Determinants of recurrence after intended curative resection for colorectal cancer.

Despite intended curative resection, colorectal cancer will recur in ∼45% of the patients. Results of meta-analyses conclude that frequent follow-up does not lead to early detection of recurrence, but improves overall survival. The present literature shows that several factors play important roles in development of recurrence. It is well established that emergency surgery is a major determinant of recurrence. Moreover, anastomotic leakages, postoperative bacterial infections, and blood transfusions increase the recurrence rates although the exact mechanisms still remain obscure. From pathology studies it has been shown that tumors behave differently depending on their location and recur more often when micrometastases are present in lymph nodes and around vessels and nerves. K-ras mutations, microsatellite instability, and mismatch repair genes have also been shown to be important in relation with recurrences, and tumors appear to have different mutations depending on their location. Patients with stage II or III disease are often treated with adjuvant chemotherapy despite the fact that the treatments are far from efficient among all patients, who are at risk of recurrence. Studies are now being presented identifying subgroups, in which the therapy is inefficient. Unfortunately, only few of these facts are implemented in the present follow-up programs. Therefore, further research is urgently needed to verify which of the well-known parameters as well as new parameters that must be added to the current follow-up programs to identify patients at risk of recurrence.

Early detection of recurrence after curative resection for colorectal cancer - obstacles when using soluble biomarkers?

OBJECTIVE: Results from monitoring studies using biomarkers in blood samples aiming at early detection of recurrent colorectal cancer (CRC) are presently evaluated. However, some serological biomarker levels are influenced by the surgical trauma, which may complicate translation of the levels in relation to recurrence. The primary purpose of the present study was to evaluate the frequency of postoperative surgical interventions during a follow-up period of patients who have undergone surgery for primary CRC. METHODS: In a prospective multicenter, clinical study, 634 patients resected for primary CRC were followed in the outpatient clinic every third month. Blood samples were drawn at each visit. A subgroup of 165 stage II and III patients, who had been followed for at least 3 years, was selected. Any recent surgical intervention associated with the primary disease and/or other diseases were recorded at each visit to the outpatient clinic. RESULTS: Among the 165 patients, 49 developed recurrence (R+), 107 did not (R-) and 11 developed a new primary cancer, including 2 in the R+ group. Within the 3 years of observation, 78 (47.3%) of the 165 patients underwent 117 (range 1-5) postoperative surgical interventions. Seventy-five operations were related to CRC and 42 to benign diseases, while none were related to a new primary, malignant disease. CONCLUSION: Patients resected for CRC are frequently undergoing surgical procedures in the postoperative follow-up period. Therefore, postoperative monitoring using soluble biomarker levels, which may be influenced by the surgical trauma, must be adjusted in relation to postoperative surgical interventions.

[The nurse as endoscopist]. / Sygeplejersker som endoskopører.

INTRODUCTION: A new diagnostic strategy for evaluation of patients with symptoms suggestive of colorectal cancer involves an increased use of flexible sigmoidoscopy. The number of endoscopists is declining, and therefore we found it interesting to describe a endoscopy training programme for the first two Danish nurses. MATERIALS AND METHODS: Two nurses were enrolled in a five-module practical training programme including a multiple-choice test and simulator training. After their completion of at least 100 sigmoidoscopies, a questionnaire on patient satisfaction was administered together with recording of technical details of the sigmoidoscopies during a three-month period. RESULTS: During the three-month period, the nurses performed 69 sigmoidocopies. Of these, 88% reached a triangular lumen, the median examination time was 25 minutes, intubation of the sigmoid was successful in all cases and video review of the sigmoidoscopies revealed that no significant pathology had been misdiagnosed. Patient satisfaction among those examined by nurses showed that fewer patients experienced pain during the endoscopy than those examined by doctors. DISCUSSION: The training programme was completed as planned, and the nurses obtained endoscopic skills comparable to that of doctors concerning patient satisfaction. Sigmodoscopy can be performed at an acceptably high standard by nurses. Training nurses to perform endoscopy requires a significant number of teaching hours and close supervision.