How to identify patients who are less likely to have metachronous neoplasms after a colon cancer: a predictive model

Abstract

Background Patients with prior colon cancer have increased risk of metachronous colorectal neoplasms; therefore, endoscopic surveillance is indicated. Current recommendations are not risk-stratified. We investigated predictive factors for colorectal neoplasms to build a model to spare colonoscopies for low-risk patients.

Methods This was a multicenter, retrospective study including patients who underwent surgery for colon cancer in 2001 – 2008 (derivation cohort) and 2009 – 2013 (validation cohort). A predictive model for neoplasm occurrence at second surveillance colonoscopy was developed and validated.

Results 421 and 203 patients were included in derivation and validation cohort, respectively. At second surveillance colonoscopy, 112 (26.6 %) and 55 (27.1 %) patients had metachronous neoplasms in derivation and validation groups; three cancers were detected in the latter. History of left-sided colon cancer (OR 1.64, 95 %CI 1.02 – 2.64), ≥ 1 advanced adenoma at index colonoscopy (OR 1.90, 95 %CI 1.05 – 3.43), and ≥ 1 adenoma at first surveillance colonoscopy (OR 2.06, 95 %CI 1.29 – 3.27) were independently predictive of metachronous colorectal neoplasms at second surveillance colonoscopy. For patients without such risk factors, diagnostic accuracy parameters were: 89.3 % (95 %CI 82.0 %-94.3 %) and 78.2 % (95 %CI 65.0 %-88.2 %) sensitivity, and 28.5 % (95 %CI 23.5 %-33.9 %) and 33.8 % (95 %CI 26.2 %-42.0 %) specificity in derivation and validation group, respectively. No cancer would be missed.

Conclusions Patients with prior left-sided colon cancer or ≥ 1 advanced adenoma at index colonoscopy or ≥ 1 adenoma at first surveillance colonoscopy had a significantly higher risk of neoplasms at second surveillance colonoscopy; patients without such factors had much lower risk and could safely skip the second surveillance colonoscopy. A prospective, multicenter validation study is needed.

• References

• 1 Arnold M, Sierra MS, Laversanne M. et al. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2017; 66: 683-691
• 2 Kjeldsen BJ, Kronborg O, Fenger C. et al. A prospective randomized study of follow-up after radical surgery for colorectal cancer. Br J Surg 1997; 84: 666-669
• 3 Kahi CJ, Boland CR, Dominitz JA. et al. Colonoscopy surveillance after colorectal cancer resection: recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2016; 150: 758-768.e11
• 4 Hassan C, Wysocki P, Fuccio L. et al. Endoscopic surveillance after surgical or endoscopic resection for colorectal cancer: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Digestive Oncology (ESDO) Guideline. Endoscopy 2019; 51: 266-277
• 5 Kjeldsen BJ, Kronborg O, Fenger C. et al. The pattern of recurrent colorectal cancer in a prospective randomised study and the characteristics of diagnostic tests. Int J Colorectal Dis 1997; 12: 329-334
• 6 Mäkelä JT, Laitinen SO, Kairaluoma MI. Five-year follow-up after radical surgery for colorectal cancer. Results of a prospective randomized trial. Arch Surg 1995; 130: 1062-1067
• 7 Ohlsson B, Breland U, Ekberg H. et al. Follow-up after curative surgery for colorectal carcinoma. Randomized comparison with no follow-up. Dis Colon Rectum 1995; 38: 619-626
• 8 Fuccio L, Spada C, Frazzoni L. et al. Higher adenoma recurrence rate after left- versus right-sided colectomy for colon cancer. Gastrointest Endosc 2015; 82: 337-343
• 9 Rex DK, Kahi CJ, Levin B. et al. Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2006; 130: 1865-1871
• 10 Strum WB. Colorectal adenomas. N Engl J Med 2016; 374: 1065-1075
• 11 Collins GS, Reitsma JB, Altman DG. et al. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. Ann Intern Med 2015; 162: 55-63
• 12 Moons KGM, Altman DG, Reitsma JB. et al. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med 2015; 162: W1-W73
• 13 Demidenko E. Sample size determination for logistic regression revisited. Stat Med 2007; 26: 3385-3397
• 14 Faul F, Erdfelder E, Lang AG. et al. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39: 175-191
• 15 Hassan C, Wysocki PT, Fuccio L. et al. Endoscopic surveillance after surgical or endoscopic resection for colorectal cancer: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Digestive Oncology (ESDO) Guideline. Endoscopy 2019; 51: 266-277
• 16 Tjandra JJ, Chan MKY. Follow-up after curative resection of colorectal cancer: a meta-analysis. Dis Colon Rectum 2007; 50: 1783-1799
• 17 Wang T, Cui Y, Huang W-S. et al. The role of postoperative colonoscopic surveillance after radical surgery for colorectal cancer: a prospective, randomized clinical study. Gastrointest Endosc 2009; 69: 609-615
• 18 Cone MM, Beck DE, Hicks TE. et al. Timing of colonoscopy after resection for colorectal cancer: are we looking too soon?. Dis Colon Rectum 2013; 56: 1233-1236
• 19 Fuccio L, Rex D, Ponchon T. et al. New and recurrent colorectal cancers after resection: a systematic review and meta-analysis of endoscopic surveillance studies. Gastroenterology 2019; 156: 1309-1323.e3
• 20 Radaelli F, Paggi S, Hassan C. et al. Split-dose preparation for colonoscopy increases adenoma detection rate: a randomised controlled trial in an organised screening programme. Gut 2017; 66: 270-277
• 21 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
• 22 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
• 23 Kaminski M, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397
• 24 Mulder SA, Kranse R, Damhuis RA. et al. The incidence and risk factors of metachronous colorectal cancer: an indication for follow-up. Dis Colon Rectum 2012; 55: 522-531
• 25 Gervaz P, Bucher P, Morel P. Two colons-two cancers: paradigm shift and clinical implications. J Surg Oncol 2004; 88: 261-266
• 26 Moritani K, Hasegawa H, Okabayashi K. et al. Difference in the recurrence rate between right- and left-sided colon cancer: a 17-year experience at a single institution. Surg Today 2014; 44: 1685-1691
• 27 Gracie DJ, Kane JS, Mumtaz S. et al. Prevalence of, and predictors of, bile acid malabsorption in outpatients with chronic diarrhea. Neurogastroenterol Motil 2012; 24: 983-e538
• 28 Moon CM, Cheon JH, Choi EH. et al. Advanced synchronous adenoma but not simple adenoma predicts the future development of metachronous neoplasia in patients with resected colorectal cancer. J Clin Gastroenterol 2010; 44: 495-501