The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surveillance and Survivorship Care of Patients After Curative Treatment of Colon and Rectal Cancer

Abstract

STATEMENT OF THE PROBLEM More than 140,000 people in the United States are diagnosed annually with colorectal cancer (CRC), and 5% to 40% of patients treated with curative intent develop a recurrence, typically within 5 years.1–3 The optimal strategy for detecting recurrence would minimize cost and harm, such as psychosocial stress and unnecessary testing, and maximize survival and quality of life (QoL). Although surveillance recommendations include periodically taking a history, performing a physical examination, and evaluating laboratory blood testing, imaging studies, and endoscopy, surveillance approaches should be tailored, to a degree, by recurrence risk, incorporating clinicopathologic factors like disease stage, treatment regimen, and patient factors.4 CRC survivors compose the second largest group of cancer survivors, with ≈1.5 million survivors living in the United States.5 The number of CRC survivors is increasing, in part because of the rising incidence of early onset CRC.6 The optimal follow-up care for this growing population of posttreatment cancer survivors is unclear.7–10 Depending on the definition used, an individual may be considered a cancer survivor from the time of diagnosis, during and immediately after treatment, and for the rest of his or her life. Recognizing that CRC treatment has multiple potential late and long-term consequences, survivors should be assessed for these sequelas and treated to improve their QoL. In 2006, the Institute of Medicine released a report highlighting the need to improve the care provided to cancer survivors and increasing awareness regarding the medical, functional, and psychosocial needs related to survivorship.11,12 Although it is important to formalize CRC survivorship care and improve the transition from treatment to survivorship, the scientific evidence specific to CRC remains limited, and recommendations are often extrapolated from research regarding other cancer populations. However, generalizing survivorship goals and management strategies across heterogeneous groups of cancer survivors may result in inferior management of CRC-specific treatment-related effects. Physical and psychosocial treatment effects that impact QoL are among the long-term challenges faced by CRC survivors, and recognizing and addressing these forms the basis for tailored CRC-specific survivorship care models. The American College of Surgeons Commission on Cancer, updated in 2020, includes standards for survivorship care as part of their cancer center accreditation.13 In addition, the National Comprehensive Cancer Network (NCCN) now has a comprehensive guideline for survivorship care, which encompasses assessment and treatment of late and long-term effects of cancer therapy, as well as guidelines regarding appropriate preventive health recommendations for patients with cancer.10 Acknowledging the increasing importance of cancer survivorship care, a section dedicated to survivorship was added to this update of the previously published surveillance practice guideline. Methodology These guidelines were built in part on the American Society of Colon and Rectal Surgeons (ASCRS) Practice Guideline for the Surveillance of Patients After Curative Treatment of Colon and Rectal Cancer published in 2015.14 A systematic, organized search of MEDLINE, PubMed, EMBASE, and the Cochrane Database of Collected Reviews was performed restricted to the English language. Because the past parameter included information on risk and surveillance, searches related to these topics were limited to the interval January 1, 2014, to October 6, 2020. Searches related to survivorship included articles published January 1, 1950, to October 6, 2020, because this topic was not included in the previous guideline (Fig. 1). Search terms regarding risk assessment included key words: colorectal cancer, recurrence, risk colon cancer, rectal cancer, colorectal neoplasm, surveillance, strategies, intensity, cure, CEA, CT, colonoscopy, endoscopy, proctoscopy, ERUS, and follow-up. Medical Subject Headings included colorectal neoplasms, colonic neoplasms, rectal neoplasms, neoplasm recurrence, local, neoplasms, second primary, and neoplasm metastasis. Search terms regarding surveillance included colon cancer, rectal cancer, colorectal neoplasm, surveillance, strategies, intensity, cure, CEA, CT, colonoscopy, endoscopy, proctoscopy, ERUS, follow-up, colorectal neoplasms, colonic neoplasms, rectal neoplasms, neoplasm recurrence, local, neoplasms, second primary, and neoplasm metastasis. Search terms regarding survivorship included key words colon cancer, rectal cancer, colorectal cancer, quality of life, HRQOL, well being, wellbeing, satisfaction, life satisfaction, personal satisfaction, Health-Related Quality of Life, satisfaction, life satisfaction, personal satisfaction, fatigue, neuropathy, bowel dysfunction, sexual dysfunction, urinary dysfunction, and symptoms.FIGURE 1.: Preferred Reporting Items for Systematic Reviews and Meta-analyses literature search flow sheet.Directed searches using embedded references from primary articles and existing guidelines were performed in selected circumstances. The 2860 screened articles were evaluated for their level of evidence, favoring clinical trials, meta-analysis/systematic reviews, comparative studies, and large registry retrospective studies over single institutional series, retrospective reviews, and peer-reviewed observational studies. Peer-reviewed observational studies and retrospective studies were included when higher-quality evidence was insufficient. A final list of 130 sources was evaluated for methodologic quality, the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. 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