Follow-up of Patients Operated on for Colorectal Carcinoma Jari Ovaska, Mo, Heikki J/irvinen, ~D, Helsinki, Finland, Harry Kujari, MD, Turku, Finland, Ilkka Perttil/i, MD, Jukka-Pekka Mecklin, No, nelsinki,Finland

In order to evaluate the effectiveness of follow-up in detecting potentially curable recurrences after radical surgery for colorectal cancer, we compared the results in 368 patients undergoing regular follow-up with those in 139 patients outside the follow-up program. The cancer-related 5-year survival rate was 72% in the follow-up group and 62% in the non-follow-up group (difference not significant). Cancer recurrences were more common in the follow-up group than in the group that was not followed ( 3 2 % versus 21%; p < 0 . 0 2 ) . Curative reoperations were performed in 2 1 % and 7%, respectively (p < 0 . 0 1 ) of patients with recurrent cancer in these two groups. The cancer-related 5year survival rate after curative reoperations was 47%. Despite these differences, only the initial Dukes' classification had an independent influence on the survival rate. It is concluded that regular follow-up detects more recurrent cancers, enabling radical reoperations significantly more often than when there is no follow-up. The outcome after curative reoperations is encouraging. These aspects favor regular followup of patients with colorectal carcinoma after curative operations.

ecurrent disease after curative surgery for colorectal cancer is a well-known problem, occurring in about R a third of all patients [1,2]. However, the results a f t e r curative reoperation have been encouraging, and in a recent publication of Fortner [3], even re-reoperation was recommended in the case of liver metastases. The main problem is how to detect the recurrences early enough to perform a curative reoperation. Different follow-up programs have been proposed [4-6], and the rate of curative reoperations has varied between 13% and 58%. The resuits of follow-up have been best in series with frequently From the SecondDepartmentof Surgery,HelsinkiUniversityCentral Hospital,Helsinki,Finland, and the Departmentof Pathology,University of Turku, Turku, Finland. Requestsfor reprintsshouldbe addressedto HeikkiJ/irvinen,MD, SecondDepartmentof Surgery,HelsinkiUniversityCentral Hospital, 00290 Helsinki,Finland. ManuscriptsubmittedMay 31, 1989,revisedAugust 14, 1989,and acceptedNovember1, 1989.

repeated determination of serum carcinoembryonic antigen (CEA) [7,8]. In 1987, we analyzed the effectiveness of our followup schedule after curative colorectal surgery. In that series, a curative reoperation was possible in 22% of the patients with recurrent disease [9]. In order to further evaluate the potential of our follow-up program to identify patients suitable for curative reoperation, we have now continued the follow-up for 2 more years and compared the results with those of patients outside the regular follow-up program. MATERIAL AND M E T H O D S Within the 10-year period from 1976 to 1985, 709 patients were treated primarily for colorectal carcinoma at the Second Department of Surgery, Helsinki University Central Hospital. Radical operative treatment (patients in Dukes' A to C classes) was possible in 527 cases. Seventeen patients (3.3%) died postoperatively. The remaining 510 patients were scheduled for a follow-up program (Table I). Besides the routine examinations presented in Table I, other clinically relevant studies such as abdominal ultrasonography, computed tomography, or colonoscopy were performed when appropriate. The follow-up data were completed from the hospital records in December 1988. Three hundred sixty-eight patients (72%) attended regularly scheduled follow-up visits, while 142 patients (28%) dropped out or were followed up elsewhere: 37 patients (7%) had some clinical check-ups by their private surgeons (schedules not known) and 102 others (20%) did not come to scheduled visits by their own decision. The follow-up data on these patients were obtained from the Official Census Registry of Finland, and in all cases in which the cause of death was unknown, the official death certificates were obtained from the Central Statistical Office of Finland. Patients with renewed abdominal symptoms and suspicion or verification of cancer recurrence have been referred to our clinic from the local medical units, and data concerning these patients were obtained from our hospital records. Three patients had left the country and were excluded from the study. Thus, the follow-up group consisted of 368 patients and the non-follow-up group consisted of 139 patients. The follow-up time was from 36 to 60 months, and 433 (85%) patients have been followed for 5 years or until death. The clinical data concerning sex, age, and classification of tumors into Dukes' stages according to the Australian clinco-pathological staging (ACPS) system [10] are presented in Table II for both groups. Recurrent tumors were always verified by histologic examination or cytologic fine-needle specimens. Reoperations were considered curative when all visible tumor tissue was removed

THE AMERICAN JOURNAL OF SURGERY VOLUME159 JUNE 1990 593

OVASKA ET AL

TABLE ! Follow-Up Schedule

Physical examination Blood chemistry CEA assay* Fecal occult blood X 3 Sigmoidoscopy (25 or 60 cm) Colography t Chest X-ray

..... 3

6

+ + + + + ---

+ + -I-I-I+ -I-

Months after Surgery 12 18 24 36 48 + + -I+ + + +

+ -I+ -I-t---

+ + + + + + -I-

Jr + + + h-I+

+ + + + + -I+

60 + q+ q-I+ 4-

* Available since 1980, l Colography performed once a year until 1983, but modified to examinations at 6, 24, and 60 months thereafter. CEA = carcinoembryonic antigen.

TABLE II Clinical Data of Patients In the Follow-Up and Non-Follow-Up Groups Clinical Data

Follow-Up (n = 368)

Non-Follow-Up (n = 139)

Men Women Age (range) Dukes' class A B C

186 (51%) 182 (49 %) 62.8 (26-88)"

53 (38%) 86 (62 %) 67.4 (22-88) ~

99 (27%) 202 (55%) 67 (18%)

39 (28%) 76 (55%) 24 (17%)

* This difference is statistically significant (p

24

36

48

Figure 1. Cancer-related 5-year survival rate in the follow-up (thick line) and non-follow-up (thin line) groups.

and subsequent microscopy confirmed tumor-free surgical margins. Statistical calculations were performed with BMDP computer programs (BMDP Statistical Software, Department of Biomathematics, University of California, Los Angeles, CA). All p values are two-tailedl Frequency tables were analyzed with the chi-square test, and Fisher's exact test of probability was used when appropriate; Yates' continuity correlation was used in chi-square calTHE AMERICAN JOURNAL OFSURGERY

RESULTS The cancer-related 5-year survival rate in the followup group was 72% 4- 2% (mean 4- SE) and in the nonfollow-up group, 62% 4- 5% (mean 4- SE) (Figure 1). This difference was not statistically significant (p = 0.13). By the Cox's proportional hazard model, concerning the corrected survival rate in the relation to age at the cancer surgery, Dukes' classification, and the follow-up status, only Dukes' classification proved to be a highly significant (p