Colorectal Cancer Follow up

Should we Stratify?

John Griffith

What do we currently do?

1) Routine follow-up in secondary care

2) CT scanning (frequency)

3) CEA

Current practice

One size fits all

National inconsistencies

Delivered in secondary care

– High staff demands

– Not patient friendly

“One Size Fits All”

established follow-up

No metastases picked up by the 5 year CT

in 79 patients

The one year colonoscopy detected

– 1 cancer (ba enema pre-op)

– 13 patients with polyps

– 8 known – incomplete or not removed pre-op

– 5 new (one adenoma)

CRC Recurrence YCN study

– Retrospective study

– Included colorectal cancer AND surgical resection Excluded those who had de-functioning stomas only

– Period between 2002-2006 Ensures a full 5 year follow-up cycle completed

– 1000 Case-notes 600 Bradford (60%)

250 Calderdale and Huddersfield (25%)

150 York (15%)

– Data collected: Patient Demographic

Tumour Features

Recurred? If so, where, when and how was it detected?

Final Analysis: 1001 Cases – 877 adenocarcinomas undergoing curative resection

Location – 71.0% Colon

– 29.0% Rectum

Dukes Stage – Dukes A = 15.6%

– Dukes B = 45.1%

– Dukes C = 39.0%

Dukes C1 = 34.9%

Dukes C2 = 4.1%

Location %

Caecum/Right/Ascending 22.9

Hepatic flexure 2.39

Transverse/Splenic flexure 6.73

Left/Descending 4.33

Sigmoid/RSJ 34.66

Rectum (High >12cm) 6.61

Rectum (Mid 6-12cm) 11.74

Rectum (Low <6cm) 10.38

Anal 0.23

Survival Curve vs. Dukes Stage

0.0

00

.25

0.5

00

.75

1.0

0

0 500 1000 1500 2000analysis time

dukes = A dukes = B

dukes = C1 dukes = C2

dukes = D

Kaplan-Meier survival estimates, by dukes

Mortality and Recurrences Mortality

– 40.9% Mortality Rate

Cancer Related Deaths (51.3%)

Recurrence Rate

– 232 recurrences (26.5%)

No significant difference between centres

Recurrence

YES

Recurrence

NO Total Cases

%’age

Recurrence

Bradford 120 364 484 24.79

C&H 69 150 219 31.51

York 43 131 174 24.71

Total 232 645 877 26.45

Recurrence Location

Most common site of recurrence is “multiple”

followed closely by:

–Liver

– Anastamosis/Pelvis

– Lung

Location of Recurrences

Bones

Brain

Lymph node

Other

Lung

Anastomosis/Pelvis

Liver

Multiple

Colonic primary - Isolated liver metastasis (28.9%) Significantly greater likelihood of recurring in liver – p-value = 0.09

Rectal primary - Isolated lung metastasis (30.0%) Significantly greater likelihood of recurring in lung – p-value = 0.0004

0

5

10

15

20

25

30

35

Location of Recurrence: Colon vs. Rectal Primary

%'age Rectum

%'age Colon

Recurrence Mode of Detection

Isolated Anastomosis/Pelvis Recurrences: – Endoscopy detected 37.4%

– CT detected 46.5%

Isolated Liver Recurrences: – CT detected: 69.4%

05

1015202530354045

Mode of Detection vs. Location of Recurrence

CEA

Endoscopy

CT

USS

Other Eg. MRI/PET CT

Time to Recurrence

By 3 years, we have 84.5% of our recurrences.

Time to Recurrence (Days) Percentage of Total Recurrences

(%)

Cumulative Total of Recurrences

(%)

0-180 11.64 11.64

181-365 (1 year) 18.96 30.60

366-546 20.69 51.30

547-730 (2 years) 15.95 67.25

731-910 12.50 79.75

911-1095 (3 years) 4.73 84.48

1096-1275 2.59 87.08

1276-1460 (4 years) 3.45 90.53

1461-1640 2.59 93.12

1641-1825 (5 years) 3.02 96.14

Greater than 5 years 3.88 100.00

Why are we looking for

recurrence? Surgeons results

Patients benefits

All patients?

Impact of Resected Recurrence Of those who had their recurrence resected (n=81):

– 49.3% Completed 5 year follow-up

– 2.5% Died of non-cancer related causes eg. MI

However,

– 46.9% had a cancer related death

Count Percentage

Not died during follow-up 40 49.38%

Death not cancer related 2 2.47%

Cancer related death 38 46.91%

Unknown Cause 1 1.23%

Tumour features predicting

recurrence? Stage (A 6%, B 22%, C1 36%)

Extra-mural Vascular Invasion (EMVI)

44% vs 19%

Resection margin involvement 51% vs 25%

Risk stratification

Tumour

Low risk Dukes A & B (-ve EMV &

CRM)

Medium risk Dukes B (Either +ve

EMV OR +ve CRM)

Dukes C1 (-ve EMV &

CRM)

High risk Dukes B (+ve EMV & +

ve CRM)

Dukes C1 (Either +ve

EMV OR +ve CRM)

Dukes C2

Patients receiving neo-

adjuvant treatments

0

10

20

30

40

50

0.0 1.0 2.0 3.0 4.0 5.0 6.0

Patient

years

Low risk – 18 & 30 months CT scan

Op

Chemo/Radio

Palliative

Total of 57 recurrences of which 28 were resectable

Recurrence detected by CT – 39/57

Of the resectable recurrences – 22/28 were detected by CT

Potentially missed resectable recurrences > 30 months

3 detected – 2 by CEA and 1 by colonoscopy which was an anastomotic recurrence

Potentially missed resectable recurrences detected by CT > 30 months

1(Normal CEA) – Follow-up of lung nodule (4.5yrs)

The model applied to the low risk group –

CT at 18 and 30 months

0

10

20

30

40

50

0.0 1.0 2.0 3.0 4.0 5.0 6.0

Patients

year

Medium risk – 18 & 30 months CT scan

OP

Chemo/Radio

Palliative

The model applied to the Medium risk group

– CT at 18 and 30 months

Total of 60 recurrences of which 19 were resected

Recurrences detected by CT – 47/60

Of the resectable recurrences – 13/19 were detected by CT

Potentially missed resectable recurrences > 30 months

2 detected - 1 by Colonoscopy, which was a recurrence at anastomosis and 1 by CEA

Potentially missed resectable recurrences detected by CT > 30 months

3 - there was no CEA rise in 3 patients (1 NA York)

1022 (2.8) – thickening at anastomosis

1173 (3.2) – Right upper lobe lung lesion

0

10

20

30

40

50

0.0 1.0 2.0 3.0 4.0 5.0 6.0

patients

years

High risk – 12, 24 & 36 months CT scan

OP

Chemo/Radio

Palliative

The model applied to the High risk – CT at

12,24 and 36 months

Total of 119 recurrences of which 34 were Resectable

Recurrences detected by CT – 102/119

Of the resectable recurrences – 27/34 were detected by CT

Potentially missed resectable recurrences > 36 months

– 1 detected by Colonoscopy which was (metachronous)

Potentially missed resectable recurrences detected by CT > 36 months

6 - there was no CEA rise in 5 patients (1 NA York)

1910 (5.2) – lung lesions

1995 (5.5) – lung lesion

1809 (5.0) – lung lesion – previous inflammatory lung lesion

1497 (4.1) – lung lesion

1576 (4.3) – metachronous

Resectable recurrences potentially

missed as a proportion of all

recurrences

High 4/119 - 3%

Medium 3/60 - 5%

Low 0/57 - 0%

Overall – 3 % when accounting for

metachronous tumours and previously identified

lung lesions.

What follow-up & When?

Low and medium risk: Regular CEA, CT at

18 & 36 months, Colon 3yrs

High risk: Regular CEA, CT 12, 24 & 36

months, Colon 3yrs

Who and where?

Who do patients want to contact

Gp, consultant specialist nurse

How and where do they want to make

contact:

Regular, open access, telephone

Key Emerging Principles

Risk stratified pathways of care resulting in

a saving 1630 scans

Personalised care plan and treatment

summary with remote follow-up in

appropriate patients (70%)

Remote monitoring – proforma reporting

Conclusion

There is currently a lot of interest in the

overall package of the care our patients

receive. Follow up regimes should be

patient specific.

Many of the indices by which care will be

assessed by are currently not being

measured, and we probably have no idea

as to the services we need for many of the

problems.

Success!

Success results in survivors:

What care can we deliver & where ?

Increasing number of survivors

Increasing number of new referrals

Reduction in staff

Primary care budgets!

NHS Improvement

Remote monitoring tool

Questions we must answer

What is the unmet need of our patients?

What services do we need to provide for

them and when?

How are we going to communicate and

coordinate care.

What is life like living with recurrence:

duration, treatment, side effects, visits.