INTENSITY OF POST-TREATMENT SURVEILLANCE AND SURVIVAL IN COLORECTAL CANCER PATIENTS George J. Chang, MD, MS, FACS, FASCRS Professor of Surgical Oncology & of Health Services Research The University of Texas, MD Anderson Cancer Center Co-Chair, Cancer Care Delivery Research Program Alliance for Clinical Trials in Oncology Network
COI Disclosures George J. Chang, MD, MS, FACS, FASCRS Consultancy – Johnson and Johnson; MORE Health
1.8 million Colorectal Cancer Survivors in US
Goals of Surveillance Management of Detection of long-term sequelae Recurrence of treatment Post-treatment Continuity of Care Pyschosocial well- being
Surveillance Guidelines Vary Widely CT scan every 6 months CEA every 3 months 5 years CT scan twice in 3 years CEA every 6 months 3 years No further testing
N=735 A Curative surgery No curative surgery
Scanxiety (n) “scan zi et ee”: Anxiety and worry that accompanies the period of time before undergoing or receiving the results of a medical examination (such as MRI or CT scan).
Does Higher Surveillance Intensity Improve Detection of Recurrence or Survival?
Cohort Selection - 1 Collaboration to improve process for recurrence ascertainment within the NCDB Random sampling of 10 colorectal cancer patients within each facility for primary data abstraction
Cohort Selection - 2 14,784 Biopsy Records 61,075 CEA Records 40,272 Imaging Records 16,967 Endoscopy Records
Facility Predict each patient Test use among Compare clustering effect facility # of survivors w/o effectiveness of for O/E tests/pt for all demographic recurrence intensity by survivors P<0.0001 imaging (n=6279) facility (n=8529) tumor P<0.0001 CEA
Intensity and Recurrence Detection Mean LI:1.6 (95%CI 1.6-1.7) HI: 2.9 (95%CI 2.8-2.9) IMAGING INTENSITY CEA INTENSITY
Intensity and Overall Survival Mean LI:1.6 (95%CI 1.6-1.7) HI: 2.9 (95%CI 2.8-2.9) Overall survival by imaging test intensity Overall survival by CEA test intensity (log rank test for OE<1 vs OE≥1p=0.9118) (log rank test for OE<1 vs OE≥1 p=0.1849) 100 100 95.98 95.79 90.32 90.13 95.35 95.16 90 90 84.43 84.15 89.39 89.22 Overall survival (%) Overall survival (%) 78.70 78.38 83.39 80 80 83.13 74.27 73.62 77.77 77.48 73.70 70 70 73.09 OE<1 OE<1 60 60 OE≥1 OE≥1 50 50 0 1 2 3 4 5 0 1 2 3 4 5 Years after surveillance start date Years after surveillance start date
Intensity & Salvage Surgical Treatment Mean LI:1.6 (95%CI 1.6-1.7) HI: 2.9 (95%CI 2.8-2.9) CEA INTENSITY IMAGING INTENSITY 10 10 8 8 p=0.27, O/E<1 vs O/E>=1 for stage III p=0.27, O/E<1 vs O/E>=1 for stage III Resection rate (%) Resection rate (%) 6 6 p=0.41, O/E<1 vs O/E>1 for stage II p=0.41, O/E<1 vs O/E>1 for stage II 4 4 p=0.68, O/E<1 vs O/E>=1 for stage I p=0.68, O/E<1 vs O/E>=1 for stage I 2 2 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Years after surveillance start date Years after surveillance start date Stage I, O/E<1 Stage II, O/E<1 Stage III, O/E<1 Stage I, O/E<1 Stage II, O/E<1 Stage III, O/E<1 Stage I, O/E>=1 Stage II, O/E>=1 Stage III, O/E>=1 Stage I, O/E>=1 Stage II, O/E>=1 Stage III, O/E>=1
Summary Intensification of surveillance has a negligible impact on the detection of recurrence or survival May slightly increase rate surgery for distant recurrence No need to image more frequently than once/year Earlier - stage patients may require less follow-up Follow-up care should emphasize Management of treatment associated toxicity Health promotion and secondary prevention Psychosocial well-being https://crcdecisiontool.mdanderson.org
Thank You gchang@mdanderson.org @coloncancerdoc
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