10. Follow-up Care – Colorectal Cancer
After diagnosis and therapy of a colorectal cancer, adequate medical care is appropriate regardless of the tumor stage. After curative therapy of colorectal cancer, there is an increased risk for a local or locoregional recurrence (3-24%), distant metastases (25%), or a metachronous second tumors [1080][1081][1082][1083][1084][1085][1086][1087][1088][1089]. The risk is increased in case of a genetic predisposition [1084] and with advancing tumor stages [1090][1091]. This is the basic justification for providing regular follow-up for these patients.: a recurrence should be discovered so early that a second operation is possible with a curative intent. Follow-up should also enable the diagnosis and treatment of tumor and therapy related sequelae. Subjective goals of follow-up care are to improve a patient’s quality of life [1092].
An additional goal is quality control of the diagnostic and therapeutic measures which were carried out before. However, the effect of follow-up care seems marginal with a mean 1% improved survival for the whole group of treated patients [1093]. Data from 267 articles relating to this topic were evaluated in a meta-analysis [1094]. For long-term survival of one patient with colorectal cancer, 360 positive follow-up tests and 11 secondary operations were necessary. The remaining 359 follow-up tests and 10 operations resulted in either no therapeutic advantage or had negative consequences [1094].
A Cochrane review from 2008 which included 8 studies showed that with intensive follow-up the mortality was lower (OR 0.73 (95% CI 0.59 to 0.91) than if no or minimal follow-up was performed.
10.1 Follow-Up for Patients with UICC stage I
A regular follow-up for patients with colorectal cancer and early tumor stage (UICC I) is not recommended after R0 resection considering the low rate of recurrence and the favorable prognosis. Colonoscopy follow-up should be performed according to Chapter 10.3.9.1 .
Background
Patients with UICC stage I have a good prognosis after a curative resection. In patients with pT2 tumors recurrence occurs more frequently (UICC Ib)(13%) than in those with pT1 tumors (UICC Ia)(4%) [1095]. Altogether, the long-term survival of stage UICC I patients according to a prospective cohort study is very good with 86%, and a programmed follow-up is usually not necessary. Similar results were reported in a retrospective study with 541 patients with CRC stage 1. The pT1N0M0 (UICC Ia) tumors demonstrated 2.9% recurrences and pT2 cancer (UICC Ib) 5.6% recurrences [1096]. In stage Dukes A, recurrences were only seen in patients with rectal cancer (11%, n=6/55), not in colon cancer [238].
In individual cases, if a higher local recurrence risk is expected based on endoscopic, intraoperative (e.g. after intraoperative tumor opening), or pathological findings, a follow-up with shorter intervals may be necessary (e. g. higher risk for distant metastases with invasion of the periocolonic veins [1097][1098], angiolymphatic invasion [1099][1100], G3/G4 tumors or pT2 tumors) (see Chapter 8). Here the sole assessment of CEA was sufficient [1096].
Since patients in stage I also have a higher risk of developing metachronic secondary tumors, a colonoscopy follow-up according to Chapter 10.3 is reasonable.
10.2 Follow-Up for Patients with UICC stage II and III
However, follow-up should only be performed if a recurrence would have therapeutic consequences.
- Consensus
- Strong consensus
Background
With advanced colorectal cancer (UICC stage II and III) the risk of recurrence is significantly higher [1080][1081][1082][1083][1084][1085][1086][1087][1088][1089][1090][1091]. There are 6 randomized controlled studies [1105][1106][1107][1108][1109][1110] on the relevance of follow-up of CRC-patients of which only 2 showed a positive effect on the five-year survival rate of an intensive follow-up in comparison to a "standard follow-up” [1108][1110]. Nearly all studies also included patients with UICC stage I.
Different meta-analyses of five of the randomized and controlled studies (1 positive, 4 negative) [1093][1094][1101][1102][1103][1104] demonstrated a small survival benefit when more tests were performed compared to fewer tests. Liver imaging was significantly better as part of follow-up. The significance was lost, however, if both results were calculated as risk differences and not as odds ratios [1103]. An active follow-up led only to a slight survival benefit of 0.5 to 2% after five years [1089].
A recent Cochrane publication [1103] included 3 other studies in this meta-analysis [1110][1111][1112]. A survival advantage after 5 years was found for patients who had intensive follow-up care (OR 0.73; 95% CI 0.59-0.91). However, the absolute number of detected relapses was the same in both groups [30].
A retrospective study compared the effect of regular follow-ups according to the ASCO- guidelines (>70% of follow-up appointments were visited) with few (<70%) and no follow- ups [1113]. Compared to the other groups, regular follow-up led to a significantly better 5 and 10 year survival. This is also true for the prognosis of recurrences in these patients. In addition, a psychological benefit from the follow-up procedures can be derived for the affected patients [1114].
Unfortunately, the guidelines are not always followed. It has been observed that only 73.6 % of patients older than 65 years had the recommended colonoscopy and only 46.7 % CEA testing, whereas procedures such as CT and PET-CT were done in 48 % and 7 %, respectively [1115].
Definite recommendations on type and frequency of follow-up tests cannot be given, because good studies are missing [1116][1117][1118]. Follow-ups adapted to the UICC stage or the effect of a complete waiver of follow-up exams have so far not been tested in prospective studies.
Because of the overall poor data available, the expert conference decided, despite the grade 1a of several existing meta-analyses, merely on a Grade of Recommendation B for programmed follow-ups of CRC UICC stage II and III.
10.3 Role of Diagnostic Methods for Follow-up
The following recommendations are given concerning diagnostic tests for follow-up:
10.3.1 Medical History
A symptom-oriented medical history and physical examination are the principle components of follow-up.
- Consensus
- Strong consensus
10.3.2 CEA Testing
The testing of carcinoembryonic antigen (CEA) is recommended every six months for at least two years. An increased CEA value requires further workup, but does not justify the beginning of a systemic chemotherapy in case of suspicion of a metastasized tumor stage.
Background
CEA was shown to be superior to colonoscopy, computer tomography, and ultrasound for the early detection of liver metastases [1108][1119][1120]. A meta-analysis of 7 non- randomized studies showed a survival benefit of 9% for patients for whom the follow-up program included CEA [1101]. Other studies showed no or only minimal benefit [1106][Duffy, M. J. et al. 2001]. CEA was not recommended for follow-up in a literature review [1118]. However, American (ASCO) and European (EGTM, European Group on Tumor Markers) follow-up guidelines include the use of CEA [1117][1121][1120]. Here the testing is recommended every 2-3 months in the first 2 years.
Adjuvant therapy with 5-fluoruracil can lead to a false higher value. Thus, a sufficient interval to treatment should be observed [Moertel, C. G. et al. 1993]. 30% of all colorectal tumors do not release CEA [Moertel, C. G. et al. 1993][1122], while 44% of the patients with normal preoperative values show an increase postoperatively [Zeng, Z. et al. 1993]. The further clarification of increased CEA values requires diagnostic imaging and if necessary, 18-fluorodeoxyglucose positron emission tomography [Huebner, R. H. et al. 2000][Annovazzi, A. et al. 2003].
Due to the general controversial data for the use of CEA for the follow-up of colorectal cancer, the expert conference deviated from the recommendations of ASCO and EGTM and decided upon a biannual rather than three-month testing interval in the first two years and then annually over 3 years.
10.3.3 Other Laboratory Parameters
Background
In several studies the testing of liver enzymes was part of the follow-up program. However, a study showed that CEA and other imaging procedures became positive earlier than liver function tests [1116]. For these reasons, a routine testing of these serum parameters is not advised. The same applies for complete blood count [1121].
10.3.4 FOBT
Background
The testing of occult blood in the stool is not appropriate for follow-up. Only 12% of the local tumor recurrences led to a surface injury of the mucosal membrane [1122]. Serial testing of 1,217 patients with curative resection of colorectal cancer showed a very low sensitivity and specificity of the test for recurrent tumors or polyps [1123].
10.3.5 Ultrasound
Abdominal ultrasound is technically appropriate for the detection of liver metastases. Its routine use for follow-up of CRC is not assured by data. However, the expert committee assessed ultrasound as the simplest and least-expensive procedure and, therefore, recommends its use for the diagnosis of liver metastases.
Background
The sensitivity of abdominal ultrasound for the detection of liver metastases varies widely between 53% and 82% [1118]. In most studies it was not as accurate as computer tomography. In a controlled, randomized study [1105] the inclusion of abdominal ultrasound and computer tomography had no influence on survival and resection rates of follow-up patients. In a meta-analysis of several randomized studies the use of an imaging test for the evaluation of the liver resulted in a statistically significant survival benefit [1103]. If the calculation of these results was done as a risk difference and not as an odds ratio, this advantage was no longer detectable [1103]. Because abdominal ultrasound is faster and less expensive than other imaging tests, the participants of the consensus conference recommended abdominal ultrasound for the detection of liver metastases as part of follow-up.
10.3.6 Endoscopic Ultrasound
Endoscopic ultrasound (EUS) is appropriate for the detection of local recurrences in rectal cancer, especially in combination with an EUS-guided biopsy. Currently, no recommendation can be given for routine primary use in follow-up.
- Recommendation grade
- B: Empfehlung für oder gegen eine Maßnahme - verwendete Ausdrucksweise = sollte/sollte nicht
- Level of evidence
- 3b
- Consensus
- Strong consensus
- References
- [1124]
Background
In one study endoscopic ultrasound examinations were shown to be helpful for the detection of locoregional recurrences after sphincter-retaining rectal resection if this procedure was combined with a EUS-guided biopsy [1124].. 68 perirectal lesions detected by EUS consisted of 36 actual local recurrences in a group of 312 patients. 12 recurrences were detected with a proctoscope. For 22 of the endosonographically detected lesions, the histology was positive. In 41 lesions histology was negative and in 5 inconclusive. In 18 of the 68 patients the endoscopic ultrasound influenced the further course [1124]. EUS is not recommended as a primary diagnostic technique for follow-up due to its invasiveness when combined with a biopsy. It is, however, useful for the workup of suspected locoregional recurrences of rectal cancer that have been detected by other tests.
10.3.7 Chest X-Ray
A chest x-ray can be performed annually for patients with stage II and III rectal cancer for five years.
- Recommendation grade
- 0: offene Empfehlung (Option) bzgl. einer Maßnahme - verwendete Ausdrucksweise = kann
- Level of evidence
- 3b
- Consensus
- Consent
- References
- [1125]
Background
In a French cohort study 5.8 % of patients developed lung metastases within 5 years after curative resection of CRC [[1125]. The rate of lung metastases after 1 year was 0.9% and after 3 years 4.2%. The risk of lung metastases was significantly higher in patients with rectal cancer than colon cancer (OR 2.6 95CI 1.65-4.75). The 3-year survival after detection of metachronic lung metastases was 13.8%. After curative resection of these metastases, the relative 3-year survival was 59%.
A systematic literature search on the role of chest x-rays as follow-up examinations identified 18 studies on this topic. These showed that follow-up using chest x-ray detected 0.8 to 7.0% of lung metastases in all patients and between 3.4 and 29.4% of all recurrences. The rate of curative resection of the detected metastases in these studies was 0-100%. More detail on the effect of tumor localization and stage as well as the ideal interval of the x-ray testing is not possible based on the information given in these studies, their low case number, and their heterogeneity.
Overall, according to data by Mitry, the benefit of lung imaging seems to be higher in patients with rectal cancer. Thus, the follow-up of colon cancer patients is still not recommended due to the unknown benefit.
10.3.8 Computer Tomography
Computer tomography is technically appropriate for the detection of liver metastases, local recurrences, as well as lung metastases. The current data indicates that computer tomography should not be used routinely as part of follow-up.
Background
In a randomized, controlled study, the use of computer tomography (CT) as part of follow-up had no influence on patient survival [1109]. Liver lesions were found somewhat earlier (12 of 20 were asymptomatic), but CT did not increase the number of curative liver resections. In some studies CEA elevation detected a tumor recurrence earlier than regular CT examinations [1108][1109][1129].
An update of the ASCO guideline from 2005 led to the recommendation of annual abdominal CT examinations over 3 years [1127]. The committee justified their decision to recommend the use of abdominal CTs in follow-up exams with the work of Chau et al. [1128]. 154 tumor recurrences were retrospectively evaluated in 530 patients. The study was originally designed as a therapy study and not to investigate the role of CT in follow-ups. 65 recurrences were detected based on symptoms, 45 by repeated CEA- testing, and 49 using CTs 12 and 24 months after starting adjuvant chemotherapy. 14 of these patients also had an increased CEA and were present in both groups. Resections were performed more frequently in the CT-group (n=13, 26.5%) and the CEA-group (n=8, 17.8%). Two patients were operated in the symptomatic group (3.1%). These differences were significant. However, the importance of ultrasound in comparison to CT was not studied. More recent meta-analyses also do not allow conclusions on the type of method that should be used [1126]. Therefore, currently no recommendation can be given on regular CT-examinations in asymptomatic patients as part of follow-up care.
10.3.9 Endoscopic Procedures
10.3.9.1 Colonoscopy
Colonoscopy is appropriate to detect local recurrences or secondary tumors. All patients should have a complete colonoscopy preoperatively or within 6 months postoperatively. A colonoscopy should be performed after 1 year and subsequently, if negative, every 5 years to detect metachronic cancer or polyps. If a complete colonoscopy was done postoperatively within 6 months, the next one should be done after 5 years.
If neoplasia is detected during colonoscopy after 6 or 12 months, further follow- up should be performed according to Chapter 6.5.
10.3.9.2 Sigmoidoscopy
Sigmoidoscopy is appropriate to detect local recurrences and secondary tumors in the areas within reach. Additional sigmoidoscopies should only be performed in patients with UICC stages II and III rectal cancer who have not received neoadjuvant or adjuvant radiochemotherapy.
- Recommendation grade
- B: Empfehlung für oder gegen eine Maßnahme - verwendete Ausdrucksweise = sollte/sollte nicht
- Level of evidence
- 4
- Consensus
- Strong consensus
10.3.9.3 Rectoscopy
A rigid rectoscopy is appropriate to detect local recurrences and anastomotic changes in patients with rectal cancer. It can be used as an alternative procedure to sigmoidoscopy.
- Recommendation grade
- B: Empfehlung für oder gegen eine Maßnahme - verwendete Ausdrucksweise = sollte/sollte nicht
- Level of evidence
- 4
- Consensus
- Strong consensus
Background
The aim of endoscopic follow-up care is to detect metachronic neoplasia and anastomotic recurrences in a curative stage. It should be considered that a meta-analysis of various randomized controlled studies showed that colonoscopic follow-up is less effective than the search for extramural recurrences [1104]. Furthermore, colonoscopies are costly and there is a risk of complications (although small).
In the publications identified in the literature search (for details see evidence report) the rate of metachronic cancer varied between 0 and 6.4% and the anastomotic recurrence was between 0 and 12% during follow-up (24 to 94 months). In the studies that provided this information the calculated annual incidence of metachronic cancer was 0-2.3%. If the endoluminal anastomotic recurrences are also considered, the annual cancer incidence was 0 to 2.6%. The rate of advanced adenomas that were detected during follow-up was only reported in few studies and varied between 3.7 and 13%.
The rate of curative resections of metachronic cancer and/or anastomotic recurrences was 27 to 100%.
The necessary frequency of colonoscopies during follow-up was investigated in a study that compared intensive colonoscopic follow-up (in the first year every 3 months, in the second and third year every 6 months, and then annually) to a less intensive protocol (after 6, 30, and 60 months) [1130].. Recurrences were found in 8.1% of the intensively followed patients and in 11.4% of the patients who had colonoscopies less often. Although the overall survival was comparable, asymptomatic recurrences were significantly increased and the prognosis was better for patients who had to be reoperated. The frequency of metachronic tumors was not mentioned in this study. The high frequency of colonoscopies did not have an effect on overall survival, and especially since most recurrences develop extraluminally a less burdensome protocol for the patients is sufficient.
A study reported 20 of 1002 patients (3.1 %) with secondary cancer of which 9 were detected within 18 months [1131]. Advanced neoplasia (defined as adenoma >1 cm, villous histology, HGD, or cancer) was seen more often (15.5%) in colonoscopies after 36-60 months compared to an earlier examination within 18 months (6.9%). Although an early colonoscopy was not associated with a better survival during follow-up, the authors conclude that a first colonoscopy should be performed 12 months after surgery. This is useful to identify metachronic cancer in time that were possibly overlooked during the index examination. Based on these data, it is now recommended to have the first follow-up colonoscopy 12 months after the operation.
Rex et al. also emphasize that the primary goal of colonoscopies during follow-up is not so much the identification of rare anastomotic recurrences, but the detection of metachronic neoplasia [1128]. 2-7% of patients had at least one metachronic tumor. It cannot be concluded whether these were real metachronic lesions or whether they were synchronic cancers that were missed during the first colonoscopy. Nonetheless, the authors of this guideline also recommend that the first colonoscopy be performed 12 months after tumor resection. They justify this recommendation with a publication from 1993 from a tumor registry in Nebraska which reported an annual incidence of metachronic tumors of 0.35% [1081].. Since the risk of metachronic tumors persists, a colonoscopic follow-up analogous to the screening of colon cancer is indicated [1133].
10.3.10 Colon Contrast Enema, Virtual Colonography, and PET
Background
Only few data exist on the use of PET in follow-up care. The majority of studies includes only patients with suspected recurrence and investigates the role of PET. This procedure was not the goal of the literature search. Instead it was its use for asymptomatic patients without suspected recurrence.
A randomized study [1134] with close follow-up examinations showed that recurrences were detected earlier when PET was used after 9 and 15 months and that these were more often R0-resections.
A prospective randomized study [189] was aimed at determining the role of PET-CT in the follow-up of CRC. In addition to a follow-up that included abdominal ultrasound, chest x-ray, tumor marker assessment, and abdominal CT, a PET-CT was performed after 9 and 15 months and compared to the control group. The recurrence rate was comparable in both groups. Tumors wre detected earlier in the PET-group by an average of 3.2 months. Although resections of the recurring tumors were performed more often in the PET-CT group (15 vs 2), conclusions on a better survival could not be made. This was because the study was discontinued early due the introduction of a new PET-CT generation. Also of concern is that in three cases false positive findings were generated by PET-CT which resulted in unnecessary diagnostic measures and surgical interventions.
In a prospective case series including 31 patients [1135] a PET was performed after 2 years. The patients had previously had regular CT/MRI and were considered recurrence- free. In 6 patients the PET was positive and in 5 patients recurrences were identified. The outcome of these patients remains unknown. Overall, the the participants considered the data insufficient to include PET/PET-CT/PET-MRI-examinations in routine follow-up care.
Colon contrast enema and virtual colonoscopies have not been evaluated for follow-up and cannot replace the endoscopic methods in follow-up.
10.4 Time Course of Follow-up
The start of follow-up is calculated from the time of the operation.
- Consensus
- Strong consensus
Background
80% of all recurrences are detected within the first two years after CRC operations,, whereas practically no new recurrences are detected after 5 years [1136]. This also applies to rectal cancer, although with this tumor entity a few locoregional recurrences were observed after this period [1087]. This, however, does not justify extending follow- up beyond five years.
In most studies the follow-up interval in the first and second postoperative year was 3- months and shorter than in the following years [1101][1102][1104][1105]. A 3-month interval was found to be superior to a 6-month interval in one study with otherwise similar examination methods [1108]. However, the patients in the 3-month follow-up group received an additional annual CT, which in another study was not beneficial [1109]. Due to the lack of clear data, the consensus conference decided on examination intervals of 6 months in the first 2 years. After 5 years, only colonoscopies should be performed to exclude secondary cancers.
10.5 Age Limit for Follow-up
In controlled studies of follow-up care, patients up to 87 years of age [1105][1106][1107][1108][1109][1110]were included. One cannot derive an age limit from these studies. It makes sense to adjust type and duration of follow-up according to operability, biological age, accompanying diseases, and the will to undergo surgery again if necessary.
10.6 Special Cases
After complete removal (R0) of low-risk (pT1, low-grade (G1, G2, L0)) cancer, endoscopic surveillance examinations of the local resection site shall be performed after six months.
A complete colonoscopy shall be performed after three years.
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Level of evidence
- 4
- Consensus
- Strong consensus
After palliative tumor resection (R2 resection), programmed follow-up examinations are not necessary.
- Consensus
- Strong consensus
After curative therapy of metastases, stage IV patients should undergo a programmed follow-up.
- Consensus
- Strong consensus
For cancer patients with HNPCC who have had a hemicolectomy, colonoscopic examinations and after subtotal colectomy, rectoscopic examinations should be performed in annual intervals (see also recommendation 5.23.).
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Level of evidence
- 2a
- Consensus
- Strong consensus
For cancer patients with FAP who have undergone proctocolectomy, a pouchoscopy should be performed annually (see also recommendation 5.35.).
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Consensus
- Strong consensus
After iliorectostomy, a rectoscopy is necessary every 6 months (see also recommendation 5.35.).
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Level of evidence
- 2a
- Consensus
- Strong consensus
10.7 Rehabilitation After Resection of Colorectal Cancer
After completing primary therapy, rehabiliation should be offered to all eligible patients. If rehabiliation is done directly after surgery, it must be guaranteed that an indicated adjuvant chemotherapy can be initiated timely. Alternatively, rehabilitation can be done after completing the adjuvant chemotherapy.
- Consensus
- Strong consensus
Background
The goal of rehabilitation is the elimination of cancer or therapy-related consequences as well as help of accepting remaining handicaps with the goal of an independent occupational, private, and social life. There is no evaluable literature on the relevance of rehabilitation measures for patients with colorectal cancer. Specific rehabilitation centers or clinics with gastroenterologic and oncologic expertise who implement quality assurance standards of the DRV and the requirements of colon centers should be preferred.
The need for rehabilitation after treatment of colorectal tumors is quite variable and significantly dependent on the type and amount of operative procedures as well as the consequences of therapy (continence problems, sexual function disturbances, stoma, etc.).
Psychosocial counseling and, if necessary, support is desirable in case of problems with psychological coping with the tumor disease, with the consequences of therapy, with social adjustment difficulties, and with professional reintroduction [1114][1137][1138].
Contact with persons who have had similar experiences can be especially helpful for those affected who have to cope psychologically or adjust to the changed life situation. Those who have been affected by the same events can convince others that a high quality of life is possible. They can give own examples as well as experiences in everyday life with the disease and handicaps. Therefore, contacts should be arranged with patient organizations.
In coordination with their familial environment, patients should always wait to start rehabilitation until after completing primary therapy. If rehabilitation measures are started before an indicated adjuvant chemotherapy, it must be guaranteed that therapy will be initiated during the rehabilitation process. Aside from the surgery report including the pathological assessment (tumor formula), the decision of the tumor board is also necessary and, therefore, should be made available to the rehabilitation facility.
10.8 Tertiary Prevention
10.8.1 Care Continuity and Continuation of the Health Promoting Activities after Acute Therapy and Rehabilitation
Even after the acute therapy phases and adjuvant chemotherapy, the patient should be counseled and followed by all professionals who participated in the treatment and follow-up care such as practicing physicians, nurses, or physical therapists.
10.8.1.1 Improvement of Care Continuity
An important goal should be the improvement of care coordination to avoid early termination or delayed start of therapy after leaving the hospital or to avoid regional insufficient care due to gaps in the system. The transition management of patients between primary therapy, rehabilitation, and other support with respect to side effects and symptoms is still poor [Etzioni, D. A. et al. 2008][Grothey, A. et al. 2002]. Especially after being discharged from the hospital the ambulatory care by practicing physicians and other caregivers (such as psycho-oncology, physical therapy, ergotherapy) is poorly coordinated. Patients are often faced with a situation of competing and unconnected health professionals. "Access" and "support“ are especially poor in economically underdeveloped rural areas with low health care status [von der Schulenburg, J. M. et al. 2010][Adler, G. et al. 2007]. Studies confirm the advantage for patients of case management by concomitant professional steering of the treatment and follow-up course [Harrison, J. D. et al. 2009]. Current systematic reviews show that health care continuity can be optimized especially by care interventions [Lewis, R. et al. 2009][Howell, D. M. et al. 2008]. An improved symptom control, an increased guideline compliance, an improved patient satisfaction, and an increased health associated quality of life can be achieved by multiprofessional treatment and follow-up steering [Harrison, J. D. et al. 2009][Lewis, R. et al. 2009][Howell, D. M. et al. 2008][Ouwens, M. et al. 2009].
Patients should also be supported by multiprofessional case management at the beginning of adjuvant therapy to ensure care continuity. Old age, the presence of comorbidities, low socio-economic status, the quality of the primary care facility, and access or distance to specialists were identified as significant risk factors for irregular care during transition from primary surgical to adjuvant (radio)chemotherapy [Etzioni, D. A. et al. 2008].
10.8.1.2 Continuation of Health Promoting Activities
Patients should be encouraged to continue lifestyle activities that improve their health and quality of life. Furthermore, studies confirm that patients benefit if they can take the management of their symptoms and side effects (nausea, vomiting, pain, fatigue, depression, stoma care etc.) into their own hands [Jahn, P. et al. 2009][Jahn, P. et al. 2010]. This can be supported by simple measures such as follow-up by phone, written information, keeping a patient diary including outcome control ("patient reported outcomes“, PRO) [Harrison, J. D. et al. 2009][Howell, D. M. et al. 2008][Ouwens, M. et al. 2009][Chen, R. C. et al. 2010]. Cancer counseling centers and self-help groups play an important role in the realization of these measures.
10.8.2 Tertiary Prevention: Physical Activity, Nutrition, as well as Complementary and Alternative Therapy
10.8.2.1 Physical Activity
Cohort studies indicate a connection between physical activity and a reduced relapse rate and improved survival. Patients should be encouraged to exercise.
Background
Three cohort studies [1139][1140][1141] demonstrated that physical activity after curative CRC therapy reduces the relapse rate as well as the mortality. Exercise does not influence these parameters in untreated cancer. The positive effect of physical activity is also seen in overweight patients. However, merely losing weight has no effect on the prognosis.
A statistically significant risk reduction for disease-specific mortality is seen with a weekly physical exercise of 3 Met hours.
10.8.2.2 Nutrition
There is no study on tertiary prevention from which specific nutrition recommendations for patients following curative treatment of CRC can be derived.
Recommendations of the German Society for Nutrition are valid for a healthy lifestyle. An increased BMI does not correlate with relapse rate or survival [1139]. Weight reduction in overweight patients does not reduce the relapse rate [1139]However, if a patient is very overweight, weight reduction should be the aim for general prevention.
There are no indications that the use of food supplements (vitamins and trace elements) has a positive effect on the relapse rate [Ng, K. et al. 2010]. Vitamins and trace elements should only be substituted if a deficiency has been determined.
10.8.2.3 Complementary and Alternative Medicine
Complementary procedures are based on different methods and substances which stem partially from natural medicine or in other ways from ideas of holistic therapy concepts.
They do not replace active antitumor or supportive therapy, but are complementary methods that allow patients to become independently active.
Complementary therapies can have side effects and interactions. Therefore, it is useful to have complementary medicine counseling by oncologically experienced physicians.
The most frequently used complementary treatment is the mistletoe therapy. A review and the Cochrane-review [75][76] conclude that most of the studies published so far are of poor quality. The few methodologically well done studies show no positive effect on survival for various tumor types. For CRC there are two retrospective studies that show a survival benefit [Stumpf, C. et al. 2007][Friedel, W. et al. 2009]. However, both have definite methodological flaws. The Cochrane-review and the systematic review found only weak indications for an improvement of quality of life for mistletoe therapy.
A review on the influence of mistletoe therapy on the quality of life was last published in 2010. It included 10 non-randomized controlled studies [Kienle, G. S. et al. 2010]. Improvements were reported especially for coping, fatigue, sleep, exhaustion, nausea, appetite, depression, and anxiety. However, the studies characterized in the review as methodologically good by the authors also have considerable shortcomings.
For several mainly herbal substances preclinical data exist which indicate an antitumor effect [Shimizu, M. et al. 2008][1143]. Currently, they do not justify clinical use outside of studies. So far, two small studies on green tea extract after colon polyps or colon cancer [1143] have been published. Both studies demonstrated that in the therapy group the rate of adenomas or cancer recurrence was significantly reduced.
There are a number of publications on the use of medicinal mushrooms in curatively treated CRC patients [Ito, K. et al. 2004][Sakamoto, J. et al. 2006]. These studies are from China and Japan and have been published in the original language. It is not known whether the consistently positive effects on survival rate are scientifically valid. Due to rare, but dangerous side effects the use of preparations from medicinal mushrooms is not recommended.
In traditional Chinese medicine and Ayurveda herbal preparations from Asia traces of heavy metals, pesticides, and drug substances such as corticosteroids and coumarins were repeatedly found. The use is not recommended, because a benefit has not been proven.
A therapeutic benefit of homeopathy as supportive treatment in CRC has not been confirmed [von der Schulenburg, J. M. et al. 2010][Shimizu, M. et al. 2008]. A Cochrane-analysis [Kassab, S. et al. 2009] included a very heterogeneous group of studies. The two studies that were rated as positive did not include homeopathy as such. Therefore, no study confirms the positive effect of homeopathy for tumor patients v.
10.8.2.4 Alternative Healing Methods
A number of "alternatives" to scientifically recommended therapies are offered. There is no rationale for their use. These include: Ukrain, vitamin B 17 (apricot pits, bitter almond), "insulin potentiated therapy", low-carbohydrate diet, "vitamin-rich according to Dr. Rath", "Neue Germanische Medizin®“, autologous blood cytokines, Zapper, "redifferentiation therapy“. It is important to shield patients by taking a clear position on such offers.
Table 17: Programmed Examination for the Follow-Up of CRC UICC II or III
| Examination | Months | ||||||||||||
| 3 | 6 | 9 | 12 | 15 | 18 | 21 | 24 | 36 | 48 | 60 | |||
| Medical history, phys. exam, CEA | X | X | X | X | X | X | X | ||||||
| Colonoscopy | X* | X** | X** | ||||||||||
| Abdominal ultrasound*** | X | X | X | X | X | X | X | ||||||
| Sigmoidoscopy (rectoscopy) **** | X | X | X | X | |||||||||
| Spiral computer tomography x | X | ||||||||||||
| Chest x-ray ***** | X | X | X | X | X | ||||||||
|
* if a complete colonoscopy was not done pre-operatively ** if result is negative (no adenoma, no cancer), next colonoscopy after 5 years *** a meta-analysis showed a benefit for imaging procedures for the detection of liver metastases in follow-up care. the expert committee decided to use the simplest and cheapest method. **** only for rectal cancer without neoadjuvant or adjuvant radiochemotherapy ***** only for rectal cancer an annual chest x-ray may be done x only for rectal cancer 3 months after tumor-specific therapy has been completed (operation or adjuvant radiotherapy/chemotherapy) as initial finding |
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