Task Force Recommends Post-Operative Colonoscopy Over Endoscopy for Improved Outcomes in CRC

The US Multi-Society Task Force on Colorectal Cancer has released updated recommendations urging post-operative colonoscopy, instead of endoscopy, in patients with colorectal cancer (CRC) to improve overall survival. This follows a review of evidence that found second, concurrent cancers in 0.7% and 7% of individuals diagnosed with CRC.

The Task Force is composed of gastroenterology specialists with a special interest in colorectal cancer, representing the American Gastroenterological Association, the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy.

The updated guideline makes the following recommendations on the frequency of colonoscopy post-surgery:

• Either before cancer resection surgery or within 3 to 6 months after surgery
• One year after surgery or 1 year after the perioperative (pre-surgery) colonoscopy
• Four years after surgery or the perioperative colonoscopy
• Nine years after the perioperative colonoscopy

After 9 years, the Task Force recommends a 5-year interval between colonoscopies till the time that the diminishing life expectancy of the patient outweighs the benefit of a follow-up. If the imaging identifies pre-cancerous polyps, guidelines for polyp surveillance need to be followed.

"Patients who have had colorectal cancer resected for cure have a risk of recurrence of their colorectal cancer and also an increased risk of developing a second primary colorectal cancer. The main value of periodic colonoscopy for these patients is in preventing these second cancers. These recommendations are designed primarily to help physicians identify best practices in the use of colonoscopy after colorectal cancer resection," said Douglas K. Rex, MD, chair of the Task Force, in an e-mail response to The American Journal of Managed Care. Rex is also distinguished professor of medicine at Indiana University School of Medicine, and director of endoscopy at Indiana University Hospital.

Surveillance of Rectal Cancer

• For patients with rectal cancer (they are known to have a much greater risk of local recurrence) additional local surveillance is recommended with flexible sigmoidoscopy or endoscopic ultrasound, every 3 to 6 months for the first 2 to 3 years post surgery.
• Recommended colonoscopy surveillance for occurrence of secondary cancers.

Additional Surveillance

• In case of an obstructive CRC, computerized tomography (CT) colonography is recommended to exclude synchronous neoplasms. If patients do not have access to a CT colonography, double-contrast barium enema is recommended.
• The Task Force has recommended against routine fecal immunohistochemical tests or fecal DNA tests for surveillance citing insufficient evidence.

However, CMS, in its 2016 Physician Fee Schedule Final Rule, has finalized significant reductions in physician reimbursement for colonoscopies. According to the American Gastroenterological Association, payment for some colonoscopy procedures has been slashed by nearly 17%. Providers, meanwhile, are rallying against these deep cuts.

CRC is the third most common cancer in the United States across genders, and the American Cancer Society estimates 134,500 new cases and over 49,000 deaths in 2016.