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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 65-68

Is colonoscopic surveillance necessary after curative resection of colorectal cancer in elderly patients?


1 Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Australia
2 Department of Surgery, Deakin University, Victoria, Australia

Date of Submission07-Mar-2019
Date of Decision30-Mar-2019
Date of Acceptance24-Apr-2019
Date of Web Publication24-Oct-2019

Correspondence Address:
Dr. Suat Chin Ng
8 Arnold Street, Box Hill 3128, Victoria
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_8_19

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  Abstract 


Background: Surveillance colonoscopy is routinely offered to patients who have undergone curative resections for colorectal cancer (CRC). The purpose of this study is to investigate the early detection of metachronous tumors or anastomotic recurrences. Few studies have investigated the utility of surveillance scopes in the elderly population. Objective: To investigate the incidence of metachronous cancer or anastomotic recurrence in patients over the age of 80 years who underwent resection of CRC with curative intent. Design: This is a retrospective study of a prospectively maintained database. Setting: University Hospital Geelong. Patients and Methods: All patients ≥80 years of age who underwent resection of CRC with curative intent at University Hospital Geelong between January 2002 and December 2014 were studied. Demographic information, comorbidities (Charlson score), types of surgery, postoperative complications (Clavien–Dindo), tumor staging, and details regarding postoperative colonoscopies were recorded. Patients were followed up for life whenever possible. The mean length of hospital stay and follow-up were determined. Survival analysis was done using the Kaplan–Meier method. The incidence of metachronous and locally recurrent CRC was calculated. Main Outcome Measures: Incidence of metachronous or locally recurrent CRC. Sample Size: One hundred and eighty-three patients. Results: Ninety-nine patients (54%) were female and 147 (80%) had elective resections. Seventy-one (39%) patients had moderate-to-severe comorbidities (Charlson Comorbidity Index ≥3). There were 139 patients who had had colon cancer and 44 with rectal cancer who had been resected with curative intent. Stages I, II, and III cancers comprised 16%, 47%, and 37%, respectively. The mean length of hospital stay was 13.3 days. The mean duration of follow-up was 3.43 years. Median survival after surgery by stage was 93 months (Stage I), 92 months (Stage II), and 72 months (Stage III). A total of 26 surveillance colonoscopies were performed on 24 patients. After a total of 627.21 patient-years of follow up, one metachronous CRC was detected, but no local recurrences were observed. Conclusion: It is extremely uncommon to detect clinically significant metachronous tumors in patients aged over 80. Limitation: Small cohort size. Conflict of Interest: None.

Keywords: Colorectal cancer, elderly patients, metachronous cancer, surveillance colonoscopy


How to cite this article:
Ng SC, Kong J, Stupart D, Watters D. Is colonoscopic surveillance necessary after curative resection of colorectal cancer in elderly patients?. World J Colorectal Surg 2019;8:65-8

How to cite this URL:
Ng SC, Kong J, Stupart D, Watters D. Is colonoscopic surveillance necessary after curative resection of colorectal cancer in elderly patients?. World J Colorectal Surg [serial online] 2019 [cited 2020 Aug 5];8:65-8. Available from: http://www.wjcs.us.com/text.asp?2019/8/3/65/269823




  Introduction Top


Patients with colorectal cancer (CRC) are followed up regularly after surgery with curative intent to allow early detection of potentially curable recurrent disease, thereby offering a better chance of survival.[1]

The majority of tumor recurrences develop within the first 5 years and can appear in three different forms, namely, locoregional, metachronous, or metastatic. There is a 1.5%–3% risk of developing metachronous cancer[2],[3],[4],[5],[6] and a 2%–4% risk of developing locoregional recurrences at 5 years despite curative surgery and the use of modern chemoradiotherapy.[2],[7],[8] The locoregional recurrence rate is generally higher in patients with rectal cancer, particularly those who have not had total mesorectal excision and/or pelvic radiation therapy.[9] When the disease is widespread, the treatment outcomes are often poor. Re-resection is associated with substantial morbidity and mortality as it often involves complex exenteration and reconstructive procedures.[10] Therefore, the majority of patients with recurrent CRCs are not potentially curable when diagnosed.

An ideal surveillance regimen should target high-risk patients, and target likely sites of recurrent disease. The Australian Guidelines have recommended that follow-up should be offered to all patients who had curative surgery and are fit for further intervention if disease is detected.[11] The schedule includes an early postdischarge review and 3–6 monthly review for the first 2 years and yearly review thereafter, along with serum carcinoembryonic antigen (CEA). Surveillance colonoscopy is performed at 1 year (or earlier if the patient had an incomplete scope preoperatively) and every 5 years thereafter. Computed tomography (CT) imaging of the chest, abdomen, and pelvis is done annually for at least the first 3 years. However, this type of follow-up is intensive, expensive, and resource consuming and should only be offered to those at high risk and are most likely to benefit.

Careful interpretation of the existing surveillance guidelines is especially important for the elderly population, particularly as data on elderly patients have often been extrapolated from younger patients.[12],[13],[14],[15] There are few guidelines addressing specific strategies for this unique cohort. The available evidence from published trials do not include sufficient patients above the age of 75.[12] Shared decision-making with this group of patients must address the great heterogeneity in their functional status, comorbidities, management goals, and life expectancy. These factors challenge decision-making on the value of performing a surveillance colonoscopy, a relatively inconvenient procedure that involves anesthesia or sedation, and is not risk free, especially in patients who may not be fit for curative resection of any tumor that may be identified.


  Patients and Methods Top


This is a retrospective study of a prospectively maintained database of colorectal operations. The study population included all patients over 80 years of age who underwent resection of their primary CRC with curative intent at University Hospital Geelong (a regional referral hospital in Victoria, Australia) between January 2002 and December 2014. This study (project number EC2013/1/1) was approved by the Australian Institute of Health and Welfare Ethics Committee.

Patients had lifelong clinical follow-up wherever possible. When patients were lost to clinical follow-up (26 patients), and when clinical status was uncertain, attempts were made to contact the patients, their family, or general practitioner. Follow-up was continued until at least December 31, 2015.

Descriptive data of patients including demographic details, comorbidities, postoperative complications, types of surgery, tumor staging, findings of CT scans, and details of colonoscopies postcurative resection were collected and analyzed. Comorbidities were classified according to Charlson scores[16] and categorized into 0, 1, 2, 3, 4, and ≥5. Postoperative complications were categorized according to Clavien–Dindo classification.[17] Outcome variables such as length of hospital stay, length of follow-up, and survival were also recorded.

Colonoscopies performed in asymptomatic patients were classified as “surveillance” scopes. These included colonoscopies that were performed subsequent to a raised CEA level in asymptomatic patients. Patients who required a completion colonoscopy for an incomplete or no colonoscopy preoperatively were not considered as surveillance scopes.

The primary outcome measure was the incidence of metachronous cancer and/or anastomotic recurrence based on person-time at risk. The secondary outcomes included the sequelae of patients who proceeded to an intervention following discovery of recurrences on surveillance colonoscopies, as well as the rate of adenoma detection.

Survival analysis was done using the Kaplan–Meier method to allow for variable follow-up, and comparisons were made using the Cox proportional hazards method. P ≤ 0.05 was considered statistically significant. Statistical analysis was done using MedCalc® (Acacialaan 22 8400 Ostend Belgium).


  Results Top


We identified a total of 183 patients. Of these, 139 (76%) had colon cancer and 44 (24%) had rectal cancers. There were 99 females (54%) and 84 males (46%). The mean age was 84.2 years (80–95 years). Of these, 147 (80%) patients underwent elective resections, and 36 patients presented as emergencies. Using the Charlson Comorbidity Index (CCI), 36 (20%) patients had no comorbidities, 76 (41%) had mild comorbidities (CCI score 1–2), 51 (28%) had moderate comorbidities (CCI score 3–4), and 20 (11%) had severe comorbidities (CCI score ≥5) [Table 1].
Table 1: Comorbidities according to Charlson Comorbidity Index

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One hundred and twenty-three (67.2%) patients had postoperative complications [Table 2]. The mean length of stay was 13.3 days (2–90 days).
Table 2: Postoperative (primary cancer) complications in the elderly

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The mean follow-up was 3.43 years (0.01–12.9 years). Only one patient was lost to follow-up. There was a total of 627.21 patient-years of follow-up.

Kaplan–Meier estimates of long-term survival after surgery grouped by tumor stage are illustrated in [Figure 1]. Median survival after surgery was 93 months for patients with stage I, 92 months for stage II, and 71 months for stage III cancers. The Kaplan–Meier estimate of overall median survival was 84 months.
Figure 1: Long-term survival grouped by colorectal cancer stage after curative surgery estimated by Kaplan–Meier estimate

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Of the 183 patients, 40 (28%) were offered surveillance colonoscopy. Of these 40 patients, 16 (40%) chose not to undergo the procedure, so a total of only 24/183 (13%) underwent any surveillance colonoscopies. A total of 26 colonoscopies were performed on these 24 patients [Table 3].
Table 3: Outcomes from surveillance and symptomatic colonoscopy

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Only one metachronous bowel cancer was detected on surveillance colonoscopy in an 89-year-old woman, who 4 years earlier had had an abdominoperineal resection for a stage II rectal cancer. A metachronous hepatic flexure lesion was detected, and she underwent a right hemicolectomy with curative intent. Unfortunately, she developed metastatic disease 1.7 years later. No anastomotic recurrent tumors were detected.

Adenomas were detected and removed on three surveillance colonoscopies.

Eleven (6.0%) patients underwent colonoscopies for bowel symptoms, including changes in bowel habit, hematochezia, weight loss, iron deficiency anemia, and abdominal pain. No new bowel cancers (neither metachronous cancers nor anastomotic recurrence) were detected in this group of patients. Adenomas were detected, however, in two of these patients.

During the follow-up period, none of the unsurveilled patients presented with emergency presentations of bowel cancer (obstruction, perforation, or bleeding) nor did any receive further surgery for CRC aside from the one with metachronous cancer detected on surveillance colonoscopy, as described above.


  Discussion Top


In this cohort of 183 elderly patients who had undergone surgery for CRC with curative intent, only one metachronous cancer was diagnosed after a median follow-up of 3.43 years (crude rate of 0.5%; or 1.6 cancers/1000 person-years follow-up), and no anastomotic recurrences were diagnosed. This is similar to the previously reported cumulative incidence of metachronous cancers of 0.35% per year in a cohort unselected for age.[18]

Only 13% of the cohort underwent surveillance colonoscopy, hence, asymptomatic metachronous or locally recurrent bowel cancers may have occurred in our patients. However, we did achieve over 99% complete follow-up, so clinically significant metachronous or locally recurrent cancers were not missed.

In this study, only one-third of the patients were offered surveillance colonoscopy. This reflects the clinicians' wish to avoid uncomfortable and potentially harmful interventions in the elderly population, especially as many of them would not be fit for further surgery if metachronous or locally recurrent cancers were detected, and an awareness that elderly patients are at a significantly higher risk of developing complications from colonoscopy.[18] Further, among those who were offered colonoscopy, one-third of the patients chose not to undergo the procedure. This is unsurprising in a cohort of elderly patients, as even small adverse events can cause great stresses in this group of patients.[19]

A total of five adenomatous polyps were detected and removed at colonoscopy, however, the benefit of this is uncertain. Detecting premalignant polyps in a patient with limited life expectancy, who would die of another cause before cancer transformation,[20] may not justify the risk and inconvenience of periodic colonoscopies.


  Conclusion Top


Clinically important metachronous and locally recurrent CRC are rare in elderly patients who have undergone resection of CRC with curative intent. Colonoscopic surveillance strategies in this population group need to be individualized, taking into account the potential risks and benefits of the procedure.

Acknowledgment

The authors would like to acknowledge the general support by the Department of Surgery, University Geelong Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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