December
1990
SELECTED SUMMARIES
symptoms. The authors did find two groups in which specific symptoms and motor abnormalities seemed to be associated-those with tonic duodenal contractions occurring at the same time as abdominal pain and vomiting and those with PPHM in whom a liquid meal caused distention and diaphoresis. Others have found instances of an association between certain motor responses and specific symptoms (Gut 1988;29:1236-1243) but the true incidence remains unclear. To address this problem, prospective studies with predefined groups of patients and manometric patterns will be necessary. In the present studies, the authors’ main goal appears to be to demonstrate the possibility of using antromanometry to study children with undiagnosed GI problems: they have succeeded in showing this. Understanding of these complex relationships, however, will be enhanced by studies of better-characterized subgroups of patients, preferably free of prior surgery, and by a clear concept of the meaning we are attaching to the term “functional disease.” J. SWEETING, M.D. Reply. In his critique, Dr. Sweeting devotes considerable attention to the use of the term “functional.” This term is confusing when it is not carefully defined. We used the term to indicate that the children had no anatomical, physiological, biochemical, or psychiatric abnormalities to account for their symptoms based on the “usual” tests. We purposely shunned the use of another confusing term, chronic intestinal pseudoobstruction, in an attempt to avoid just this kind of semantic wrestling. We believe that energy should be focused not on semantics but on the data that are beginning to define a new taxonomy for motility disorders. We are learning by doing, and antroduodenal manometry is one more tool toward understanding previously unexplained or misunderstood symptoms, It seems that the more studies we do, the more we understand about the meaning of manometric patterns. Sorting abnormalities into “myogenic” or “neurogenic” types is heuristic and undoubtedly an oversimplification, but it has a rational basis. We anticipate that this primitive classification scheme will be refined as newly accrued data are analyzed. Although there were only a few instances in which a discrete manometric abnormality correlated in time with symptoms, there was an excellent correlation between the severity of manometric disorganization and the severity of symptoms. By the time children are referred for manometry, their parents have a specific agenda. They ask three questions about the condition affecting their child: What is it? Will it go away? What can we do about it? Many patients arrive with a diagnosis that begins with “idiopathic . .‘Ior without a diagnosis at all. Many parents are guiltridden and full of doubts about their competence because they understood their doctors to say that there was no reason for their child’s symptoms. Creating a manometric taxonomy of motility disorders will help answer their first question and ease some of the fears associated with fighting an unknown, unnamed disease. Longitudinal studies of these children will help answer the next two.
There is an organization that provides a network of information and support for both adults and children with intestinal motility disorders. For more information, write or cell the North American Pediatric Pseudo-obstruction Society (NAPPS). P.O. Box 772, Medford, Massachusetts 02155; phone, (617) 395-4255. P. E. HYMAN, T. Q. GARVEY
M.D.
III, M.D.
SURVEILLANCE AFTER COLON CANCER: IS IT WORTHWHILE? Ovaska J, Jarvinen H, Kujari N, et al. [Second Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland; and Department of Pathology, University of Turku,
Turku, Finland). Follow-up of patients operated colorectal carcinoma. Am J Surg 1990;159:593-596.
1849
on for
To evaluate the potential of a follow-up program for identifying patients with recurrent colorectal cancer suitable for reoperation, 507 patients were entered into such a program after radical colon resection. Of these, 368 (72%) patients returned for regular follow-up visits and are herein known as the follow-up (F/U) group. The remaining 139 (27%) patients either chose not to be followed up or returned to their private physicians, and together they make up the no-follow-up (no-F/U) group. Follow-up time was 36-60 months, and 433 (85%) patients were followed up for 5 years or until death. The data were obtained through retrospective review of hospital records, the Official Census Registry of Finland, and death certificates obtained from the Central Statistical Office of Finland. The F/U group consisted of 186 men and 182 women with a mean age of 62.8 years, while the no-F/U group comprised 58 men and 86 women with a mean age of 67.4 years. Only the difference in age was statistically significant. The two groups were identical with respect to Dukes’ classification of the primary tumors. Patients in the F/U group underwent physical examination, blood chemistries, plasma carcinoembryonic antigen JCEA) assay, fecal occult blood testing (FOBT), and sigmoidoscopy every 3-12 months and colography and chest radiography at 6.24, and 60 months. One hundred twelve (32%) patients undergoing regular follow-up were subsequently found to have recurrent colon cancer; 83% of these were asymptomatic, while 30 (21%) patients in the no-F/U group developed recurrent cancer with these being identified as a result of symptoms (P c: 0.02). Of these patients, 25 (7%) patients in F/U group and 2 (1%) in the no-F/U group could undergo second curative resections (P c 0.01). Overall, the cancer-related 5-year survival rate was 72% for the F/U group as compared with 62% for the no-F/U group (P = 0.13), but 5-year survival after curative reoperation was 47%, and disease-free 5-year survival was 41%. A new primary (metachronous colorectal) cancer was detected in 12 (3%) patients in the F/U group and 2 (1%) patients in the no-F/U group (P = 0.43). The authors conclude that the follow-up program resulted in a significant increase in radical reoperations in cases of cancer recurrence compared with patients not in the follow-up program. They attribute the higher rate of recurrence detection in the F/U group to early detection (asymptomatic patients] on the basis of elevated CEA values. They recommend more frequent use of serial CEA assays with shorter intervals to detect asymptomatic recurrences and close follow-up with colonoscopy for detection of metachronous cancers as well as premalignant lesions. Comment. Despite attempts to improve diagnostic techniques of early detection and surgical cure rates, the likelihood of cancer recurrence following curative resection for colorectal cancer remains at about 30%-40% overall and even higher for the advanced stages (Br J Surg 1982$X725-728]. The nonsurgical modes of treatment, chemotherapy and radiation, have been considered merely palliative therapy because their curative rates remain quite low. The concept of continued clinical follow-up of patients after
1850 SELECTED SUMMARIES
curative resection of colorectal cancer developed from the belief by some that patients with recurrent colorectal cancer could be operated on again for potential cure. Many doctors continue to recommend postoperative follow-up with scheduled visits, blood tests, and radiologic and endoscopic studies in the hope of discovering asymptomatic recurrent or metachronous cancers. This issue of postoperative follow-up is not universally accepted, and even today the methods, cost, and overall benefit of follow-up remain a controversy. In the 1950s. second-look laparotomy arose as a method of potential cure of recurrent colon cancer. Wangensteen hypothesized that a second-look operation within 6 months of primary resection, with the removal of any residual or recurrent disease, would offer the best chances of cure (Lancet 1951;1:303-307). After performing second-look operations on patients undergoing resections for gastric, colonic, and rectal, cancer Staab et al. concluded that patients with colonic cancer benefitted the most from secondlook operations and that the optimal timing for reoperation was t6 months (Am J Surg 1965;149:196-204). As a result of these and other studies, many clinicians began routine follow-up programs for colonic cancer patients. The subsequent experience of other groups has varied, with some showing better survival rates following second-look operations and others concluding that the procedure is of no benefit (Br Med J 1980;260:593-595). At issue are the lack of efficacy of the timeconsuming office follow-up, the high rate of negative second-look operations, and the lack of demonstrated benefit of these surgical procedures. Tornqvist and colleagues prospectively followed patients after curative surgery for colorectal cancer and found a recurrence rate of 33%. a rate of reoperation for cure of only 13%, and a survival after reoperation of 53% at 9-41 months. They found that more intensive clinical follow-up would permit earlier detection of a recurrence, but because no effective treatment was available for disseminated disease, that follow-up of colon cancer patients would not necessarily lead to a better outcome (Br J Surg 1982:69:725-728). In this series, the most common sites of recurrence were liver (26%). lung (19%), pelvis (18%), anastomosis (15%], and multiple organs (14%). The investigators also looked at five other studies that reported reoperation for cure rates of only 5%-20%. At the time of these reports in the 1970s major hepatic resection for metastatic colon cancer was not routinely performed; presumably, a substantial number of patients were not offered the curative operations that would be performed today. Since the early 1980s reoperation for resection of liver metastases has become more common and has demonstrated reasonable success [Am J Surg 1988:155:378-382). In addition, the plasma CEA assay has become more widely used. This antigen has provided a more sensitive marker of recurrent disease, and therefore has increased the chances of detecting asymptomatic recurrences earlier. In 1985, Martin showed that when an increase in the CEA level above baseline was used as an indicator of recurrent disease in 146 patients followed up after curative resection for colorecta1 cancer, 95% of those with elevated CEA levels could be shown to have recurrence when evaluated with chest radiographs, liver-spleen scans, colonoscopy, bone scans, computed tomography (CT] scans, or hepatic arteriography (Ann Surg 1985;202:310-317). Of detected recurrences, 58% could have additional surgery and be resected for potential cure. The 5-year survival after reoperation was 31%. Based on these findings, Martin suggested that the CEA assay was the best tool for surveillance of colon cancer recurrence and that an interval of 1-2 months during the first 2 years after the initial surgical procedure would permit the best timing for earliest detection and reoperation. Similarly, Sugarbaker and colleagues showed that routine follow-up using CT scanning, lung tomography, and liver-spleen scanning were of little benefit in the routine screening of patients
GASTROENTEROLOGY
Vol. 99. No. 6
following resection (Surgery 1987;102:79-87). They found that serial CEA assays and routine history and physical examinations were most effective in early detection of colonic cancer recurrence. A progressive increase in CEA level detected 67% of recurrences, and an abnormal review of symptoms or physical examination picked up 21%, while CT scans, bone scans, and lung tomograms detected 13% of recurrences each. Studies have shown that hepatic metastases of colorectal cancer are resectable for cure if they are solitary, localized to a single lobe, or scattered but easily removed by wedge resections. In Former’s series of 380 patients, 33% were resectable by major hepatic resection or wedge resection. The 30-day operative mortality was 4.8%, and survival estimates for the 77 patients who had curative resections were 95%. 65%, and 49% at 1, 3, and 5 years, with a median survival estimate of 59 months [Am J Surg 1988;155:378382). On the other side of the argument, Kievit et al recently challenged the use of CEA to monitor patients following curative resection of colorectal cancer. Based on a Markov analysis, they believe that the influence of CEA on quality-adjusted life expectancy is marginal. They state that CEA monitoring should not be performed because the cost of follow-up, work-up, and reoperation of a patient based on an elevated CEA can be quite high, whereas the benefits in terms of days in extended life expectancy may be minimal (Cancer 1990;65:2580-2587). Although the current study supports the concept of careful follow-up, the rationale for the surveillance and work-up of patients following curative colorectal cancer surgery still is not fully accepted. The proper and timely use of the routine office visit and CEA assay is certainly of benefit in the early detection of recurrent colorectal cancer, but its utility and that of the second-look operation can only be demonstrated by improved survival of a greater number of patients. To date, most studies have shown that the greater predictor of survival is the patient’s initial Dukes’ staging and, although reoperation and removal of recurrent disease may permit some with recurrent cancer to live longer, for the group as a whole, second-look surgery does little to improve overall prognosis as initially predicted by Dukes’ staging. Improved surgical techniques have permitted better survival, as reported by a few centers, but major hepatic resection for metastatic disease is available only at those specialized centers. Those recurrences, particularly at the anastomosis and metachronous lesions, should not go unnoticed and untreated with the current ease of detection by colonoscopy. However, major hepatic resection should be performed only by experienced liver surgeons. In the past 30 years there has been progress in the diagnosis and treatment of colorectal cancer and its recurrences, but there is still much to learn. Surgery with curative intent is not likely to be effective in patients with multiple sites of metastatic disease. most pelvic wall recurrences, and pulmonary and skeletal recurrences because these are all indicators of widespread dissemination. However, for local, anastomotic recurrences, hepatic metastases, and some pelvic walI recurrences, reoperation does offer a second chance for cure. To date only one study of adjuvant chemotherapy has shown a ray of hope for these patients. A recent report by Moertel et al. shows a 41% reduction in the risk of recurrence in Dukes’ C patients (P < 0.0001) and a 33% reduction in the death rate (P (c 0.006) by 3 years in the same group (N Engl J Med 1990;322:352358). No clear benefit could be demonstrated for Dukes’ B2 patients. While we await breakthroughs in the management of colonic cancer, we must continue to promote means of prevention and early detection because the early stages of colorectal cancer are those most likely to be cured. Sigmoidoscopy and FOBT are useful for early detection, but currently too many patients are missed by virtue of their entering the health care system in the later stages of disease, only after symptoms have developed. Education of the public, as well as continued screening and case finding by primary clinicians,
December 1898
should help reduce the numbers of patients presenting at later stages. Similarly, after curative surgery for colorectal cancer, patients should undergo close follow-up with regular physical examination, CBA assays, FOBT, and endoscopic examinations of the colon. Although data are still being accumulated with regard to long-term patient follow-up, the World Health Organization (WHO) recommends colonoscopy or flexible sigmoidoscopy combined with
SELECTED SUMMARIES
1851
air-contrast barium enema approximately every 8 years after establishment of a “clean colon” (Winawer SJ, WHO, in press). The close follow-up of patients after curative colorectal surgery is likely to be beneficial, especially if an experienced surgeon is able to resect the recurrent disease. H. GERDES, M.D.
1990
SELECTED SUMMARIES
symptoms. The authors did find two groups in which specific symptoms and motor abnormalities seemed to be associated-those with tonic duodenal contractions occurring at the same time as abdominal pain and vomiting and those with PPHM in whom a liquid meal caused distention and diaphoresis. Others have found instances of an association between certain motor responses and specific symptoms (Gut 1988;29:1236-1243) but the true incidence remains unclear. To address this problem, prospective studies with predefined groups of patients and manometric patterns will be necessary. In the present studies, the authors’ main goal appears to be to demonstrate the possibility of using antromanometry to study children with undiagnosed GI problems: they have succeeded in showing this. Understanding of these complex relationships, however, will be enhanced by studies of better-characterized subgroups of patients, preferably free of prior surgery, and by a clear concept of the meaning we are attaching to the term “functional disease.” J. SWEETING, M.D. Reply. In his critique, Dr. Sweeting devotes considerable attention to the use of the term “functional.” This term is confusing when it is not carefully defined. We used the term to indicate that the children had no anatomical, physiological, biochemical, or psychiatric abnormalities to account for their symptoms based on the “usual” tests. We purposely shunned the use of another confusing term, chronic intestinal pseudoobstruction, in an attempt to avoid just this kind of semantic wrestling. We believe that energy should be focused not on semantics but on the data that are beginning to define a new taxonomy for motility disorders. We are learning by doing, and antroduodenal manometry is one more tool toward understanding previously unexplained or misunderstood symptoms, It seems that the more studies we do, the more we understand about the meaning of manometric patterns. Sorting abnormalities into “myogenic” or “neurogenic” types is heuristic and undoubtedly an oversimplification, but it has a rational basis. We anticipate that this primitive classification scheme will be refined as newly accrued data are analyzed. Although there were only a few instances in which a discrete manometric abnormality correlated in time with symptoms, there was an excellent correlation between the severity of manometric disorganization and the severity of symptoms. By the time children are referred for manometry, their parents have a specific agenda. They ask three questions about the condition affecting their child: What is it? Will it go away? What can we do about it? Many patients arrive with a diagnosis that begins with “idiopathic . .‘Ior without a diagnosis at all. Many parents are guiltridden and full of doubts about their competence because they understood their doctors to say that there was no reason for their child’s symptoms. Creating a manometric taxonomy of motility disorders will help answer their first question and ease some of the fears associated with fighting an unknown, unnamed disease. Longitudinal studies of these children will help answer the next two.
There is an organization that provides a network of information and support for both adults and children with intestinal motility disorders. For more information, write or cell the North American Pediatric Pseudo-obstruction Society (NAPPS). P.O. Box 772, Medford, Massachusetts 02155; phone, (617) 395-4255. P. E. HYMAN, T. Q. GARVEY
M.D.
III, M.D.
SURVEILLANCE AFTER COLON CANCER: IS IT WORTHWHILE? Ovaska J, Jarvinen H, Kujari N, et al. [Second Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland; and Department of Pathology, University of Turku,
Turku, Finland). Follow-up of patients operated colorectal carcinoma. Am J Surg 1990;159:593-596.
1849
on for
To evaluate the potential of a follow-up program for identifying patients with recurrent colorectal cancer suitable for reoperation, 507 patients were entered into such a program after radical colon resection. Of these, 368 (72%) patients returned for regular follow-up visits and are herein known as the follow-up (F/U) group. The remaining 139 (27%) patients either chose not to be followed up or returned to their private physicians, and together they make up the no-follow-up (no-F/U) group. Follow-up time was 36-60 months, and 433 (85%) patients were followed up for 5 years or until death. The data were obtained through retrospective review of hospital records, the Official Census Registry of Finland, and death certificates obtained from the Central Statistical Office of Finland. The F/U group consisted of 186 men and 182 women with a mean age of 62.8 years, while the no-F/U group comprised 58 men and 86 women with a mean age of 67.4 years. Only the difference in age was statistically significant. The two groups were identical with respect to Dukes’ classification of the primary tumors. Patients in the F/U group underwent physical examination, blood chemistries, plasma carcinoembryonic antigen JCEA) assay, fecal occult blood testing (FOBT), and sigmoidoscopy every 3-12 months and colography and chest radiography at 6.24, and 60 months. One hundred twelve (32%) patients undergoing regular follow-up were subsequently found to have recurrent colon cancer; 83% of these were asymptomatic, while 30 (21%) patients in the no-F/U group developed recurrent cancer with these being identified as a result of symptoms (P c: 0.02). Of these patients, 25 (7%) patients in F/U group and 2 (1%) in the no-F/U group could undergo second curative resections (P c 0.01). Overall, the cancer-related 5-year survival rate was 72% for the F/U group as compared with 62% for the no-F/U group (P = 0.13), but 5-year survival after curative reoperation was 47%, and disease-free 5-year survival was 41%. A new primary (metachronous colorectal) cancer was detected in 12 (3%) patients in the F/U group and 2 (1%) patients in the no-F/U group (P = 0.43). The authors conclude that the follow-up program resulted in a significant increase in radical reoperations in cases of cancer recurrence compared with patients not in the follow-up program. They attribute the higher rate of recurrence detection in the F/U group to early detection (asymptomatic patients] on the basis of elevated CEA values. They recommend more frequent use of serial CEA assays with shorter intervals to detect asymptomatic recurrences and close follow-up with colonoscopy for detection of metachronous cancers as well as premalignant lesions. Comment. Despite attempts to improve diagnostic techniques of early detection and surgical cure rates, the likelihood of cancer recurrence following curative resection for colorectal cancer remains at about 30%-40% overall and even higher for the advanced stages (Br J Surg 1982$X725-728]. The nonsurgical modes of treatment, chemotherapy and radiation, have been considered merely palliative therapy because their curative rates remain quite low. The concept of continued clinical follow-up of patients after
1850 SELECTED SUMMARIES
curative resection of colorectal cancer developed from the belief by some that patients with recurrent colorectal cancer could be operated on again for potential cure. Many doctors continue to recommend postoperative follow-up with scheduled visits, blood tests, and radiologic and endoscopic studies in the hope of discovering asymptomatic recurrent or metachronous cancers. This issue of postoperative follow-up is not universally accepted, and even today the methods, cost, and overall benefit of follow-up remain a controversy. In the 1950s. second-look laparotomy arose as a method of potential cure of recurrent colon cancer. Wangensteen hypothesized that a second-look operation within 6 months of primary resection, with the removal of any residual or recurrent disease, would offer the best chances of cure (Lancet 1951;1:303-307). After performing second-look operations on patients undergoing resections for gastric, colonic, and rectal, cancer Staab et al. concluded that patients with colonic cancer benefitted the most from secondlook operations and that the optimal timing for reoperation was t6 months (Am J Surg 1965;149:196-204). As a result of these and other studies, many clinicians began routine follow-up programs for colonic cancer patients. The subsequent experience of other groups has varied, with some showing better survival rates following second-look operations and others concluding that the procedure is of no benefit (Br Med J 1980;260:593-595). At issue are the lack of efficacy of the timeconsuming office follow-up, the high rate of negative second-look operations, and the lack of demonstrated benefit of these surgical procedures. Tornqvist and colleagues prospectively followed patients after curative surgery for colorectal cancer and found a recurrence rate of 33%. a rate of reoperation for cure of only 13%, and a survival after reoperation of 53% at 9-41 months. They found that more intensive clinical follow-up would permit earlier detection of a recurrence, but because no effective treatment was available for disseminated disease, that follow-up of colon cancer patients would not necessarily lead to a better outcome (Br J Surg 1982:69:725-728). In this series, the most common sites of recurrence were liver (26%). lung (19%), pelvis (18%), anastomosis (15%], and multiple organs (14%). The investigators also looked at five other studies that reported reoperation for cure rates of only 5%-20%. At the time of these reports in the 1970s major hepatic resection for metastatic colon cancer was not routinely performed; presumably, a substantial number of patients were not offered the curative operations that would be performed today. Since the early 1980s reoperation for resection of liver metastases has become more common and has demonstrated reasonable success [Am J Surg 1988:155:378-382). In addition, the plasma CEA assay has become more widely used. This antigen has provided a more sensitive marker of recurrent disease, and therefore has increased the chances of detecting asymptomatic recurrences earlier. In 1985, Martin showed that when an increase in the CEA level above baseline was used as an indicator of recurrent disease in 146 patients followed up after curative resection for colorecta1 cancer, 95% of those with elevated CEA levels could be shown to have recurrence when evaluated with chest radiographs, liver-spleen scans, colonoscopy, bone scans, computed tomography (CT] scans, or hepatic arteriography (Ann Surg 1985;202:310-317). Of detected recurrences, 58% could have additional surgery and be resected for potential cure. The 5-year survival after reoperation was 31%. Based on these findings, Martin suggested that the CEA assay was the best tool for surveillance of colon cancer recurrence and that an interval of 1-2 months during the first 2 years after the initial surgical procedure would permit the best timing for earliest detection and reoperation. Similarly, Sugarbaker and colleagues showed that routine follow-up using CT scanning, lung tomography, and liver-spleen scanning were of little benefit in the routine screening of patients
GASTROENTEROLOGY
Vol. 99. No. 6
following resection (Surgery 1987;102:79-87). They found that serial CEA assays and routine history and physical examinations were most effective in early detection of colonic cancer recurrence. A progressive increase in CEA level detected 67% of recurrences, and an abnormal review of symptoms or physical examination picked up 21%, while CT scans, bone scans, and lung tomograms detected 13% of recurrences each. Studies have shown that hepatic metastases of colorectal cancer are resectable for cure if they are solitary, localized to a single lobe, or scattered but easily removed by wedge resections. In Former’s series of 380 patients, 33% were resectable by major hepatic resection or wedge resection. The 30-day operative mortality was 4.8%, and survival estimates for the 77 patients who had curative resections were 95%. 65%, and 49% at 1, 3, and 5 years, with a median survival estimate of 59 months [Am J Surg 1988;155:378382). On the other side of the argument, Kievit et al recently challenged the use of CEA to monitor patients following curative resection of colorectal cancer. Based on a Markov analysis, they believe that the influence of CEA on quality-adjusted life expectancy is marginal. They state that CEA monitoring should not be performed because the cost of follow-up, work-up, and reoperation of a patient based on an elevated CEA can be quite high, whereas the benefits in terms of days in extended life expectancy may be minimal (Cancer 1990;65:2580-2587). Although the current study supports the concept of careful follow-up, the rationale for the surveillance and work-up of patients following curative colorectal cancer surgery still is not fully accepted. The proper and timely use of the routine office visit and CEA assay is certainly of benefit in the early detection of recurrent colorectal cancer, but its utility and that of the second-look operation can only be demonstrated by improved survival of a greater number of patients. To date, most studies have shown that the greater predictor of survival is the patient’s initial Dukes’ staging and, although reoperation and removal of recurrent disease may permit some with recurrent cancer to live longer, for the group as a whole, second-look surgery does little to improve overall prognosis as initially predicted by Dukes’ staging. Improved surgical techniques have permitted better survival, as reported by a few centers, but major hepatic resection for metastatic disease is available only at those specialized centers. Those recurrences, particularly at the anastomosis and metachronous lesions, should not go unnoticed and untreated with the current ease of detection by colonoscopy. However, major hepatic resection should be performed only by experienced liver surgeons. In the past 30 years there has been progress in the diagnosis and treatment of colorectal cancer and its recurrences, but there is still much to learn. Surgery with curative intent is not likely to be effective in patients with multiple sites of metastatic disease. most pelvic wall recurrences, and pulmonary and skeletal recurrences because these are all indicators of widespread dissemination. However, for local, anastomotic recurrences, hepatic metastases, and some pelvic walI recurrences, reoperation does offer a second chance for cure. To date only one study of adjuvant chemotherapy has shown a ray of hope for these patients. A recent report by Moertel et al. shows a 41% reduction in the risk of recurrence in Dukes’ C patients (P < 0.0001) and a 33% reduction in the death rate (P (c 0.006) by 3 years in the same group (N Engl J Med 1990;322:352358). No clear benefit could be demonstrated for Dukes’ B2 patients. While we await breakthroughs in the management of colonic cancer, we must continue to promote means of prevention and early detection because the early stages of colorectal cancer are those most likely to be cured. Sigmoidoscopy and FOBT are useful for early detection, but currently too many patients are missed by virtue of their entering the health care system in the later stages of disease, only after symptoms have developed. Education of the public, as well as continued screening and case finding by primary clinicians,
December 1898
should help reduce the numbers of patients presenting at later stages. Similarly, after curative surgery for colorectal cancer, patients should undergo close follow-up with regular physical examination, CBA assays, FOBT, and endoscopic examinations of the colon. Although data are still being accumulated with regard to long-term patient follow-up, the World Health Organization (WHO) recommends colonoscopy or flexible sigmoidoscopy combined with
SELECTED SUMMARIES
1851
air-contrast barium enema approximately every 8 years after establishment of a “clean colon” (Winawer SJ, WHO, in press). The close follow-up of patients after curative colorectal surgery is likely to be beneficial, especially if an experienced surgeon is able to resect the recurrent disease. H. GERDES, M.D.
