Role of surveillance imaging and endoscopy in colorectal cancer follow-up: Quality over quantity?

Table 1 Summary of postoperative surveillance recommendations for colorectal cancer by different professional societies

Organization	History/physical	CEA	CT scan	Endoscopy
ASCO 2013[14] (stage II-III)	Every 3-6 mo for 5 yr	Every 3-6 mo for 5 yr	Chest/abdomen +/-pelvis (if rectal) annually for 3-5 yr	Colonoscopy at 1 yr; if negative, every 5 yr. Rectal cancer: proctosigmoidoscopy every 6 mo for 2-5 yr if no pelvic RT
ESMO colon 2013[15] (Stage I, II, III)	Every 3-6 mo for 3 yr, then every 6-12 mo for 2 yr	Every 3-6 mo for 3 yr, then every 6-12 mo for 2 yr	Chest and abdomen every 6-12 mo for 3 yr; transabdominal ultrasound can be used instead of CT abdomen	Colonoscopy at 1 yr; of negative, every 3-5 yr subsequently.
ESMO rectal 2013[16] (Stage II, III)	Every 6 mo for 2 yr	Every 6 mo for 3 yr	At least 2 chest/abdomen/pelvis in the first 3 yr	Colonoscopy every 5 yr up to age 75
NCCN 2018[17] (Stage II, III, resected IV)	Every 3-6 mo for 2 yr, then every 6 mo for 3 yr	Every 3 to 6 mo for 2 yr for ≥ T2 disease, then every 6 mo for 3 yr (up to 5 if resected metastatic)	Colon: Chest/abdomen/ pelvis every 6-12 mo for up to 5 yr. For rectal cancer, CT chest/abdomen and pelvis every 3-6 mo for 2 yr, then every 6-12 mo for up to 5 yr	Colonoscopy at 1 yr; if negative, repeat at 3 yr, then every 5 yr subsequently. If adenoma found, repeat at 1 yr.
USMSTF 2016[7] (only for endoscopic surveillance)				Colonoscopy at 1 yr; if negative, repeat at 3 yr, then every 5 yr. For rectal cancer, flexible sigmoidoscopy or EUS every 3-6 mo for the first 2 to 3 yr after surgery for patients at high risk for local recurrence

CEA: Carcinoembryonic antigen; CT: Computed tomography; ASCO: American society of clinical oncology; ESMO: European society for medical oncology; NCCN: National comprehensive cancer network; USMSTF: United States Multi-Society Task Force.

Table 2 Summary of recent randomized control trials evaluating intensive vs less intensive surveillance strategies

Trial	Setting	Enrollment period	Patient population	Intensive group	Control group	Results
FACS (JAMA 2014)[23]	United Kingdom	2003-2009	1201 stage I-III	Either: CEA every 3 mo for 2 yr, then every 6 mo for 3 yr, with a single chest, abdomen, and pelvis CT scan at 12-18 mo if requested; CT of the chest, abdomen, and pelvis every 6 mo for 2 yr, then annually for 3 yr; Both blood CEA measurement and CT imaging as above	No scheduled follow-up except a single CT scan of the chest, abdomen, and pelvis at 12-18 mo if requested	No difference in overall mortality for combined CEA and CT compared to minimal follow-up
GILDA (Ann Oncol 2016)[22]	Italy	1998-2006	1228 Dukes B2-C (high risk stage II and III)	Office visit, blood tests (CEA, CBC, liver tests, CA19-9) every 4 mo for 2 yr, then every 6 months for 2 yr then at 5 yr; Colonoscopy and chest X-ray every year for 5 yr; Liver ultrasound at 4, 8, 12, 16, 24, 36, 48, and 60 mo	Office visit, CEA, every 4 mo for 2 yr, then every 6 mo for 2 yr then at 5 yr; Colonoscopy at 1 yr and at 4 yr; Liver ultrasound at 8 and 20 mo	No difference in overall survival or health-related quality of life scores
COLFOL (JAMA 2018)[11]	24 centers in Sweden, Denmark, and Uruguay	2006-2010	2509 stage II and III	CEA and CT thorax/abdomen at 6, 12, 18, 24, and 36 mo	CEA and CT thorax/abdomen at 12 mo and 36 mo	No difference in overall mortality, cancer-specific mortality, and cancer recurrence
PRODIGE-13[24]	96 centers in France and Belgium	2009-2015	1997 stage II and III	Clinical assessments every 3 mo until year 3 and every 6 mo until year 5, then at least yearly thereafter; Alternating assessments every 3 mo of CT thorax/abdomen/pelvis or abdominal ultrasound until year 3 and then every 6 mo until year 5; Colonoscopy at 3 yr after surgery then every 3 to 6 yr thereafter	Clinical assessments every 3 mo until year 3 and every 6 mo until year 5, then at least yearly thereafter; Abdominal ultrasound every 3 mo until year 3 and then every 6 mo until year 5; chest X-ray every; 6 mo until year 3 and then annually until year 5; Colonoscopy at 3 yr after surgery then every 3 to 6 yr thereafter	Pending for 2021

CEA: Carcinoembryonic antigen; CT: Computed tomography.