Carcinoembryonic Antigen Test Research Articles

Receipt of guideline‐recommended follow‐up in older colorectal cancer survivors

After curative resection for colorectal cancer, routine follow-up with office visits, carcinoembryonic antigen (CEA), and colonoscopy is recommended. The actual adherence to these guidelines as well as the potential overuse of testing in routine practice has not been well studied. The authors identified 9426 eligible patients aged > or = 66 years in a linked tumor registry-claims database who were diagnosed with adenocarcinoma of the colon or rectum from 2000 to 2001. Patients were observed to 3 years after diagnosis. Receipt of > or = 2 office visits per year, > or = 2 CEA tests per year (years 1 and 2), and > or = 1 colonoscopy within 3 years constituted guideline fulfillment. Guidelines for office visits, colonoscopy, and CEA testing were met in 92.3%, 73.6%, and 46.7% of patients, respectively. In addition, receipt of 2 nonrecommended procedures, abdominal/pelvic computed tomography scans and positron emission tomography scans, was documented in 47.7% and 6.8%, respectively. Overall, 60.2% received testing below recommended levels, 17.1% at recommended frequency, and 22.7% above guideline recommendations. In a multivariate analysis, factors associated with meeting guidelines included younger age group, white race, regional stage cancers, and poorly differentiated tumors. Considerable geographic variation in meeting guidelines was also observed. Many older colorectal cancer survivors in this population-based cohort underwent testing below a minimum frequency specified by clinical practice guidelines, especially with regard to CEA. Further studies should ascertain the reasons for poor compliance and the effect on patient outcome.

Colon carcinoma. Preoperative CEA, tumor differentiation and prognosis

Investigations on 279 patients with colon carcinoma revealed an increase in the sensitivity of the CEA (carcinoembryonic antigen) test with regard to tumor stage from 42% (Dukes A) to 86% (Dukes D). Curative operable carcinoma without lymph-node or distant metastases had CEA levels up to 70 ng/ml. CEA values below 20 ng/ml had no predictive value concerning resectability at first operation. When the CEA level rose above 20 ng/ml, the proportion of curative operations fell from 83% (CEA values below 20 ng/ml) to 17%. Recurrence rate rose with the preoperative level of CEA from 22% (CEA less than 2.5 ng/ml) to 62% (CEA greater than 10 ng/ml). The resection rate at second operation had a closer relationship than at first operation to the preoperative CEA level; it fell from 50% (CEA less than 5.0 ng/ml) to 0% (CEA greater than 20 ng/ml). At operation, highly differentiated tumors were found to be at an early stage in 50% of cases, compared to 26% of G2 and 11% of G3 tumors. In 44% of dedifferentiated tumors CEA levels were above 20 ng/ml. An influence of tumor differentiation on CEA remained even after division into the individual tumor stages.

Community Compliance with Carcinoembryonic Antigen: Follow-up of Patients with Colorectal Cancer

The aim of this study was to determine whether recommendations for surveillance carcinoembryonic antigen (CEA) testing in stage II/III colorectal cancer (CRC) are adhered to upon discharge from our cancer center, patterns of care after CEA elevation, and whether differences in outcomes exist between patients who did and did not receive recommended CEA monitoring. A retrospective, single-institution chart review was completed at the Cross Cancer Institute (CCI) in Edmonton, Alberta. The Alberta Cancer Registry (ACR) identified patients with CRC diagnosed between January 1 and December 31, 2001. Patients with stage II/III CRC seen and/or treated at the CCI and later discharged to the community with follow-up recommendations based on American Society of Clinical Oncology guidelines were included. Carcinoembryonic antigen monitoring > or = every 4 months for > or = 2 years was deemed acceptable for study purposes. The ACR identified 152 stage II/III CRC cases meeting inclusion criteria. Eleven patients (7.2%) received the minimum predefined CEA follow-up. Eighty-seven CEA follow-up tests were elevated; only 20 (23%) elevated CEAs were investigated with predefined timely intervention. Twenty-six patients (17.1%) had documentable tumor recurrence. There was no difference in overall survival or time to recurrence between the groups who received and did not receive appropriate follow-up, although small numbers limit the effectiveness of statistical analysis. Post-therapy surveillance is important in CRC management. Our study reveals follow-up recommendations based on best available evidence for interval CEA testing are not followed in the community. These findings suggest the need for review of recommendations and change in management for monitoring discharged patients with stage II/III CRC.

Postsurgical surveillance: How intensive should it be?

The best target group for surveillance after curative surgery is the stage III and postcurative stage IV disease group of patients. Most patients who relapse will do so 3 to 5 years after surgery. Newer drugs might delay the relapse period. Overall, only a small number of patients will benefit. There is a need for large, well designed, randomized studies, but these are difficult to do. Additional techniques will have to be validated as they come along. A general recommendation at the present time could be: physician evaluation, carcinoembryonic antigen testing, liver imaging, and colonoscopy. The frequency of these modalities at 3 and 6 months seems reasonable knowing that there is no final survival advantage demonstrated by randomized studies as of yet.

Therapy of Colon Carcinoma: An Oncology Perspective

r Piotr Czaykowski is an Assistant Professor and MedicalOncologist, Department of Medical Oncology andHaematology, CancerCare Manitoba, Winnipeg.PA: As gastroenterologists we are often thephysicians that make the diagnosis of coloncancer…It seems that decisions about postop-erative therapy are based on this assessment. Isthis ideal at the present time?PC:There is no question that a medical oncolo-gist’s recommendation regarding the need for sys-temic therapy is heavily dependent on thestaging information gleaned in the initialworkup. We look for the following crucial ele-ments: Is the cancer localized? If localized, is itrectal or colon cancer? If localized, what is thestatus of the parameters that are linked with therisk of recurrence after surgery? If not localized,what is the extent of metastatic disease?Most commonly, the first investigation is anendoscopic evaluation of the cancer, and fre-quently this is performed by a gastroenterologist.This not only allows for confirmation of malig-nancy, but also proves crucial in helping medicaland radiation oncologists determine the need forradiotherapy in distal large bowel tumours.Although the definition of where the rectum ends and the sig-moid begins remains controversial, clinical trials commonlydefine the rectum as being the distal 12 cm to 15 cm of the largebowel, and most of us use that as our day-to-day reference point.If I start cursing in clinic, it is usually because I have an endo-scopic report that says rectal cancer (without any measurement),an operative note that calls the tumor rectosigmoid, and a com-puted tomography scan that calls it sigmoid. Because we only useradiotherapy routinely for rectal cancers, this question of locationbecomes an important one – so an explicit statement by theendoscopist of the location of the tumour is of great consequence.It is also helpful in advanced cancers to have some indication ofthe patency of the lumen.Even in this day and age, a surprising number of patientsundergo a primary bowel resection without adequate staging.This leads to some unnecessary surprises, and occasionally leadsto poor intraoperative choices. There appears to be an emergingconsensus that patients with extensive metastatic disease withrelatively asymptomatic primary tumours are probably best servedby commencing chemotherapy as soon as possible, and worryingabout the primary tumour later, if symptoms necessitate (1).Thus, the key staging investigations, often initiated by the gas-troenterologist, ideally should be done before resection of the pri-mary tumour, and should include chest imaging and a computedtomography scan of the abdomen and pelvis. A preoperative car-cinoembryonic antigen test (CEA) is helpful, primarily as a prog-nostic indicator (2). Because I am focusing on colon cancer, I willnot address the role of magnetic resonanceimaging and endoscopic ultrasound in stagingrectal cancer.When the patient does undergo surgery, gen-erally for apparently localized disease, it isimportant that the surgeon confirm that thereare no obvious metastases (and reports on this),and that he or she focuses on harvesting an ade-quate number of lymph nodes. It has been rec-ognized for some time that insufficient nodalsampling leads to under-staging; the exact num-ber of nodes necessary for accurate nodal stagingremains controversial but many centres use 12 asthe magic number. Clearly, finding an adequatenumber of nodes depends to some extent on thesurgeon, but it is also heavily reliant on thepathology team. Even if positive nodes are iden-tified, it appears to be important to remove asmany as possible, because there are now somedata that suggest the number and ratio of posi-tive nodes are also important in prognosis (3,4).Currently, there are no recommendationsfor the routine use of positron emission tomography scanningin apparently localized colon cancer. Those centres that haveready access most commonly use this modality for trying todetermine if a patient with metastatic disease can be consid-ered for resection of the metastases with curative intent.Similarly, the use of other tumour markers (for example CA19-9) and the use of molecular profiling (eg, looking formicrosatellite instability or for overexpression of vascularendothelial growth factor or epidermal growth factor) remainsthe domain of clinical trials for the most part.A problem across most of Canada is that there are often exces-sive delays in getting the patient through the whole process ofdiagnosis and treatment. In a recent review of 93 Manitobapatients with stage III colon cancer who received adjuvantchemotherapy, we found that of the 58 identified as having coloncancer before surgery, the median time from diagnosis to surgerywas 24 days, with 40% of patients waiting more than four weeks.After surgery, the median wait to start adjuvant chemotherapywas 55 days, with approximately one-third of this time reflectinga delay in referral to medical oncology.PA:Can you update us on the optimal oncology treatments forcolon cancer in Canada?PC: Although there are some minor variations amongprovinces, most seem to adhere to very similar standards. Because

Carcinoembryonic antigen (CEA) measurement during follow-up for rectal carcinoma is useful even if normal levels exist before surgery. A retrospective study of CEA values in the TME trial

Background Carcinoembryonic antigen (CEA) as a marker in the follow-up after curative resection of colorectal carcinoma (CRC) is often omitted from follow-up despite guideline recommendations. One reason is the assumption that when a normal CEA value exists before curative resection of CRC, it will neither rise during follow-up. This study investigates this relationship. Method Data were derived from a study initiated to evaluate treatment regimes for rectal carcinoma (Dutch TME trial, n = 1861) from which 954 were eligible for analysis. Recurrent disease occurred in 272 of these patients (29.5%). The pre-operative CEA value was compared to CEA values during follow-up, using threshold values of 2.5 and 5.0 ng/ml. Results Normal pre-operative CEA values were present in 63% (CEA < 5.0) and 39% (CEA < 2.5) of patients with recurrent disease. Patients with a normal pre-operative CEA and recurrent disease had elevated CEA values during follow-up in 41% (CEA < 5.0), 50% (CEA < 2.5) and in 60% with both threshold values when the last measurement was done within 3 months before recurrent disease was diagnosed. Conclusion A normal pre-operative CEA is common in patients with rectal carcinoma. CEA does rise due to recurrent disease in at least 50% of patients with normal pre-operative values. Serial post-operative CEA testing cannot be discarded based on a normal pre-operative serum CEA.

Combined Measurement of Hepatocyte Growth Factor and Carcinoembryonic Antigen as a Prognostic Marker for Patients with Dukes A and B Colorectal Cancer: Results of a Five-Year Study

There is no marker capable of differentiating patients with Dukes A and B colorectal cancer with aggressive diseases from those with indolent diseases. We evaluated the results of five years of actuarial survival data to determine whether serial monitoring of serum hepatocyte growth factor could provide prognostic information on these patients. Blood samples of 147 colorectal cancer patients were obtained and the serum concentration of hepatocyte growth factor was measured. Elevated serum hepatocyte growth factor levels were associated with stage progression. Although the overall positive rate of hepatocyte growth factor in the patients was the same as that of the carcinoembryonic antigen, the positive rate of hepatocyte growth factor in the Dukes A patients was two times higher than that of the carcinoembryonic antigen, and nearly 40 percent of the carcinoembryonic antigen-negative patients had a positive serum hepatocyte growth factor in the Dukes A and B classification. In this subgroup, patients with positive serum hepatocyte growth factor or carcinoembryonic antigen levels had a poorer prognosis, whereas positive serum hepatocyte growth factor level after surgery could predict disease recurrence. A combination of serum hepatocyte growth factor and carcinoembryonic antigen tests might be useful for selecting patients with aggressive diseases in Dukes A and B classification.

Strategies of follow-up for colorectal cancer: a survey of the American Society of Colon and Rectal Surgeons

The postoperative surveillance of patients who have undergone curative treatment for colorectal cancer (CRC) is controversial. The aim of this study was to investigate the follow-up practice of colorectal surgeons in the United States. A postal survey was sent to 1641 active members of the American Society of Colon and Rectal Surgeons practicing in the United States to assess the frequency of follow-up and the methods used in the surveillance of asymptomatic patients following curative surgery for CRC. Only 582 (36%) of the questionnaires that were sent were returned fully completed. Of these, 173 surgeons (30%) followed their patients according to guidelines. Ninety-four percent of surgeons during the first year and 81% during the second year saw their patients regularly every 3 or 6 months. The most widely used tests were colonoscopy and carcinoembryonic antigen (CEA) testing. There was wide discrepancy in the frequency of follow-up and techniques employed, with only about 50% of surgeons following recommended practice. Surveillance strategies mainly rely on clinical examination, CEA monitoring and colonoscopy. No clear consensus on surveillance programs for CRC patients exists.

Asymptomatic Liver Mass

Asymptomatic Liver Mass

Is Routine Magnetic Resonance Imaging Justified for the Early Detection of Resectable Liver Metastases From Colorectal Cancer?

This study was designed to determine whether routine follow-up by magnetic resonance imaging improves the detection of resectable liver metastases from colorectal cancer and patients' survival. Patients who underwent curative surgery for colorectal cancer were included in a program of liver surveillance by routine magnetic resonance imaging, in addition to the standard follow-up protocol consisting of clinical examination and biochemical tests. The median follow-up was 41 (interquartile range, 30-53) months, with a median magnetic resonance imaging surveillance period of 20 (interquartile range, 12-27) months. Cases were analyzed for mode of diagnosis, resectability, and overall survival. Liver metastases were found in 37 (13 percent) of 293 patients studied. Magnetic resonance imaging diagnosed hepatic metastases with 84 percent sensitivity and 90 percent specificity. In 28 (76 percent) patients, carcinoembryonic antigen and/or liver function tests were abnormally elevated and 5 patients (14 percent) were symptomatic. Hepatic resection was possible in only nine patients (24 percent). Magnetic resonance imaging detected all resectable cases, whereas traditional follow-up would have missed three (33 percent) cases suitable for surgery. Although magnetic resonance imaging surveillance increased the number of patients suitable for liver resection by 50 percent, these represented only 1 percent of the patients included in the study. Whether these results are enough to justify the allocation of expensive resources is controversial.

Imaging Techniques Contribute to Increased Surgical Rescue of Relapse in the Follow-Up of Colorectal Cancer

This study analyzes the results of a follow-up policy in colorectal cancer at our institution and evaluates the possible benefit provided by each test performed. Six hundred nineteen patients who had radical surgery and adjuvant treatment for colorectal cancer were followed up with a protocol that included carcinoembryonic antigen testing and clinical examination every three months for the first two years, every four months in the third year, and every six months in the fourth and fifth years. Chest X-ray and colonoscopy were performed yearly for five years and abdominal ultrasound was done every six months for the first three years and yearly afterward. Abdominopelvic computerized tomography was performed yearly for the first two years in cases with rectal cancer. If relapse was detected, all operable cases underwent surgery if possible. Between 1993 and 1999, 619 patients were followed-up. Mean follow-up was 66.9 months. Two hundred eight relapses were detected, 83.6 percent in the first three years and 73 (35.1 percent) underwent surgical resection. Carcinoembryonic antigen testing detected 44.2 percent of recurrences and 31.9 percent of them were operated on. Imaging techniques detected a lower percentage of recurrences (18.7 percent) but were more often resectable: 52 percent and 60 percent of the recurrences detected by computerized tomography and chest X-ray, respectively, underwent surgery. Median overall survival of patients with resected relapse was 62 months, significantly higher than those who were not operable (12.4 months). Imaging techniques in the surveillance of resected colorectal cancer contribute to early detection of relapse with a high proportion of operable metastatic disease.

Intensive Surveillance After Stage II or III Colorectal Cancer: Is It Worth It?

After treatment for a newly diagnosed stage II or III colorectal cancer, the patient— hoping the worst is over—focuses on restored physical vigor and self confidence while resuming pre-illness roles. Meanwhile, practitioners focus on orchestrating patient follow-up, knowing that some 30% to 40% will recur or develop a second bowel cancer. Most residual disease will manifest itself as recurrence within 3 years, and almost all cases will be diagnosed within 5 years of initial diagnosis. How good is the evidence for choosing what follow-up examinations to order? For years, prevailing wisdom was that early recurrence detection, including for colorectal cancers, is seldom useful. In this scenario, intensive testing leads to anxiety, financial burden, and seldom changes disease outcomes. In that circumstance, waiting for signs or symptoms, rather than detecting early disease manifestations is defensible, albeit somewhat paternalistic. Arguably, we spare patients the knowledge that they have a lethal disease and can husband scarce resources. However, for many discerning patients and physicians, particularly with respect to colorectal cancer, this minimalist approach has never been intellectually satisfying. Physical examination virtually never discerns early hepatic, lung, or anastomotic recurrence and carcinoembryonic antigen (CEA) is only elevated in 60% of patients with recurrence. Waiting for signs and symptoms seems contrary to instincts in life and medicine that early detection and prompt disease management is best. Also, despite the suspicion that tumor cells are embolic to many sites, some colorectal cancer patients develop a single or a few metastases, some amenable to curative surgical resection. Fong reported that a subset of 1,001 patients at Memorial SloanKettering Cancer Center with a single liver metastasis resected had cure rates as high as 60%. Other series have noted that lung lesions, as well as recurrence at the site of colonic anastamosis and second primary tumors, were potentially curable. With more effective chemotherapy and biologic therapies for colorectal cancer, the potential for cure with medical therapy alone, a singularly elusive end point in the past, may have come within reach. In the North Center Cancer Treatment Group N9741 study, patients with advanced colorectal cancer were randomly assigned to folinic acid, fluorouracil (FU), and oxaliplatin (FOLFOX), irinotecan, FU, and leucovorin (IFL), or irinotecan and oxaliplatin (IROX). Approximately 11% of patients treated with FOLFOX, of whom only a minority underwent resection, are alive at 4 years, suggesting that patients with metastatic disease may be long-term survivors with chemotherapy alone (unpublished data). These combined advances in diagnostics and treatments suggest early detection of recurrence could translate into a second chance for cure for some patients faced with recurrent or metastatic cancer. In 2000, the American Society of Clinical Oncology (ASCO) convened experts to make evidence-based recommendations on follow-up. Their conclusion was that periodic clinical evaluations with CEA testing and colonoscopy were justifiable, but that other testing added little additional benefit. Despite this recommendation, we all have anecdotal triumphs in our practices of relapsed patients cured when recurrent disease was extirpated, and want more such happy endings and the best and most efficient way to turn anecdotes into standard practice. Randomized trials of more intensive versus less intensive follow-ups have been hard to conduct, forcing decisions based on retrospective reviews and metaanalyses. Additionally, the continuous improvement in diagnostic and treatment technology suggests the need for reassessment of best strategies. In this setting, Rodriguez-Moranto et al report the results of their randomized trial of two different follow-up strategies in this issue. Their study enrolled 259 stage II or III colorectal cancer patients from three hospitals in Catalonia. Their simple strategy included medical history, physical examination, CBC, liver function tests, and CEA. Their intensive strategy included the simple strategy methods plus abdominal computed tomography (CT) or ultrasound imaging, chest x-ray, and colonoscopy. Work-up for signs or symptoms of recurrent disease was comparable in both study arms. After a median follow-up of 4 years from diagnosis, there is no significant survival difference between the two strategies (hazard ratio [HR] 0.87, P .62). In subset analysis, the 76 intensive strategy patients with stage II colon cancer (HR 0.34, P .045) and the 29 with rectal cancer (HR 0.09, P .03) had a survival advantage over the simple strategy stage II groups. In those patients with recurrence on the intensive strategy 51% (18 of 35) were amenable to resection compared to 29% (10 of 34) in the simple strategy. The Rodriguez-Moranto et al study has strengths and weaknesses, some of which are acknowledged in their discussion. By conducting the study in three institutions, the authors limited the number of participating radiologists, gastroenterologists, medical oncologists, and surgeons. The ineligibility rate was minimal and no patients were lost to follow-up. The analysis is carefully done JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 24 NUMBER 3 JANUARY 2

Do Increases in the Market Share of Managed Care Influence Quality of Cancer Care in the Fee-For-Service Sector?

Increases in the market share of managed care in an area are associated with decreases in expenditures in the fee-for-service sector (i.e., a spillover effect). Given concerns that these decreases in expenditures result from reductions in necessary care, we examined associations between increases in managed care market share and changes in the quality of care delivered to cancer patients in the fee-for-service sector. We studied a population-based sample of fee-for-service Medicare beneficiaries aged 66 years or older who were diagnosed with breast (N = 41,394) or colorectal (N = 48,027) cancer during 1993-1999. We used fixed effects regression analysis of SEER cancer registry and Medicare claims data to assess whether county-level increases in the market share of managed care over time were associated with the quality of cancer care. All statistical tests were two-sided. Increases in the market share of managed care were not associated with most quality indicators, including receipt of surveillance mammography after diagnosis for patients with breast cancer (P = .83), receipt of radiation after breast-conserving surgery among women who underwent breast-conserving surgery (P = .16), receipt of adjuvant chemotherapy for patients with stage III colorectal cancer (P = .94), or surveillance colonoscopy after treatment for colorectal cancer (P = .39). Increases in the market share of managed care were associated with increased rates of surveillance carcinoembryonic antigen testing for colorectal cancer patients (P = .001). Increases in managed care market share had limited or no effect on the quality of care for cancer patients. Concerns that increases in managed care would have large negative spillover effects on the quality of cancer care appear to be unfounded; however, the potential for managed care to stimulate improved quality throughout the medical care system have not yet been realized.

Cystic lesion of the pancreas

Cystic lesion of the pancreas

Artificial Neural Networks Analysis of Surface-Enhanced Laser Desorption/Ionization Mass Spectra of Serum Protein Pattern Distinguishes Colorectal Cancer from Healthy Population

The low specificity and sensitivity of the carcinoembryonic antigen test makes it not an ideal biomarker for the detection of colorectal cancer. We developed and evaluated a proteomic approach for the simultaneous detection and analysis of multiple proteins for distinguishing individuals with colorectal cancer from healthy individuals. We subjected serum samples (including 55 colorectal cancer patients and 92 age- and sex-matched healthy individuals) from 147 individuals, for analysis by surface-enhanced laser desorption/ionization (SELDI) mass spectrometry. Peaks were detected with Ciphergen SELDI software version 3.0. Using a multilayer artificial neural network with a back propagation algorithm, we developed a classifier for separating the colorectal cancer groups from the healthy groups. The artificial neural network classifier separated the colorectal cancer from the healthy samples, with a sensitivity of 91% and specificity of 93%. Four top-scored peaks, at m/z of 5,911, 8,930, 8,817, and 4,476, were finally selected as the potential "fingerprints" for detection of colorectal cancer. The combination of SELDI-TOF mass spectrometry with the artificial neural networks in the analysis of serum protein yields significantly higher sensitivity and specificity values for the detection and diagnosis of colorectal cancer.

1199 Carcinoembryonic antigen testing in colorectal cancer follow-up: a study of patients' attitudes and preferences

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Follow-up strategies after curative resection of colorectal cancer

Consensus is lacking as to the best strategy for following patients who have undergone definitive surgical medical treatment for colon cancer. The goal of any surveillance program should be detection of recurrent disease at a sufficiently early time to allow subsequent curative therapy. Although periodic clinical examinations, laboratory tests, radiographic imaging, and carcinoembryonic antigen (CEA) testing have been utilized as a form of surveillance, such aggressive and costly intervention has not been validated through clinical studies. Four of the five randomized trials comparing such an intensive surveillance strategy to less frequent testing have not demonstrated the intensive approach to lead to an improvement in overall survival. Furthermore, intensive testing is both costly and has been shown not to improve quality of life. Further research designing appropriate postoperative testing is needed to guide physicians and patients after the curative resection of a colorectal cancer.

Cancer physicians’ attitudes toward colorectal cancer follow-up

The optimal follow-up strategy for colorectal cancer is unknown. We surveyed all Canadian radiation oncologists, medical oncologists and surgeons specializing in colorectal cancer to assess their recommendations for follow-up after potentially curative treatment, the beliefs and attitudes underlying these practices, and the cost implications of different follow-up strategies. One hundred and sixty practitioners (58%) returned completed surveys. Most recommended clinical assessments every 3-4 months in the first 2 years including carcino-embryonic antigen testing, gradually decreasing in frequency over 5 years. Ninety per cent recommend a surveillance colonoscopy in the first year. The majority felt that specialist involvement in follow-up was important because of the increased opportunities for patients to contribute to research (76%) and teaching (73%). About half felt that specialists were more efficient at providing follow-up than primary care physicians, but these same physicians recommended significantly longer and more expensive follow-up routines on average than others. Primary care physicians were felt to be important allies, especially in managing the psychosocial concerns of patients. Surveillance practices are generally in keeping with published recommendations. Most specialists feel that they should remain involved in follow-up, but this may result in increased resource utilization.

Identifying patients at risk of early postoperative recurrence of lung cancer: a new use of the old CEA test

Background In the current study, we report the carcinoembryonic antigen (CEA) capability to predict early tumor relapses after a pulmonary resection for nonsmall cell lung cancer (NSCLC). Methods We studied 118 consecutive NSCLC patients who were clinically judged operable and were eventually operated upon. Anthropometric, clinical, and CEA data along with the results of both preoperative and postoperative stage classifications were recorded. All patients were followed up for at least 1 year after surgery and the time to the first clinical recurrence recorded. Receiver-operating characteristic (ROC) curves and diagnostic formulas were used for data analysis. Results In this series the CEA test was among the most accurate methods to predict an early postoperative recurrence (ROC area: 0.72, 95% confidence interval [CI]: 0.60 to 0.85, p = 0.001; accuracy rate for CEA at the threshold of 10 ng/mL: 83%, CI: 76% to 90%). Also predictive was the postoperative pathologic stage of disease (ROC area: 0.68, CI: 0.56 to 0.80, p = 0.007). In tumors pathologically classified in stage Ia to IIb, a preoperative CEA level higher than 10 ng/mL was associated with a 67% probability of tumor relapse. In the same stages of disease, a CEA level less than 10 ng/mL increased the baseline probability of no recurrence from 80% to 88%. Conclusions In operable patients with NSCLC the frequency of abnormal serum concentrations of CEA is low (17% in our series). However, it is important to identify such a small group of high-risk patients as many of them (in our study, 55% and 70% of those with a CEA value in excess of, respectively, 5 and 10 ng/mL) will develop an early postoperative recurrence. Such patients should be investigated preoperatively by mediastinoscopy or positron emission tomography in even in the absence of suspicious symptoms and signs. Then after an apparently successful operation, they should be carefully followed up. These patients could represent a suitable target for neoadjuvant clinical trials of selected high-risk groups.

Follow-up of patients with colorectal cancer: numbers needed to test and treat

Follow-up after curative treatment of patients with colorectal cancer has as its main aims the quality assessment of the treatment given, patient support, and improved outcome by the early detection and treatment of cancer recurrence. How often, and to what extent, the final aim, improved survival, is indeed realised is so far unclear. A literature search was performed to provide quantitative estimates for the main determinants of the effectiveness of the follow-up. Data were extracted from a total of 267 articles and databases, and were aggregated using modern meta-analytic methods. In order to provide one more colorectal cancer patient with long-term survival through follow-up, 360 positive follow-up tests and 11 operations for colorectal cancer recurrence are needed. In the remaining 359 tests and 10 operations, either no gains are achieved or harm is done. As the third aim of colorectal cancer follow-up, improved survival, is realised in only few patients, follow-up should focus less on diagnosis and treatment of recurrences. It should be of limited intensity and duration (3 years), and the search for preclinical cancer recurrence should primarily be performed by carcino-embryonic antigen (CEA) testing and ultrasound (US). The focus of colorectal cancer follow-up should shift from the early detection of recurrence towards quality assessment and patient support. As support that is as good or even better can be provided by a patient's general practitioner (GP) or by specialised nursing personnel, there is no need for routine follow-up to be performed by the surgeon.