1. Potentially curative re-resection of recurrent CRC  Suture line recurrences  Isolated liver metastases  Isolated pulmonary metastases

2. Controversies  How often ?  What to check ?  To what costs ? Protocol for follow-up Regular visits

3. Protocol for active follow-up Ohlson et al. DCR, 1995.

4. A suggested follow-up programme from Parikh and Attiyeh Follow-up Parikh S and Attiyeh F, Cancer of the Colon Rectum and Anus, 1995.

5.  Meta analysis of 1679 patients from 6 studies  Different regimens of follow-up, intensive, regular and minimal  CEA testing  Liver imaging  Survival and radical reoperation rates were monitored Follow-up of patients with curatively resected CRC: a practice guidelines A. Figueredo et al, BMC Cancer 2003

6. Percent of Patients with Recurrence at 5 Years by Site of Initial Tumor A. Figueredo et al, BMC Cancer 2003 ColonRectumDiagnostic method Liver 3530CEA, US or CT, RIS, Sx, Chest X ray Lung 2030Chest X ray, CEA, Sx Peritoneal 20 CEA, Sx, CT, RIS Retroperitoneal 155CEA, CT, RIS, Sx Peripheral lymph node 27Physical exam, CEA Others (brain, bones) <5 Sx, Scans Loco-regional 1535CT pelvis, CEA, RIS, Sx, endoscopy, FOB Second or metachronous CRC 33Colonoscopy, FOB Follow-up of patients with curatively resected CRC: a practice guidelines

7. Conclusions  Overall survival better in patients included in intensive follow-up  Recurrence rates in all groups similar  Higher rate of asymptomatic recurrences in groups with intensive follow-up  Curative second-look surgery more frequent in groups with intensive follow-up  CEA levels and liver imaging made significant impact on survival A. Figueredo et al, BMC Cancer 2003 Follow-up of patients with curatively resected CRC: a practice guidelines

8. Summary  Intensive follow-up -Overall survival is significantly improved -The incidence of asymptomatic recurrence is higher -Reoperation for cure-more common  Minimal follow-up -Better quality of life -Cost effectiveness (low costs) Follow-up protocol

9. Follow-up cost-benefit Recurrent disease R. Graham, Ann Surg 1998.  Conclusions: CEA level was the most cost-effective in detecting potentially curable recurrence  96 patients (7,1%) were identified with potentially curable disease

10. Costs  Estimated cost per patient 27000 $ yearly  Total cost per year greater than 1 billion $ Follow-up K. Virgo, JAMA 1995 Sole purpose, the detection of curable recurrence!?

11. Follow-up To improve cost-benefit  Stratify patient groups according to the risk  Most recurrent tumors within the first 2 years  Metachronous tumours occur later Recurrent disease R. Graham, Ann Surg 1998.