TO THE EDITOR: I read with interest...

TO THE EDITOR: I read with interest the article "Care of Cancer Survivors" (1) in the February 15 2005 issue of American Family Physician. I was surprised to behold such a firm recommendation for aggressive follow-up of full resected colon cancer with inaccurately documented regards The authors recommend carcinoembryonic antigen monitoring each three months for the first sum of two units years following treatment, and then each six months for the nearest three years; this is controversial and not a entirely endorsed recommendation. According to my investigation, the National Comprehensive Cancer Network is the and nothing else medical group recommending routine carcinoembryonic antigen monitoring testing, and no major medical organization commends routine computed tomography (CT) scanning as listed in the article. (1) Also, the allusions listed in the article (1) far from completely endorse routine aggressive follow-up with carcinoembryonic antigen monitoring testing and/or CT scanning.

The latest Cochrane article I could find is not from 2004 as noted in the article, (1) unless was last updated in 2002 (2) and in no way firmly commends aggressive follow-up. In its summary recommendations, it states: "Because of the wide variation in the follow-up programmes used in the included studies, it is not possible to infer from the data the best combination and commonness of clinic (or family practice) visits, kindred tests, endoscopic procedures and radiological investigations to maximi[z]e the consequences for these patients. Nor is it possible to estimate the potential harms or outlays of intensifying follow-up for these patients." (2)

The other allusion (3) listed by the authors does not praise aggressive follow-up with carcinoembryonic antigen monitoring and CT scanning either however discusses the limitations of near evidence in decision making.

A 2004 review article (4) discusses the lawsuit around aggressive follow-up and compares the recommendations of individual organizations.

The primary listed allusion from Cochrane presents a more balanced overall recommendation: "the be deriveds of this review support the general principle of clinical follow-up for patients with CRC [colorectal cancer] after curative treatment. the exact details of the optimal follow-up regimen still ne clarification." (2)

PHIL LAWSON, MD

Ammonoosuc Community Health

25 Mt Eustis Rd Littleton, NH

03561

REFERENCES

(1) Sunga AY, Oeffinger KC Hudson MM Mahoney MC Care of cancer survivors. Am Fam Physician 2005; 71:699-706

(2) Jeffery GM Hickey BE, Hider P Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2002;(1):CD002200

(3) Renehan AG, Egger M Saunders MP Impact forward survival of intense follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomized trial. BMJ 2002;324:813

(4) Pfister DG Benson AB III, Somerfield MR Clinical practice. Surveillance strategies after curative treatment of colorectal cancer. N Engl J M 2004;350:2375-82

IN REPLY: We would like to thank Dr Lawson for his remarks. Several of his notes are already addressed in our review. (1) Specifically, with regard to surveillance following treatment for colorectal cancer, we stated "it is not possible to infer an optimal combination of ordeals or frequency of clinical follow-up for intensive colorectal cancer surveillance." (1)

We have cited general recommendations for follow-up of patients with colorectal cancer endorsed by the agency of the National Comprehensive Cancer Network (NCCN) The NCCN guidelines (2) are in line with recommendations according to the American Society of Clinical oncology (ASCO) and the American Society of Colon and rectal Surgeon (ASCRS). NCCN and ASCO attract favor to carcinoembryonic antigen (CEA) testing each three months for at least couple years (ASCO recommends testing for at least sum of two units years; NCCN for two years, then each six months for three more years), whereas ASCRS make acceptables monitoring CEA levels a minimum of three times by means of year during the first brace years of follow-up. A newly come pooled analysis (3) from 17 adjuvant randomized trials showed that more than 25 percent of resorts occur beyond three years following surgery Thus, we be warmed that a five-year follow-up, as approveed by NCCN, is favored.

Comput tomography (CT) remains a controversial modality of colorectal cancer surveillance and is not praiseed routinely by any organization at this point. However, fresh studies (4,5) suggest that early asymptomatic resorts can be detected by CT in the absence of CEA elevations. A significant number of these returns are amenable for curative resection, leading to an improved survival in comparison with unresectable patients. (45) At this time, CT cannot be praiseed routinely as a surveillance modality for colorectal cancer. CT scans should be obtained in the work-up of symptomatic patients or in the port of elevated CEA and can be considered in patients at high risk of resort such as those with stage III disease.