Z. S. Dawood1, Z. Moazzam1,2, L. Alaimo2, Y. Endo2, H. A. Lima2, C. F. Shaikh2, M. M. Munir1,2, J. Beane2, A. Ejaz2, M. Dillhoff2, J. Cloyd2, T. M. Pawlik2 1Aga Khan University Medical College, Department Of Surgery, Karachi, Sindh, Pakistan 2Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Department Of Surgery, Columbus, OH, USA
Introduction:
Almost one-third of patients with colorectal cancer (CRC) experience recurrence after surgical resection. Although postoperative surveillance strategies aid in the early detection of recurrent disease, adherence to surveillance guidelines largely dictate their efficacy. We sought to systematically assess and compare adherence to postoperative surveillance guidelines related to carcinoembryonic antigen (CEA), imaging (abdominal CT scan, ultrasound, and chest x-ray) and colonoscopy.
Methods:
PubMed, Medline, Embase, Scopus, Cochrane, Web of Science, and CINAHL were systematically searched for cross-sectional studies, cohort studies and randomized control trials conducted between 1990-2022. The Newcastle Ottawa Scale was used to assess the methodological quality of the included studies. We performed a random-effects meta-analysis and compared the pooled adherence for each surveillance strategy.
Results:
Fifteen studies with a total of 55,776 patients met inclusion criteria and were included in the meta-analysis. Overall, adherence with colonoscopy guidelines was the highest (71%; 95%CI 68%-74%) followed by compliance with imaging (59%; 95%CI 44%-74%) and CEA (54%; 95%CI 43%-66%) guidelines (Figure). Among the 8/15 (53.3%) studies that specifically examined adherence to the American Society of Clinical Oncology (ASCO) guidelines, adherence to colonoscopy recommendations was highest (73%; 95% CI 70%-76%); in contrast, only roughly one-half of patients had goal-compliant surveillance imaging (52%; 95%CI 41%-64%) or CEA levels (45%; 95%CI 37%-52%). Of note, guideline adherence to CEA was much lower than compliance with colonoscopy recommendations among patients with colon (OR 0.21; 95%CI 0.20-0.22) and rectal (OR 0.25; 95%CI 0.23-0.28) cancer (both p<0.05). In fact, guideline adherence to CEA was lower than colonoscopy among most patient groups, including the elderly (OR 0.23; 95%CI 0.22-0.24), as well as patients with stage II (OR 0.18; 95%CI 0.05-0.71) and III (OR 0.36; 95%CI 0.34-0.39) disease (all p<0.005). Of note, guideline adherence to CEA was also lower than compliance with imaging recommendations among elderly patients (OR=0.62; 95%CI 0.42-0.93), as well as patients with stage II (OR=0.80; 95%CI 0.76-0.84) and III (OR=0.88; 95%CI 0.82-0.94) disease (all p<0.005).
Conclusion:
While guideline adherence with postoperative surveillance colonoscopy was high, adherence to both surveillance CEA and imaging was markedly lower following colorectal cancer resection. Greater emphasis on surveillance guideline adherence among health care providers is needed in order to maximize post-operative follow-up of colorectal cancer patients.
