Surveillance tests

The underlying premise for follow up cancer testing after treatment, is that detection of recurrence at an early stage can lead to early interventions that will eradicate the cancer or prolong survival.
Such diagnostic testing is only beneficial if interventions exist they can alter the clinical course of the disease.
Otherwise, the only impact of early detection is to prolong the lead-time bias which can provide asymptomatic patients with a detrimental impact to the quality of their lives, despite not prolonging survival.
Increase use of surveillance testing can increase anxiety in patients.

The evidence that surveillance for metastases reduces mortality or improves health related quality of life is limited.

Randomized trials do not support surveillance for metastatic disease in asymptomatic female survivors of breast cancer.

Overall survival is unchanged between the asymptomatic screen population and women who undergo surveillance testing when they are symptomatic.

In colon cancer surveillance improves the likelihood of finding respectable hepatic metastasis and with liver resection and systemic chemotherapy it may result in long-term survival in some cases.

For colon cancer surveillance ASCO and NCCN guidelines recommend CEA testing every 3 to 6 months and a CT scan of the chest, abdomen and pelvis every 6-12 months for 3 to 5 years in patients with resected stage II and III colorectal cancer.

For colorectal cancer colonoscopy is also recommended 1 year after resection

For breast cancer other than history and physical examination and mammograms surveillance does not improve survival.

For breast cancer in asymptomatic patients testing for tumor markers, other blood tests and radiographic imaging are not recommended for routine screening to detect metastatic disease as the false positive rate for these tests range from 10-50%.

For breast cancer in 2 randomized studies revealed no survival benefits from intensive screening for asymptomatic metastatic disease as compared with routine clinical evaluation, and one trial showed decreased quality of life in the intensive screening group.

Routine use of CEA for breast cancer surveillance following primary therapy is not recommended.

Colonoscopic surveillance recommended for patients with adenomas because of the risk of new adenomas and colorectal cancer among such patients which is greater by 2-4 fold than among patients without adenomas.

Imperative in colorectal cancer since 1.5% of patients develop a second primary at 5 years.

Patients with prior colon cancer should undergo surveillance colonoscopy 6 to 12 months after cancer surgery.

Surveillance tests-with the use of serial CT’s of abdomen and chest and CEA levels in postoperative stage II and II patients with colorectal cancer 23.8% underwent potentially curative liver or lung resections compared to 3.1% of patients with symptomatic recurrence, indicating the value of postoperative follow-up.

In a meta-analysis addressing the impact of surveillance strategies for colorectal cancer: it was calculated that 360 positive follow-up tests and 11 surgeries would be needed to provide one patient with colorectal cancer a long-term survival (Kievit et al).

In another meta-analysis of 2923 patients, a more intensive follow-up increased detection of asymptomatic recurrences, increased rates of surgical resection and decreased overall mortality (Tjandra jj, Chan MK).

In the above analysis there was no improvement in cancer related mortality, and overall survival did not correlate with early detection of recurrencevor surgical resections.

In patients followed after curative resection in stage II and III colorectal cancers, more intensive follow-up improved survival for patients with stage II colon and rectal cancers (Rodriguez-Moranta F et al).

Among patients treated with curative surgery for colorectal cancer, intensive imaging or CEA screening each provided an increased rate of surgical treatment of recurrence with curative intent compared with minimal follow-up (Primrose JN et al).

In the above study no advantage occurred with combining of CEA and CT.

In the above study a survival advantage to any cancer surveillance for colorectal cancer strategy is small.

Ca 125 tests and CT scans of the abdomen and pelvis in patients with ovarian cancer who are in clinical remission does not improve the value of cancer care, and results in poor quality of life without improving survival and should be avoided (Esselen K).

For patients with stage I renal cell cancer following surgery a H and P with a metabolic panel is recommended every 6 months for the first 2 years, than annually up to 5 years.

For patients that undergo a partial nephrectomy for renal cell caner, a baseline abdominal CT/MRI or US is recommended within 3-12 months , then annually for 3 years.

No clear benefit for surveillance scans in lymphomas have been shown.

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