The association between post-treatment surveillance testing and survival in stage II and III colon cancer patients: An observational comparative effectiveness study

Robert B Hines,Priya Vishnubhotla,Shunpu Zhang,Eunkyung Lee,Adrian V Specogna,Md Jibanul Haque Jiban

doi:10.1186/s12885-019-5613-5

Abstract

BackgroundThe best strategy for surveillance testing in stage II and III colon cancer patients following curative treatment is unknown. Previous randomized controlled trials have suffered from design limitations and yielded conflicting evidence. This observational comparative effectiveness research study was conducted to provide new evidence on the relationship between post-treatment surveillance testing and survival by overcoming the limitations of previous clinical trials.MethodsThis was a retrospective cohort study of the Surveillance, Epidemiology, and End Results database combined with Medicare claims (SEER-Medicare). Stage II and III colon cancer patients diagnosed from 2002 to 2009 and between 66 to 84 years of age were eligible. Adherence to surveillance testing guidelines—including carcinoembryonic antigen, computed tomography, and colonoscopy—was assessed for each year of follow-up and overall for up to three years post-treatment. Patients were categorized as More Adherent and Less Adherent according to testing guidelines. Patients who received no surveillance testing were excluded. The primary outcome was 5-year cancer-specific survival; 5-year overall survival was the secondary outcome. Inverse probability of treatment weighting (IPTW) using generalized boosted models was employed to balance covariates between the two surveillance groups. IPTW-adjusted survival curves comparing the two groups were performed by the Kaplan-Meier method. Weighted Cox regression was used to obtain hazard ratios (HRs) with 95% confidence intervals (CIs) for the relative risk of death for the Less Adherent group versus the More Adherent group.ResultsThere were 17,860 stage II and III colon cancer cases available for analysis. Compared to More Adherent patients, Less Adherent patients experienced slightly better 5-year cancer-specific survival (HR = 0.83, 95% CI 0.76–0.90) and worse 5-year noncancer-specific survival (HR = 1.61, 95% CI 1.43–1.82) for years 2 to 5 of follow-up. There was no difference between the groups in overall survival (HR = 1.04, 95% CI 0.98–1.10).ConclusionsMore surveillance testing did not improve 5-year cancer-specific survival compared to less testing and there was no difference between the groups in overall survival. The results of this study support a risk-stratified, shared decision-making surveillance strategy to optimize clinical and patient-centered outcomes for colon cancer patients in the survivorship phase of care.

Highlights

The best strategy for surveillance testing in stage II and III colon cancer patients following curative treatment is unknown
More surveillance testing did not improve 5-year cancer-specific survival compared to less testing and there was no difference between the groups in overall survival
In the United States (US), guideline issuing groups such as the National Comprehensive Cancer Network (NCCN) have supported surveillance testing consisting of physical exams, carcinoembryonic antigen (CEA) blood tests, colonoscopy, and computed tomography (CT) scans of the chest and abdomen in the years following primary treatment [5,6,7]

Summary

Introduction

The best strategy for surveillance testing in stage II and III colon cancer patients following curative treatment is unknown. Earlier randomized controlled trials (RCTs) and meta-analyses of these trials demonstrated that surveillance for local/regional colon cancer improved overall survival [10,11,12,13], the evidence that more intensive surveillance improves cancer-specific survival has not been demonstrated [9, 12,13,14] This scenario has been complicated by the fact that the clinical trial data pertaining to this issue:1) has spanned a number of decades in which treatments for colon cancer have dramatically improved and surveillance strategies have evolved [15, 16], 2) includes heterogeneous studies with varying surveillance protocols that make comparisons between trials and inclusion of trials in meta-analyses problematic [15,16,17,18,19], and 3) has been derived from small controlled trials with limited follow-up, and lacks the statistical power to detect meaningful survival differences [18, 19]. The resulting contradictory evidence has led some clinicians/researchers to question whether surveillance guidelines represent the best follow-up strategy and even if surveillance testing should be done at all [15, 20,21,22]

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