Revista»European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology
Follow-up after curative treatment for colorectal cancer (CRC) puts pressure on outpatient services due to the growing number of CRC survivors. The aim of this state-of-the-art review was to evaluate setting, manner and provider of follow-up. Moreover, perceptions of CRC survivors and health care providers regarding standard and alternative follow-up were examined. After a comprehensive literature search of the PubMed database, 69 articles were included reporting on CRC follow-up in the hospital, primary care and home setting. Hospital-based follow-up is most common and has been provided by surgeons, medical oncologists, and gastroenterologists, as well as nurses. Primary care-based follow-up has been provided by general practitioners or nurses. Even though most hospital- or primary care-based follow-up care requires patients to visit the clinic, telephone-based care has proven to be a feasible alternative. Most patients perceived follow-up as positive; valuing screening and detection for disease recurrence and appreciating support for physical and psychosocial symptoms. Hospital-based follow-up performed by the medical specialist or nurse is highly preferred by patients and health care providers. However, willingness of both patients and health care providers for alternative, primary care or remote follow-up exists. Nurse-led and GP-led follow-up have proven to be cost-effective alternatives compared to specialist-led follow-up. If proven safe and acceptable, remote follow-up can become a cost-effective alternative. To decrease the personal and financial burden of follow-up for a growing number of colorectal cancer survivors, a more acceptable, flexible and dynamic care follow-up mode consisting of enhanced communication and role definitions among clinicians is warranted.
BACKGROUND: This is the fourth update of a Cochrane Review first published in 2002 and last updated in 2016.It is common clinical practice to follow patients with colorectal cancer for several years following their curative surgery or adjuvant therapy, or both. Despite this widespread practice, there is considerable controversy about how often patients should be seen, what tests should be performed, and whether these varying strategies have any significant impact on patient outcomes.
OBJECTIVES: To assess the effect of follow-up programmes (follow-up versus no follow-up, follow-up strategies of varying intensity, and follow-up in different healthcare settings) on overall survival for patients with colorectal cancer treated with curative intent. Secondary objectives are to assess relapse-free survival, salvage surgery, interval recurrences, quality of life, and the harms and costs of surveillance and investigations.
SEARCH METHODS: For this update, on 5 April 2109 we searched CENTRAL, MEDLINE, Embase, CINAHL, and Science Citation Index. We also searched reference lists of articles, and handsearched the Proceedings of the American Society for Radiation Oncology. In addition, we searched the following trials registries: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform. We contacted study authors. We applied no language or publication restrictions to the search strategies.
SELECTION CRITERIA: We included only randomised controlled trials comparing different follow-up strategies for participants with non-metastatic colorectal cancer treated with curative intent.
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently determined study eligibility, performed data extraction, and assessed risk of bias and methodological quality. We used GRADE to assess evidence quality.
MAIN RESULTS: We identified 19 studies, which enrolled 13,216 participants (we included four new studies in this second update). Sixteen out of the 19 studies were eligible for quantitative synthesis. Although the studies varied in setting (general practitioner (GP)-led, nurse-led, or surgeon-led) and 'intensity' of follow-up, there was very little inconsistency in the results.Overall survival: we found intensive follow-up made little or no difference (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.80 to 1.04: I² = 18%; high-quality evidence). There were 1453 deaths among 12,528 participants in 15 studies. In absolute terms, the average effect of intensive follow-up on overall survival was 24 fewer deaths per 1000 patients, but the true effect could lie between 60 fewer to 9 more per 1000 patients.Colorectal cancer-specific survival: we found intensive follow-up probably made little or no difference (HR 0.93, 95% CI 0.81 to 1.07: I² = 0%; moderate-quality evidence). There were 925 colorectal cancer deaths among 11,771 participants enrolled in 11 studies. In absolute terms, the average effect of intensive follow-up on colorectal cancer-specific survival was 15 fewer colorectal cancer-specific survival deaths per 1000 patients, but the true effect could lie between 47 fewer to 12 more per 1000 patients.Relapse-free survival: we found intensive follow-up made little or no difference (HR 1.05, 95% CI 0.92 to 1.21; I² = 41%; high-quality evidence). There were 2254 relapses among 8047 participants enrolled in 16 studies. The average effect of intensive follow-up on relapse-free survival was 17 more relapses per 1000 patients, but the true effect could lie between 30 fewer and 66 more per 1000 patients.Salvage surgery with curative intent: this was more frequent with intensive follow-up (risk ratio (RR) 1.98, 95% CI 1.53 to 2.56; I² = 31%; high-quality evidence). There were 457 episodes of salvage surgery in 5157 participants enrolled in 13 studies. In absolute terms, the effect of intensive follow-up on salvage surgery was 60 more episodes of salvage surgery per 1000 patients, but the true effect could lie between 33 to 96 more episodes per 1000 patients.Interval (symptomatic) recurrences: these were less frequent with intensive follow-up (RR 0.59, 95% CI 0.41 to 0.86; I² = 66%; moderate-quality evidence). There were 376 interval recurrences reported in 3933 participants enrolled in seven studies. Intensive follow-up was associated with fewer interval recurrences (52 fewer per 1000 patients); the true effect is between 18 and 75 fewer per 1000 patients.Intensive follow-up probably makes little or no difference to quality of life, anxiety, or depression (reported in 7 studies; moderate-quality evidence). The data were not available in a form that allowed analysis.Intensive follow-up may increase the complications (perforation or haemorrhage) from colonoscopies (OR 7.30, 95% CI 0.75 to 70.69; 1 study, 326 participants; very low-quality evidence). Two studies reported seven colonoscopic complications in 2292 colonoscopies, three perforations and four gastrointestinal haemorrhages requiring transfusion. We could not combine the data, as they were not reported by study arm in one study.The limited data on costs suggests that the cost of more intensive follow-up may be increased in comparison with less intense follow-up (low-quality evidence). The data were not available in a form that allowed analysis.
AUTHORS' CONCLUSIONS: The results of our review suggest that there is no overall survival benefit for intensifying the follow-up of patients after curative surgery for colorectal cancer. Although more participants were treated with salvage surgery with curative intent in the intensive follow-up groups, this was not associated with improved survival. Harms related to intensive follow-up and salvage therapy were not well reported.
AIM: It is common clinical practice to follow patients for a period of years after curative intent treatment of non-metastatic colorectal cancer, but follow-up strategies vary widely. The aim of this systematic review was to provide an overview of recommendations in guidelines from ESCP member countries on this topic, with supporting evidence.
METHODS: A systematic search of Medline, Embase and guidelines databases Tripdatabase, BMJ Best Practice and Guidelines International Network was performed. Quality assessment included usage of the AGREE-II tool. All topics with recommendations from included guidelines were identified and categorized. For each subtopic, a conclusion was made followed by the degree of consensus and the highest level of evidence.
RESULTS: Twenty one guidelines were included. The majority recommended that structured follow-up should be offered, except for patients where treatment of recurrence would be inappropriate. It was generally agreed that clinical visits, CEA measurement, and liver imaging should be part of follow-up, based on high level of evidence, although frequency is controversial. There was also consensus on imaging of the chest and pelvis in rectal cancer, as well as endoscopy, based on lower levels of evidence and with a level of intensity that was contradictory.
CONCLUSION: In available guidelines, multimodality follow-up after curative intent treatment of colorectal cancer is widely recommended, but exact content and intensity is highly controversial. International agreement on the optimal follow-up schedule is unlikely to be achieved on current evidence, and further research should re-focus on individualized 'patient-driven' follow-up and new biomarkers. This article is protected by copyright. All rights reserved.
Propósito Obtener una comprensión clara de las necesidades de salud y las preocupaciones de las personas con cáncer de colon y / o recto puede ayudar a identificar maneras de ofrecer un paquete de atención integral. Nuestro objetivo era evaluar sistemáticamente la literatura pertinente y sintetizar las pruebas disponibles. Métodos Una revisión sistemática se llevó a cabo de acuerdo con las directrices de la Declaración PRISMA. Se realizaron búsquedas en cinco bases de datos electrónicas para identificar estudios que emplearan métodos cualitativos y / o cuantitativos. Se aplicaron criterios de selección preespecificados a todos los registros recuperados. Los hallazgos se integraron en una síntesis narrativa. Resultados De 3709 referencias recuperadas inicialmente, se conservaron 54 estudios únicos. Se identificaron un total de 136 necesidades individuales y se clasificaron en ocho dominios. Un poco más de la mitad de las necesidades (70, 51%) se referían a problemas de comunicación de información / educación o sistema de salud / paciente-clínico. Apoyo emocional y reaseguro cuando se trata de lidiar con el miedo a la recurrencia del cáncer aparece como la necesidad más importante independientemente de la fase clínica o fase de tratamiento. Información sobre la dieta / nutrición y sobre la autogestión a largo plazo de los síntomas y las complicaciones en el hogar; Abordar cuestiones relacionadas con la calidad y el modo de suministro de información relacionada con la salud; Ayudar a controlar la fatiga; Y el contacto continuo con un profesional de la salud digno de confianza también aparece como necesidades destacadas. La evidencia de investigación disponible es de moderada a buena calidad. Conclusiones Investigar el tiempo para indagar con sensibilidad sobre las necesidades de atención de apoyo de esta población de pacientes es clave, mientras que la evaluación y la reconstrucción de las interacciones clínicas basadas en las prioridades de los pacientes es igualmente esencial. Las diversas necesidades identificadas requieren un enfoque multiprofesional y multiagencial para asegurar que se aborden las necesidades no satisfechas o se ofrezcan medidas.
OBJETIVO: La vigilancia tras el tratamiento del cáncer colorrectal (CRC) es rutinaria, pero un seguimiento intensivo puede ofrecer poco o ningún beneficio de supervivencia global. Teniendo en cuenta la creciente población de supervivientes del CRC, se intentó evaluar sistemáticamente la literatura para la perspectiva del paciente en dos preguntas: (1) ¿Cómo perciben los pacientes CRC la vigilancia rutinaria después del tratamiento curativo y qué esperan obtener de sus pruebas de vigilancia o visitas? (2) ¿Qué proveedores (especialistas, enfermería, atención primaria) son los preferidos por los supervivientes del CRC para guiar la vigilancia post-tratamiento? MÉTODOS: Se realizaron búsquedas sistemáticas de PubMed MEDLINE, Embase, el Registro Central de Ensayos Controlados, CINAHL y PsycINFO. Los estudios fueron seleccionados para su inclusión por dos revisores, con discrepancias adjudicadas por un tercer revisor. Los datos fueron extraídos y evaluados utilizando herramientas de reporte validadas (CONSORT, STROBE, CASP) apropiadas para el diseño del estudio. RESULTADOS: Se revisaron las citas (3691), se revisaron 91 artículos completos y 23 se incluyeron en la revisión final: 15 cuantitativas y 8 cualitativas. En total, 12 estudios indicaron que los pacientes con CRC perciben la vigilancia de rutina de manera positiva, esperando obtener la tranquilidad de la continuación de la supresión de la enfermedad. Las percepciones negativas descritas en seis estudios incluyeron ansiedad e insatisfacción relacionadas con la calidad de vida o problemas psicosociales durante el seguimiento. Aunque 5 estudios apoyaron la atención dirigida por especialistas, 9 estudios indicaron que el paciente estaba dispuesto a tener seguimiento con proveedores no especializados (atención primaria o enfermería). CONCLUSIONES: Las percepciones de los pacientes de seguimiento después de la CRC son predominantemente positivas, aunque las necesidades no satisfechas incluyen apoyo psicosocial y calidad de vida. IMPLICACIONES PARA LOS SUPERVIVIENTES DEL CÁNCER: Los supervivientes percibieron el seguimiento como tranquilizador, sin embargo, el cuidado de la vigilancia debe ser más informativo y enfocado en las necesidades específicas del sobreviviente.
ANTECEDENTES: Una amplia variedad de estrategias de seguimiento se utilizan para los pacientes con cáncer colorrectal (CCR) después de la cirugía curativa. El objetivo de este estudio es revisar la evidencia del impacto de las diferentes estrategias de seguimiento en pacientes con CRC no metastásico después de la cirugía curativa, en relación con la supervivencia global y otros resultados.
Pacientes y métodos: una búsqueda sistemática en PubMed, EMBASE, SCOPUS e ISI Web of Knowledge hasta junio de 2014 se llevó a cabo. Los estudios elegibles eran todos los ensayos clínicos aleatorios que compararon la efectividad de diferentes estrategias de seguimiento después de la resección curativa en nonmetastatic CRC.
RESULTADOS: Once estudios con n = 4055 participantes fueron incluidos en un meta-análisis. Una mejora significativa en la supervivencia global se observó en pacientes con seguimiento de las estrategias más intensivas [hazard ratio = 0,75; 95% intervalo de confianza (IC) 0,66 a 0,86]. Una mayor probabilidad de detección de recidivas asintomáticas [riesgo relativo (RR) = 2,59; IC 95% 1,66-4,06], la cirugía curativa intentó en recurrencias (RR = 1,98; IC del 95% 1,51-2,60), la supervivencia después de recurrencias (RR = 2,13; IC del 95% 1,24-3,69), y un tiempo más corto en la detección de recurrencias ( diferencia de medias -5,23 meses; IC del 95%: -9,58 a -0,88) se observó en el grupo de intervención. No hubo diferencias significativas en las recurrencias total del tumor, ni en la mortalidad relacionada con la enfermedad.
CONCLUSIÓN: estrategias de seguimiento intensivos mejoran la supervivencia en general, aumentan la detección de recidivas asintomáticas y cirugía curativa intentó a la recurrencia, y se asocian con un menor tiempo en la detección de recurrencias. Esta más intensivo seguimiento no podría estar asociado con una mejoría en la supervivencia cáncer específica ni con un aumento en la detección de recurrencias tumorales totales. Seguimiento con el antígeno carcinoembrionario sérico y colonoscopias se relacionan con un aumento en la supervivencia global.
Follow-up after curative treatment for colorectal cancer (CRC) puts pressure on outpatient services due to the growing number of CRC survivors. The aim of this state-of-the-art review was to evaluate setting, manner and provider of follow-up. Moreover, perceptions of CRC survivors and health care providers regarding standard and alternative follow-up were examined. After a comprehensive literature search of the PubMed database, 69 articles were included reporting on CRC follow-up in the hospital, primary care and home setting. Hospital-based follow-up is most common and has been provided by surgeons, medical oncologists, and gastroenterologists, as well as nurses. Primary care-based follow-up has been provided by general practitioners or nurses. Even though most hospital- or primary care-based follow-up care requires patients to visit the clinic, telephone-based care has proven to be a feasible alternative. Most patients perceived follow-up as positive; valuing screening and detection for disease recurrence and appreciating support for physical and psychosocial symptoms. Hospital-based follow-up performed by the medical specialist or nurse is highly preferred by patients and health care providers. However, willingness of both patients and health care providers for alternative, primary care or remote follow-up exists. Nurse-led and GP-led follow-up have proven to be cost-effective alternatives compared to specialist-led follow-up. If proven safe and acceptable, remote follow-up can become a cost-effective alternative. To decrease the personal and financial burden of follow-up for a growing number of colorectal cancer survivors, a more acceptable, flexible and dynamic care follow-up mode consisting of enhanced communication and role definitions among clinicians is warranted.
