Oakville Trafalgar Memorial Hospital Institutional Policy on Colorectal Cancer Survivor
Surveillance
Dr. Michael Herman, Dr. Ketan Ghate, Dr. Syed Hussaini, Dr. Ian Choy, Dr. Sandra Demontbrun,
Dr. Federico Pampaloni, Dr. Miles Kealey, Dr. Nicole Callan, Dr. Manoj Sayal, Dr. Dalal Aziz, Dr.
Qasim Khan, Dr. John Iskander, Dr. Miriam Tsao
Colorectal Cancer Staging
Review of the Evidence
SEER data gives the 5-year survival for colon cancer of 93% for stage 1, compared to 85% stage
2A, 72% stage 2B and 44-83% for stage 3. Although stage 3 and subsets of stage 2 colorectal
cancer derive benefit from adjuvant chemotherapy, there is no evidence to support benefit from
adjuvant therapy in stage 1 disease.
Intensive surveillance allows for the detection of asymptomatic recurrences, polyps, or second
primary cancers, with potential for curative therapy. A meta-analysis of (N=4055) stage I, II, or III
CRC patients reported that intensive follow-up was associated with a significantly higher
probability of detecting asymptomatic recurrence (RR 2.59, 95%CI 1.66-4.06), of curative intent
surgery at recurrence (RR1.98, 95%CI: 1.51-2.60) and overall survival after tumour relapse (RR
2.13, 95%CI 1.24-3.69), however, this did not translate into a significant disease-specific survival
benefit. (1).
The latest ASCO guideline recommendations recommend colonoscopy surveillance
approximately 1 year after the initial surgery. The frequency of subsequent surveillance
colonoscopies should be dictated by the findings of the previous one, but they generally should
be performed every 5 years if the findings of the previous one are normal. If a complete
colonoscopy was not performed before diagnosis, a colonoscopy should be done as soon as
reasonable after completion of adjuvant therapy and not necessarily at the 1-year time point.
For stage 2-3 colon cancers, but not for stage 1, a medical history, physical examination, and CEA
testing should be performed every 3 to 6 months for 5 years. Abdominal and chest imaging using
a CT scan is recommended annually for 3 years. For high-risk patients, it is reasonable to
consider imaging every 6 to 12 months for the first 3 years.
Updated guidelines from CCO in 2021 recommend surveillance for stage 1-3 colon cancer with a
medical history and physical exam every 6 months for 3 years, CT scan of the chest, abdomen
and pelvis at 1 and 3 years, or at 18 months and optional use of CEA. Surveillance colonoscopy
should be performed one year after the initial surgery. The frequency of subsequent surveillance
colonoscopy should be dictated by the findings of the previous one, but it generally should be
performed every five years if the findings of the previous one is normal. Follow-up beyond 3
years is left to the discretion of the physician. Key to this recommendation was a Cochrane
metanalysis that demonstrated no improvement in overall survival or the detection of
recurrence with intensifying follow up (2). Stage 1 colon cancer was included in the surveillance
guidelines as the available evidence did not separate benefit to surveillance strategies by stage.
The working group and Expert panel supported a shared care model for colon cancer follow-up,
while acknowledging limited evidence for this recommendation. Evidence from the systematic
reviews showed that there was no difference in patient outcomes, including overall survival and
recurrence, whether care was provided by surgeons, primary care physicians, or nurse
practitioners.
There is very limited data available to guide recommendations for posttreatment surveillance in
stage I CRC patients. While several published clinical practice guidelines do not recommend
surveillance for stage I CRC patients, others do not make a stage- based distinction for
posttreatment follow-up recommendations.
Additional guideline recommendations are as follows:
 American society of colon and rectal surgeons: Surveillance recommendations apply
to higher-risk stage I (eg, rectal cancer posttransanal excision, colorectal cancers with
endoscopic excision only, or non-guideline based therapy), stage II, stage III, and stage IV
disease treated by curative intent
 BCCA: Surveillance guidelines are for resected stage II and III colon and rectal cancer.
Patients with significant comorbidities, very advanced age, or limited 5-year life
expectancy are not routinely offered surveillance.
 ESMO: Surveillance guidelines are for localized colon cancer; do not explicitly state if
applicable to resected stage I disease.
 NCCN: Surveillance recommendations apply to stage II, III, and resected stage IV colon
cancer, and for stage I, II, III, or resected stage IV rectal cancer.
Surveillance recommendations are left to physician discretion for patients older than 75, with
rectal cancer, stage 4 colon cancer, patients undergoing non-operative management, or with
hereditary or other inflammatory disorders that increase risk of colon cancer.
Patients should have pathology reviewed for MMR proficiency, and patients with deficient MMR
tumors in the absence of BRAF V600E mutation or MLH1 promoter methylation should be
referred for genetic testing.
OTMH Guidelines
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Given the available metanalysis does not show a clear improvement in overall survival in
the subgroup of patients with stage 1 colon cancer, and this group of patients generally
have a favorable prognosis we do not recommend routine imaging and bloodwork
surveillance for patients with stage 1 colon cancer.
Imaging and bloodwork surveillance can be considered on a case-by-case basis in patients
with higher-risk stage 1 disease (eg. rectal cancer post transanal excision, colorectal
cancers with endoscopic excision only, or non-guideline-based therapy.)
Patients with complex stage 1 disease can be discussed in an MCC setting to review
surveillance strategies.
Patients with stage 2-3 colon cancer, but not stage 1, will be referred to a medical
oncologist for opinion on adjuvant chemotherapy and discussion on surveillance.
Patients should have pathology reviewed for MMR proficiency, and patients with
deficient MMR tumors in the absence of BRAF V600E mutation or MLH1 promoter
methylation should be referred for genetic testing.
OTMH Colon Cancer Surveillance Policy
Stage+
1
2-3
Intervention
History &
CEA
CTcap
Physical
Exam
Not routinely recommended*
Q 6 months
Q 6 months
CT CAP at
for years 1-3 for years 1-3 Years 1 and 3
then at the
then at the
OR
discretion of discretion of CT CAP at 18
the treating
the treating
months
physician
physician
years 4-5
years 4-5
At the discretion of the treating physician
Colonoscopy
At 1 year following surgery, the
frequency of subsequent surveillance
colonoscopies should be dictated by the
findings of the previous one but
generally, should be performed every 5
years if the findings of the
previous one are normal. If a complete
colonoscopy was not performed before
diagnosis, a colonoscopy should be
Resected
done as soon as reasonable after
stage 4
completion of adjuvant therapy and not
necessarily at the 1-year time point.
*consider on a case by case basis in patients with higher-risk stage 1 disease (eg, rectal cancer
posttransanal excision, colorectal cancers with endoscopic excision only, or non-guideline based
therapy).
+ Patients should have pathology reviewed for MMR proficiency, and patients with deficient
MMR tumors in the absence of BRAF V600E mutation or MLH1 promoter methylation should be
referred for genetic testing.
References:
1. Pita-Fernández S, Alhayek-Aí M, González-Martín C, López-Calviño B, Seoane-Pillado T,
Pértega-Díaz S. Intensive follow-up strategies improve outcomes in nonmetastatic
colorectal cancer patients after curative surgery: a systematic review and meta-analysis.
Ann Oncol 2015 Apr;26(4):644-65
2. Jeffery M, Hickey BE, Hider PN. Follow-up strategies for patients treated for nonmetastatic colorectal cancer. Cochrane Database Syst Rev. 2019;9:CD002200.