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• W2120939042 abstract "Background & Aims: The benefit of colonoscopy in the follow-up of colorectal cancer survivors is uncertain, and findings of surveillance colonoscopy are not well-characterized. We sought to estimate survival among colorectal cancer patients according to receipt of a follow-up colon examination and to describe the findings of such exams. Methods: We studied health maintenance organization enrollees with colorectal cancer who underwent surgical resection. Mortality was estimated by using survival analysis, and findings of colon examinations were determined by review of pathology reports. Results: One thousand two patients were eligible for study; 5-year survival was higher (76.8%) for patients who had at least one follow-up exam than for patients who did not undergo follow-up (52.2%, P < .0001). In multivariate analysis, colon examination remained independently associated with improved survival (hazard ratio, 0.58; 95% confidence interval, 0.44–0.75). Twenty patients (3.1%) were diagnosed with a second colorectal cancer, including 9 cancers detected within 18 months of initial cancer diagnosis. Advanced neoplasia was more common (15.5%) among patients followed up between 36–60 months after diagnosis compared with patients followed up within 18 months (6.9%, P = .02). History of adenomas was associated with advanced neoplasia on follow-up (P = .002). Patients with advanced neoplasia on initial follow-up were at high risk for advanced neoplasia on subsequent examinations (13/16, 81%). Conclusions: After colorectal cancer resection, patients have a high risk of interval cancers, some of which represent missed lesions at initial diagnosis. Therefore, surveillance colonoscopy within 1 year of initial diagnosis is warranted. After adjusting for key variables, endoscopic surveillance is associated with improved survival. Background & Aims: The benefit of colonoscopy in the follow-up of colorectal cancer survivors is uncertain, and findings of surveillance colonoscopy are not well-characterized. We sought to estimate survival among colorectal cancer patients according to receipt of a follow-up colon examination and to describe the findings of such exams. Methods: We studied health maintenance organization enrollees with colorectal cancer who underwent surgical resection. Mortality was estimated by using survival analysis, and findings of colon examinations were determined by review of pathology reports. Results: One thousand two patients were eligible for study; 5-year survival was higher (76.8%) for patients who had at least one follow-up exam than for patients who did not undergo follow-up (52.2%, P < .0001). In multivariate analysis, colon examination remained independently associated with improved survival (hazard ratio, 0.58; 95% confidence interval, 0.44–0.75). Twenty patients (3.1%) were diagnosed with a second colorectal cancer, including 9 cancers detected within 18 months of initial cancer diagnosis. Advanced neoplasia was more common (15.5%) among patients followed up between 36–60 months after diagnosis compared with patients followed up within 18 months (6.9%, P = .02). History of adenomas was associated with advanced neoplasia on follow-up (P = .002). Patients with advanced neoplasia on initial follow-up were at high risk for advanced neoplasia on subsequent examinations (13/16, 81%). Conclusions: After colorectal cancer resection, patients have a high risk of interval cancers, some of which represent missed lesions at initial diagnosis. Therefore, surveillance colonoscopy within 1 year of initial diagnosis is warranted. After adjusting for key variables, endoscopic surveillance is associated with improved survival. See CME exam on page 407. See CME exam on page 407. Nearly 150,000 cases of colorectal cancer are diagnosed in the United States each year,1Jemal A. Murray T. Ward E. et al.Cancer statistics, 2005.CA Cancer J Clin. 2005; 55: 10-30Crossref PubMed Scopus (5590) Google Scholar and three fourths of such patients will undergo a surgical resection with curative intent.2Easson A.M. Cotterchio M. Crosby J.A. et al.A population-based study of the extent of surgical resection of potentially curable colon cancer.Ann Surg Oncol. 2002; 9: 380-387Crossref PubMed Google Scholar Nevertheless, approximately one third of resected patients will develop a recurrence of colorectal cancer, and most of these patients will ultimately die of this disease.3Galandiuk S. Wieand H.S. Moertel C.G. et al.Patterns of recurrence after curative resection of carcinoma of the colon and rectum.Surg Gynecol Obstet. 1992; 174: 27-32PubMed Google Scholar, 4Safi F. Link K.H. Beger H.G. Is follow-up of colorectal cancer patients worthwhile?.Dis Colon Rectum. 1993; 36: 636-643Crossref PubMed Scopus (99) Google Scholar, 5Read T.E. Mutch M.G. Chang B.W. et al.Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon.J Am Coll Surg. 2002; 195: 33-40Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar Colorectal cancer patients are also at increased risk to develop metachronous colorectal cancers and adenomas.6Cali R.L. Pitsch R.M. Thorson A.G. et al.Cumulative incidence of metachronous colorectal cancer.Dis Colon Rectum. 1993; 36: 388-393Crossref PubMed Scopus (158) Google Scholar, 7Togashi K. Konishi F. Ozawa A. et al.Predictive factors for detecting colorectal carcinomas in surveillance colonoscopy after colorectal cancer surgery.Dis Colon Rectum. 2000; 43: S47-S53Crossref PubMed Google Scholar, 8Chen F. Stuart M. Colonoscopic follow-up of colorectal carcinoma.Dis Colon Rectum. 1994; 37: 568-572Crossref PubMed Scopus (62) Google Scholar, 9Green R.J. Metlay J.P. Propert K. et al.Surveillance for second primary colorectal cancer after adjuvant chemotherapy: an analysis of Intergroup 0089.Ann Intern Med. 2002; 136: 261-269Crossref PubMed Scopus (151) Google Scholar For these reasons, published guidelines recommend surveillance colonoscopy as part of colorectal cancer follow-up care, although guidelines differ with respect to recommended timing of such exams.10Fleischer D.E. Goldberg S.B. Browning T.H. et al.Detection and surveillance of colorectal cancer.JAMA. 1989; 261: 580-585Crossref PubMed Scopus (177) Google Scholar, 11Engstrom P.F. Benson 3rd, A.B. Cohen A. et al.NCCN colorectal cancer practice guidelines: the National Comprehensive Cancer Network.Oncology. 1996; 10: 140-175PubMed Google Scholar, 12Richard C.S. McLeod R.S. Follow-up of patients after resection for colorectal cancer: a position paper of the Canadian Society of Surgical Oncology and the Canadian Society of Colon and Rectal Surgeons.Can J Surg. 1997; 40: 90-100PubMed Google Scholar, 13Winawer S.J. Fletcher R.H. Miller L. et al.Colorectal cancer screening: clinical guidelines and rationale.Gastroenterology. 1997; 112: 594-642Abstract Full Text Full Text PDF PubMed Scopus (1834) Google Scholar, 14Winawer S. Fletcher R. Rex D. et al.Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence.Gastroenterology. 2003; 124: 544-560Abstract Full Text PDF PubMed Scopus (1992) Google Scholar, 15Desch C.E. Benson 3rd, A.B. Smith T.J. et al.Recommended colorectal cancer surveillance guidelines by the American Society of Clinical Oncology.J Clin Oncol. 1999; 17: 1312-1321PubMed Google Scholar, 16Benson 3rd, A.B. Desch C.E. Desch C.E. et al.2000 update of American Society of Clinical Oncology colorectal cancer surveillance guidelines.J Clin Oncol. 2000; 18: 3586-3588PubMed Google Scholar, 17Rex D.K. Kahi C.J. 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: 1865-1871Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar The efficacy of intensive surveillance of patients with colorectal cancer with physical examination, laboratory tests, radiographic studies, and endoscopy is unknown. Randomized trials18Makela J.T. Laitinen S.O. Kairaluoma M.I. Five-year follow-up after radical surgery for colorectal cancer: results of a prospective randomized trial.Arch Surg. 1995; 130: 1062-1067Crossref PubMed Scopus (329) Google Scholar, 19Ohlsson 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: 619-626Crossref PubMed Scopus (313) Google Scholar, 20Kjeldsen B.J. Kronborg O. Fenger C. et al.A prospective randomized study of follow-up after radical surgery for colorectal cancer.Br J Surg. 1997; 84: 666-669Crossref PubMed Scopus (280) Google Scholar, 21Schoemaker D. Black R. Giles L. et al.Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients.Gastroenterology. 1998; 114: 7-14Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar, 22Pietra N. Sarli L. Costi R. et al.Role of follow-up in management of local recurrences of colorectal cancer.Dis Colon Rectum. 1998; 41: 1127-1133Crossref PubMed Scopus (317) Google Scholar, 23Secco G.B. Fardelli R. Gianquinto D. et al.Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial.Eur J Surg Oncol. 2002; 28: 418-423Abstract Full Text PDF PubMed Scopus (201) Google Scholar and meta-analyses24Renehan A.G. Egger M. Saunders M.P. et al.Impact on survival of intense follow-up after curative resection of colorectal cancer: systematic review and meta-analysis of randomized trials.BMJ. 2002; 324: 1-8Crossref PubMed Google Scholar, 25Jeffery G.M. Hickey B.E. Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer.Cochrane Database Syst Rev. 2002; 1 (CD002200)PubMed Google Scholar of these trials have reported inconsistent results, with some reporting benefit22Pietra N. Sarli L. Costi R. et al.Role of follow-up in management of local recurrences of colorectal cancer.Dis Colon Rectum. 1998; 41: 1127-1133Crossref PubMed Scopus (317) Google Scholar, 23Secco G.B. Fardelli R. Gianquinto D. et al.Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial.Eur J Surg Oncol. 2002; 28: 418-423Abstract Full Text PDF PubMed Scopus (201) Google Scholar, 24Renehan A.G. Egger M. Saunders M.P. et al.Impact on survival of intense follow-up after curative resection of colorectal cancer: systematic review and meta-analysis of randomized trials.BMJ. 2002; 324: 1-8Crossref PubMed Google Scholar, 25Jeffery G.M. Hickey B.E. Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer.Cochrane Database Syst Rev. 2002; 1 (CD002200)PubMed Google Scholar and others observing no effect.18Makela J.T. Laitinen S.O. Kairaluoma M.I. Five-year follow-up after radical surgery for colorectal cancer: results of a prospective randomized trial.Arch Surg. 1995; 130: 1062-1067Crossref PubMed Scopus (329) Google Scholar, 19Ohlsson 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: 619-626Crossref PubMed Scopus (313) Google Scholar, 20Kjeldsen B.J. Kronborg O. Fenger C. et al.A prospective randomized study of follow-up after radical surgery for colorectal cancer.Br J Surg. 1997; 84: 666-669Crossref PubMed Scopus (280) Google Scholar, 21Schoemaker D. Black R. Giles L. et al.Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients.Gastroenterology. 1998; 114: 7-14Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar Nonetheless, colonoscopy is regarded as a key component in the surveillance of colon cancer survivors, although neither the precise survival benefit of endoscopic surveillance nor the optimal timing of such exams has been defined.26Figueredo A. Rumble R.B. Maroun J. et al.Follow-up of patients with curatively resected colorectal cancer: a practice guideline.BMC Cancer. 2003; 3: 26Crossref PubMed Scopus (311) Google Scholar, 27Audisio R.A. Setti-Carraro P. Segala M. et al.Follow-up in colorectal cancer patients: a cost-benefit analysis.Ann Surg Oncol. 1996; 3: 349-357Crossref PubMed Scopus (59) Google Scholar Moreover, the yield and outcomes of surveillance colonoscopy have not been characterized in a population-based setting. The purpose of this study was to evaluate the relation between surveillance examination and survival in a well-defined population-based cohort of colorectal cancer patients and to determine the rate and time interval for newly discovered interval cancers and adenomas in patients who have had colon cancer resection. This study was conducted at Group Health Cooperative (GHC), a large health maintenance organization (HMO) serving approximately 500,000 individuals in Washington State. The study cohort included all patients diagnosed with a first adenocarcinoma or adenocarcinoma-variant tumor of the colon or rectum between January 1, 1993–December 31, 1999 (n = 1292). Colorectal cancer cases were identified by linkage between the GHC enrollment database and the Seattle-Puget Sound Surveillance, Epidemiology, and End Results (SEER) cancer registry.28Ries LAG, Eisner MP, Kosary CL, et al (eds). SEER Cancer Statistics Review, 1973-1999, National Cancer Institute. Bethesda, MD. Available at: http://seer.cancer.gov/csr/1973_1999/; Accessed September 2002.Google Scholar The study included cases of colorectal cancer with American Joint Commission on Cancer stages 0, I, II, or III.29Fleming I.D. Cooper J.S. Henson D.E. American Joint Committee on Cancer cancer staging manual. 5th ed. Lippincott-Raven, Philadelphia1997Google Scholar Cases with metastatic disease at presentation (stage IV cancers) (n = 190) were excluded because such patients are generally not candidates for colon surveillance. Patients with stage 0 disease (also known as carcinoma in situ) were included because colon surveillance after initial resection has been recommended with similar frequency in these patients as for patients with more advanced tumors.30Ehrinpreis M.N. Kinzie J.L. Jaszewski R. et al.Management of the malignant polyp.Gastroenterol Clin North Am. 1988; 17: 837-850PubMed Google Scholar, 31Masaki T. Mori T. Matsuoka H. et al.Colonoscopic treatment of colon cancers.Surg Oncol Clin N Am. 2001; 10: 693-708PubMed Google Scholar Subjects were ineligible for study if their stage of disease was missing or unknown (n = 21), or if they were not treated with surgical or endoscopic resection (n = 23). We also excluded patients who underwent total proctocolectomy for ulcerative colitis (n = 8), Crohn’s disease (n = 8), or other indications (n = 11). Finally, any remaining patients who survived less than 6 months after diagnosis were excluded from the cohort (n = 29). No member of the cohort had a diagnosis of a familial colon cancer syndrome in the HMO automated database or their medical record. Study patients were followed from the date of diagnosis until one of the following events: death, loss to follow-up, or the end of the study period (December 31, 2001). For subjects who were lost to follow-up, the end of the follow-up interval was defined as the date of the last clinical encounter recorded in the GHC databases. Dates and types of colon examinations after diagnosis were ascertained from electronic medical records of ambulatory and inpatient encounters at GHC. Colon examinations were identified by using Current Procedural Terminology–4 procedure codes32American Medical AssociationCurrent procedural terminology. American Medical Association, Chicago2001Google Scholar and included either colonoscopy or sigmoidoscopy and barium enema. Flexible sigmoidoscopy without a barium enema was not considered to constitute an adequate colon surveillance examination. Colon examinations performed within 2 months after diagnosis were excluded from our surveillance analysis, because these exams are often conducted to evaluate postoperative complications or to exclude synchronous lesions. GHC does not have a formal guideline for postdiagnostic colon surveillance and does not restrict access to colon examination procedures. We ascertained pathologic outcomes of colon examinations by linking procedures among study participants to electronic pathology reports. Reports were reviewed by a single gastroenterologist (S.J.R.) for the following histologic findings: carcinoma, adenoma (tubular, villous, unspecified), and hyperplasia. Lesion size was coded as the actual or aggregate size of the lesion given on the pathology report. Pathologic size estimation was chosen because electronic clinical data systems of endoscopic reports were not available for the entire study period. In addition, previous studies have reported that endoscopic size estimates might be less reliable than pathologic estimates.33Schoen R.E. Gerber L.D. Margulies C. The pathologic measurement of polyp size is preferable to the endoscopic estimate.Gastrointest Endosc. 1997; 46: 492-496Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar Neoplasia was classified according to the most advanced histologic finding noted in the pathology report. Advanced neoplasia was defined by 1 or more of the following: adenoma ≥10 mm in size, adenoma with villous architecture, adenoma with high-grade dysplasia, or carcinoma. The location of the lesion within the colon was also determined from the pathology report where possible. When no pathology data corresponding to an endoscopic procedure were available, the exam was considered to be negative for dysplasia because a previous pilot study found complete ascertainment for the pathology database when compared with findings described in the endoscopy report (data not shown). Covariates of interest were selected a priori and were drawn from the SEER registry and GHC databases. These included patient age at diagnosis, sex, race, tumor stage, tumor location, receipt of adjuvant chemotherapy or radiotherapy, marital status, socioeconomic status, and medical comorbidity. History of adenomatous polyps was also ascertained by review of the pathology database and by abstraction of medical records from the date of HMO enrollment until the date of diagnosis. A family history of colorectal cancer was also determined by abstraction of medical records from date of HMO enrollment until the date of diagnosis. Family history was considered missing if there was no mention of either a positive or negative family history of colon cancer in the medical record. Medical comorbidity was estimated by using the Chronic Disease Score, which uses automated pharmacy data to estimate health status.34Clark D.O. Von Korff M. Saunders K. et al.A chronic disease score with empirically derived weights.Med Care. 1995; 33: 783-795Crossref PubMed Scopus (508) Google Scholar The Chronic Disease Score is a validated measure of comorbidity that has been shown to have similar predictive validity to other comorbidity scores including the Charlson Index.35Schneeweiss S. Maclure M. Use of comorbidity scores for control of confounding in studies using administrative databases.Int J Epidemiol. 2000; 29: 891-898Crossref PubMed Scopus (330) Google Scholar, 36Schneeweiss S. Seeger J.D. Maclure M. et al.Performance of comorbidity scores to control for confounding in epidemiologic studies using claims data.Am J Epidemiol. 2001; 154: 854-864Crossref PubMed Scopus (621) Google Scholar, 37Perkins A.J. Kroenke K. Unutzer J. et al.Common comorbidity scales were similar in their ability to predict health care costs and mortality.J Clin Epidemiol. 2004; 57: 1040-1048Abstract Full Text Full Text PDF PubMed Scopus (303) Google Scholar, 38Boulos D.L. Groome P.A. Brundage M.D. et al.Predictive validity of five comorbidity indices in prostate carcinoma patients treated with curative intent.Cancer. 2006; 106: 1804-1814Crossref PubMed Scopus (45) Google Scholar We calculated the Chronic Disease Score by using automated pharmacy data from third through ninth month after the date of diagnosis to limit the influence of early postoperative morbidity on the comorbidity estimate. Outcomes of the cohort were estimated by using survival analysis, with between-group comparisons based on the log-rank test.39Kaplan E.L. Meier P. Nonparametric estimation from incomplete observations.J Am Stat Assoc. 1958; 53: 457-481Crossref Scopus (48517) Google Scholar Because the receipt of colon examination is dependent on patient survival, the prognostic importance of colon examination was modeled as a time-dependent covariate.40Hosmer D.W. Lemeshow S. Applied survival analysis: regression modeling of time to event data. John Wiley & Sons, Inc, New York1999Google Scholar The independent effect of covariates on mortality, measured by the associated hazard ratio (HR), was estimated by using Cox proportional hazards models.41Cox D.R. Regression models and life tables.J Royal Stat Soc. 1972; B34: 187-220Google Scholar, 42Prentice R.L. Williams B.J. Petersen A.V. On the regression of multivariate failure time data.Biometrika. 1981; 68: 373-379Crossref Scopus (908) Google Scholar The final proportional hazards model excluded covariates if they were neither independent predictors nor influenced the risk estimates for other predictors. We tabulated findings of colon examinations of the cohort according to the length of time between diagnosis and the examination, personal history of adenomas, or a family history of colorectal cancer. The findings of flexible sigmoidoscopies conducted during follow-up of the subset of patients with rectal cancer were also examined. Statistical comparisons were performed by using the χ2 test, Fisher exact test, or log-rank test, as appropriate. All data analyses were performed with Stata 8.0 (Stata Corp, College Station, TX), and the type I error level (α) was .05. A total of 1002 patients met inclusion criteria for the study, and characteristics of these patients are given in Table 1. The study sample consisted of equal proportions of men and women, and most patients (78%) were 60 years of age or older at diagnosis. Most patients were white (93%), reflecting the racial composition of the Puget Sound geographic area. Two thirds of patients (66%) had local disease at diagnosis, and 25% had nodal disease at diagnosis. A minority of patients received adjuvant chemotherapy (35%) or radiation (13%). Follow-up after diagnosis ranged from 6 months–8.7 years (median, 3.6 years). Reasons for censoring included death (n = 217; 22%), loss to follow-up (n = 183; 18%), or the end of the study period (n = 602; 60%).Table 1Characteristics of 1002 Subjects Diagnosed With Colorectal Cancer, 1993–1999aCases with missing data excluded from column totals.CharacteristicNumber%Gender (n = 1002) Male50450.3 Female49849.7Age at diagnosis (y) (n = 1002) <50878.7 50–5913313.3 60–6924524.4 70–7935735.6 80+18018.0Race (n = 995) White92292.7 Black353.5 Otherb“Other” races include Asian or Pacific Islander (n = 29), Latino (n = 5), Native American (n = 3), other (n = 1).383.8AJCC tumor stage (n = 1002) 0878.7 I32632.5 II33933.8 III25025.0Tumor location (n = 1002) Colon77877.6 Rectum22422.4Received adjuvant therapy Radiotherapy (n = 998)13013.0 Chemotherapy (n = 991)34534.8AJCC, American Joint Commission on Cancer.a Cases with missing data excluded from column totals.b “Other” races include Asian or Pacific Islander (n = 29), Latino (n = 5), Native American (n = 3), other (n = 1). Open table in a new tab AJCC, American Joint Commission on Cancer. Sixty-five percent of the study cohort (n = 652) underwent 1 or more colon examinations during the study period. A total of 936 exams were conducted on members of the cohort, with an average of 1.4 (standard deviation, 0.6) exams per patient during follow-up. This included 730 exams among 505 patients with colon cancer and 206 exams among 146 patients with rectal cancer. The majority of examinations performed were colonoscopies (97%), and relatively few patients underwent examination with flexible sigmoidoscopy combined with barium enema (3%). Using survival analysis to account for variability in follow-up time, 61% (95% confidence interval [CI], 58%–64%) of the cohort underwent a colon examination within 18 months of diagnosis, and 80% (95% CI, 77%–84%) underwent a colon examination within 5 years of diagnosis. Seven hundred four patients (70%) were alive at the end of the study period, and the cumulative survival of the study cohort was 96% (95% CI, 94%–97%) at 1 year and 68% (95% CI, 64%–71%) at 5 years. As expected, stage at diagnosis was strongly associated with survival (Table 2). In addition, colorectal cancer patients who underwent 1 or more colon examinations during follow-up had improved survival compared with patients who did not undergo colon examination (P < .0001; Figure 1). Estimated 5-year survival was similar regardless of whether the initial colon examination was performed within 18 months of diagnosis, between 18–35 months of diagnosis, or between 36–60 months of diagnosis (78.0% [95% CI, 72.4%–82.7%]; 75.7% [95% CI, 63.9%–84.2%]; 77.3% [95% CI, 51.9%–90.4%], respectively). In comparison, 5-year survival was at least 45% lower (52.2%; 95% CI, 45.4%–58.6%) among members of the cohort who did not undergo a colon examination during follow-up.Table 2Factors Associated With Mortality Among Colorectal Cancer Patients With Local or Regional Disease at Diagnosis (n = 1002)FactorHR95% CIReceipt of surveillance colonoscopy0.58aP < .05.0.44–0.75AgebPer 1-year increase in age.1.03aP < .05.1.01–1.04Female gender0.68aP < .05.0.53–0.86Race White1.00 Black1.92aP < .05.1.03–3.57 Other0.900.45–1.76Chronic disease scorecPer 10% change in chronic disease score.1.11aP < .05.1.05–1.16AJCC stage 01.00 I0.950.56–1.62 II1.94aP < .05.1.15–3.29 III3.81aP < .05.2.17–6.68Tumor site Colon1.00 Rectum1.010.71–1.47Receipt of adjuvant chemotherapy0.50aP < .05.0.35–0.72Receipt of adjuvant radiotherapy1.78aP < .05.1.14–2.77NOTE. Cox proportional hazards model χ2 = 182.6, 12 df, P < .0001.a P < .05.b Per 1-year increase in age.c Per 10% change in chronic disease score. Open table in a new tab NOTE. Cox proportional hazards model χ2 = 182.6, 12 df, P < .0001. Receipt of a colon examination was a significant independent predictor of decreased overall mortality (HR, 0.58; 95% CI, 0.44–0.75) after adjustment for other prognostic variables (Table 2). In addition, female gender (HR, 0.68; 95% CI, 0.53–0.86) and the receipt of adjuvant chemotherapy (HR, 0.50; 95% CI, 0.35–0.72) were associated with decreased mortality. Increased mortality was seen among black patients (HR, 1.92; 95% CI, 1.03–3.57) as well as among older patients, patients with greater medical comorbidity, patients with more advanced tumor stage, and among patients treated with radiotherapy. The most significant findings on follow-up colonoscopies included carcinoma (n = 10, 1.1%), adenoma (n = 206, 22.0%), or hyperplastic polyp (n = 159, 17.0%) (Table 3). Advanced neoplasia was identified in 7.3% (n = 68) of follow-up colonoscopies, including 23 exams detecting an adenoma ≥10 mm and 35 exams detecting adenomas with villous architecture. Most patients underwent their initial follow-up colonoscopy within 18 months of initial diagnosis (n = 484), with fewer patients undergoing initial follow-up colonoscopy between 18 and 36 months since initial diagnosis (n = 110) or between 36 and 60 months since initial diagnosis (n = 58). Advanced neoplasia was more commonly identified when the initial postdiagnostic surveillance examination was deferred until 36–60 months after diagnosis (n = 9, 15.5% of exams) compared with initial exams performed within 18 months of diagnosis (n = 33, 6.9% of exams) (P = .02).Table 3Most Advanced Finding on Initial and Subsequent Follow-up ColonoscopyFindingAll colonoscopies (n = 936)Initial exam (n = 652)Subsequent examsaDistribution of subsequent follow-up exams: 2 exams (n = 242), 3 exams (n = 33), 4 exams (n = 7), 5 exams (n = 2). (n = 284)No.% of examsNo.% of examsNo.% of examsCarcinoma101.171.131.1Adenoma20622.013320.47325.7 Tubular12913.88012.34917.3 Villous353.7253.8103.5 Unspecified424.5284.3144.9Advanced neoplasia687.3517.8176.0Hyperplastic polyp15917.09915.26021.1a Distribution of subsequent follow-up exams: 2 exams (n = 242), 3 exams (n = 33), 4 exams (n = 7), 5 exams (n = 2). Open table in a new tab Overall, 20 interval cancers were found during follow-up, including 9 cancers diagnosed within 18 months of the initial cancer diagnosis (Table 4). A total of 10 cancers were diagnosed on follow-up colonoscopy, and the majority of these were found on the initial follow-up exam. Most cancers diagnosed on follow-up colonoscopy were found in different segments of the colon than the original cancer (n = 6), although 2 cancers were found at the anastomotic site, and 2 were found in the same segment of the colon as the anastomosis. In addition, 44% (n = 98) of rectal cancer patients in the cohort underwent a total of 209 flexible sigmoidoscopies during follow-up, and these examinations diagnosed 10 (4.8%) additional carcinomas arising in the rectum and 11 (5.3%) other advanced neoplastic lesions.Table 4Interval Cancers Detected on Initial Surveillance Exam With Colonoscopy or SigmoidoscopySite of original cancerNo. of patientsNo. with follow-up colonoscopy or sigmoidoscopyFollow-up intervalNo. of interval cancersInitial follow-up examSubsequent follow-up examsColon cancer778505<18 mo (n = 373)4018–35 mo (n = 86)2236–60 mo (n = 46)11Rectal cancer224186<18 mo (n = 105)4118–35 mo" @default.
• W2120939042 created "2016-06-24" @default.
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• W2120939042 date "2007-04-01" @default.
• W2120939042 modified "2023-09-23" @default.
• W2120939042 title "Outcome of Follow-up Colon Examination Among a Population-Based Cohort of Colorectal Cancer Patients" @default.
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