Cancer Treatment Today » Surveillance

Surveillance CT for head and neck cancer – pro

M Levin, MD — Wed, 29 Aug 2012 02:04:40 +0000

Surveillance CT scans are not recommended foir treated head and neck cancer. Multiple studies show that the routine follow-up program after treatment for laryngeal carcinoma did not lead to survival benefit for asymptomatic patients with tumor recurrence. A proven correlation between intensive follow-up and improved patient survival is lacking and should be consdiered unproven and investigtional at this time. NCCN recommend imaging of the primary site and neck within 6 months and afterwards only if clinically indicated.
Manikantan K, Khode S, Dwivedi RC, et al. Making sense of post-treatment surveillance in head and neck cancer: when and what of follow-up. Cancer Treat Rev 2009; 35:744.
Joshi A, Calman F, O’Connell M, et al. Current trends in the follow-up of head and neck cancer patients in the UK. Clin Oncol (R Coll Radiol) 2010; 22:114.
Ritoe SC, de Vegt F, Scheike IM, et al. Effect of routine follow-up after treatment for laryngeal cancer on life expectancy and mortality: results of a Markov model analysis. Cancer 2007; 109:239.
Francis DO, Yueh B, Weymuller EA Jr, Merati AL. Impact of surveillance on survival after laryngeal cancer in the medicare population. Laryngoscope 2009; 119:2337.

Surveillance for endometrial cancer – pro

M Levin, MD — Mon, 27 Aug 2012 19:56:35 +0000

Current guidelines of the National Comprehensive Cancer Network (NCCN) and the American Congress of Obstetricians and Gynecologists recommend physical examination every 3-6 months for 2 years, then every 6 months or annually. Further evaluation with vaginal cytologic evidence is recommended every 6 months for 2 years and annually thereafter. To date, there are no prospective studies that have evaluated the role of surveillance in endometrial cancer follow-up evaluation

Bristow RE, Purinton SC, Santillan A, Diaz-Montes TP, Gardner GJ, Giuntoli RL. Cost-effectiveness of routine vaginal cytology for endometrial cancer surveillance. Gynecol Oncol. 2006;103:709–713Tjalma WAA, Van Dam PA, Makar AP, Cruickshank DJ. The clinical value and the cost-effectiveness of follow-up in endometrial cancer patients. Int J Gynecol Cancer. 2004;14:931–937

Posttreatment surveillance after hepatic metastases resection for colorectal cancer – pro

M Levin, MD — Fri, 24 Aug 2012 19:56:26 +0000

There are few guidelines on how to follow metastatic colon cancer patients with no evidence of disease because it is fairly new situation, with wider use of metasatectomy and after new effective drugs came on the scene and there are no mature studies. For high risk non-metastatic colon cancer, NCCN guidelines for high risk colon cancers recommend annual CT of chest, abdomen and pelvis. Post-surgery surveillance is also warranted following resection of isolated colorectal cancer metastases because a minority of the recurrent patients can be treated with metastatectomy from the liver and lung, and some fo them will enjoy long-term survival and even cure. The liver is the only site of recurrence in approximately 35 to 40 percent. Five-year survival rates up to 43 percent are reported following repeat liver resection for a second recurrence, with acceptable morbidity and perioperative mortality.

The impact of CT-based follow-up for the detection of resectable disease recurrence was addressed in a review of 705 patients who underwent resection of isolated colorectal cancer liver metastases at a single institution over a 14-year period. All were followed with a similar surveillance protocol, which included outpatient clinical examinations at 3, 6, 12, 18, and 24 months, and annually thereafter, with measurement of CEA and CA 19-9 levels at each visit. In addition, all patients had CT of the thorax, abdomen and pelvis every three months for the first two years, at six monthly intervals for three more years, then annually from year six to ten.

Of the 444 patients with a recurrence diagnosed on a surveillance CT, 404 were detected within two years. The site of recurrent disease was liver only in 36 percent, extrahepatic only in 38 percent, and both hepatic and extrahepatic sites in 26 percent. The authors did not report how many recurrences were detected by serum tumor markers versus CT scans.

In total, recurrent disease was treated surgically in 124 patients. At every time point (within one year of original surgery, one to two years, beyond two years), those patients treated by liver and/or lung resection had significantly better median survival than did those who received palliative chemotherapy alone. The mean number of scans performed per resectable recurrence was 35.3, and the cost per life-year gained was £2883, a value that compares favorably to other cost-effectiveness ratios that are considered acceptable in the US and elsewhere. UPTODate recommends the following surveillance strategy for patients with stage IV disease who are rendered surgically NED (no evidence of disease):

CEA every three months for two years, then every six months for three to five years

CT of the chest/abdomen and pelvis every three to six months for two years, then every 6 to 12 months up to a total of five years
Colonoscopy in one year; if no advanced adenoma repeat in three years, then every five years; if advanced adenoma is found, repeat in one year

Gomez D, Sangha VK, Morris-Stiff G, Malik HZ, Guthrie AJ, Toogood GJ, Lodge JP, Prasad KR

SO Outcomes of intensive surveillance after resection of hepatic colorectal metastases. Br J Surg. 2010;97(10):1552.

Yan TD, Sim J, Black D, Niu R, Morris DL Systematic review on safety and efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma. Ann Surg Oncol. 2007;14(7):2069.

http://www.uptodate.com/contents/management-of-potentially-resectable-colorectal-cancer-liver-metastases#H650939148

Read the Layperson version here.

Radiologic follow-up of pituitary tumors – pro

M Levin, MD — Fri, 24 Aug 2012 17:51:46 +0000

Pituitary tumors are classified as micoradenomas, sometimes called incidentalomas, because they tend to be asymptomatic and discovered incidentally, and macroadenomas. BMJ Best PRactice (2012) says that there is no consensus about the follow-up duration of patients with non-functional pituitary microadenomas, but recommends a follow-up MRI in 1 year with no further routine imaging study if the tumour is stable, especially in those with a pituitary microadenoma < 6 mm in size, unless the patient develops symptoms or signs suggestive of mass effect.

The risk of tumour growth for pituitary macroadenomas is expected to be higher since the tumour has already shown the propensity to grow. There is no consensus, but a pragmatic approach would be to obtain a follow-up MRI at 6 months and then yearly for 5 years. This can be followed by an imaging study every 2 to 3 years if the pituitary tumour is stable. This recommendation is in line with that of the Endocrine Society and Best Practice.

Biochemchemical and laboratory followup is not discussed in this review of radiologic followup.

http://bestpractice.bmj.com/best-practice/monograph/1030/follow-up.html, 2012

http://www.endo-society.org/guidelines/upload/032811_PituitaryIncident_FinalA-2.pdf

Read the Layperson version here.