How Closely Should We Follow Gastric Cancer Patients Following Surgical Resection?

Abstract

The utility of intensive follow-up of patients with gastrointestinal malignancies following surgical resection has been a source of persistent debate. Most of the studies on this topic have been performed for patients with colorectal cancer, and the conclusions are mixed. In a meta-analysis of 8 randomized trials with 2923 colorectal cancer patients, more intensive follow-up was found to detect recurrences 5.9 months earlier and increased the proportion of recurrences amenable to surgical re-resection (10.7% vs 5.7%). 1 Curiously, overall mortality was improved for patients with more intensive surveillance (odds ratio 0.074, P = 0.01), but cancer-related mortality was not different in the 2 groups. There is significantly less randomized data on the follow-up of patients with gastric cancer. In this issue, Eom et al. from the National Cancer Center in Gyeonggi-do, Korea, report on the effectiveness of regular follow-up in their series of 1767 gastric cancer patients who underwent surgical resection. 2 The follow-up regimen varied for early gastric cancers (defined at T1 tumors) and for late gastric cancers (defined at T2 or greater tumors), but included routine physical examinations, laboratories (CBC, LFTs, CEA, and CA-19-9), abdomen/pelvis computed tomography (CT) scans, chest X-rays, and yearly endoscopy. A total of 310 patients (17.5%) developed recurrences, but median follow-up was not reported. Three-quarters of recurrences were detected by follow-up while one-quarter were detected following evaluation of symptoms. There was no survival difference between patients who had recurrences detected by follow-up studies versus those who had recurrences detected between follow-up visits, and the authors concluded that ‘‘the oncologic effectiveness of regular follow-up after curative resection for gastric cancer was found to be unsatisfactory.’’ Unfortunately, it is difficult to make conclusions on the effectiveness of follow-up when retrospectively analyzing patients who all received relatively intensive follow-up. In order for intensive follow-up of patients to impact on subsequent survival, several conditions need to be met. First, a significant proportion of patients need to recur. Any benefit for intensive follow-up will be diminished if only a small percentage of patients actually recur. Second, the surveillance program must detect asymptomatic recurrences significantly earlier than without surveillance. If there is a short interval between detection of asymptomatic recurrence and the onset of symptoms, the potential benefit of initiating therapy early in recurrence is decreased. Third, there must be effective therapy for recurrent disease. There will be no effect of surveillance on survival if we have no effective therapy for recurrence. Finally, therapy for recurrent disease must be more efficacious for earlier recurrences compared with later recurrences. In terms of the proportion of patients that recur, only 17.5% of patients in this study recurred, which is a relatively low percentage compared with Western series. The low percentage of patients who recurred is likely because the majority of patients had early-stage disease (although the stage of patients is not included in the article). In countries such as the United States where no endoscopic screening programs exist and patients generally present with later-stage disease, the percentage of patients who recur after potentially curative surgery is significantly higher, and thus the potential for identifying recurrences from intensive follow-up is greater. 3,4 The current study does not tell us exactly how much earlier recurrences are identified in patients with more intensive follow-up compared with less intensive follow-up given all patients were followed by relatively intensive