancreas cancer

3. 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

4. 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)

5. 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)

6. Levels of Evidence I.Meta-analysis and good RCT (high power) II.At least one well designed trial or RCT with low power III.Well designed but quasi-experimental trials cohort, case-control studies IV.Comparative and case studies V.From case reports and clinical examples

7. ASCO & BCCA Guidelines 1.History and physical exam every 3-6 months x 3yrs then annually BCCA- every 3mos x 3yrs then annually –Level V 2.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

8. ASCO & BCCA Guidelines 3.Colonoscopy – pre or post-op then q3-5 yrs (level I) Ba enema & sigmoidoscopy 4.Liver function testing – NR (level IV) 5.FOBT – NR (level II) 6.CT scan – NR (level II) 7.CXR – NR (level II) J. Clin Oncol – 20:3586 2000

9. ASCO & BCCA Guidelines 8.Proctosigmoidoscopy – only if no XRT No interval suggested (level IV) If XRT colonoscopy as usual 9.Pelvic imaging – NR (level IV) 10.CBC – NR (level IV) J. Clin Oncol – 20:3586 2000

10. ASCO & BCCA Guidelines Summary: Do: –History and physical –CEA –Colonoscopy –Investigate symptoms/signs as appropriate

11. ASCO & BCCA Guidelines Summary Don’t do: –CBC, liver tests, FOBT –Proctosigmoidoscopy unless no prior XRT –Pelvic imaging/ CT scan –CXR

12. 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

13. 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

14. Anal Canal Carcinoma Primary therapy is chemoradiotherapy Salvage is possible with surgery (APR) Need to be monitored closely for recurrence/ spread –Q2mo X 2yrs, 6mos x 1yr then q yearly to 5 –Examine anus and inguinal nodes

15. 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

16. Summary - GI Follow-up More intensive follow-up helpful: Colorectal Anal canal carcinoma

17. Summary - GI Follow-up Clinical follow-up only: Stomach Esophagus Pancreas