Real-world data on the pattern of recurrence of colorectal cancer at a tertiary cancer center in South India: A retrospective observational study

Abstract

Background: Recurrent colorectal cancer may be amenable to curative treatment. As the debate on the ideal set of investigations and frequency of follow-up continues, it is important to review the pattern of recurrence in the real-world setting, which could help tailor future follow-up strategies. Objectives: Our primary objective was to study the varying clinical presentations and patterns of recurrence of colorectal cancer. The secondary objectives were to study the site of recurrence, method of diagnosis of recurrence, incidence of second primary colorectal cancer, and salvage rates after recurrence of colorectal cancer. Material and Methods: We reviewed the data of patients who were treated from January 2010 to December 2016 at the Malabar Cancer Center, a tertiary cancer center in Kerala, India. We recorded the clinicopathologic details of patients who were treated with curative intent and had serologic (carcinoembryonic antigen [CEA] elevation), clinical, or radiological evidence of disease recurrence. We also studied the timing and anatomical location of recurrence, symptoms, and the method by which the recurrence was diagnosed. Results: We included 675 patients in the study. There were 324 (48%) female patients; the median age was 55 years (interquartile range [IQR], 47.2-65). The primary diagnosis was colon cancer in 326 (48.3%) and rectal in 349 (51.7%) patients. Multimodality therapy was administered to 393 (58.2%) patients in the form of surgery with or adjuvant neoadjuvant chemoradiation adjuvant radiation, or neoadjuvant short-course radiation with neoadjuvant and adjuvant chemotherapy. Recurrences occurred in 109 (16.1%) patients, only 50 (45.9%) of whom were symptomatic. Recurrences were diagnosed by CEA elevation in 65 (59.6%), imaging in 12 (11%), clinical examination in 4 (3.7%), and colonoscopy in 1 (0.9%) patient. The median time to recurrence was 17 months (95% CI, 14-22). Local and distant recurrences occurred in 29 (4.2%) and 80 (11.9%) patients, respectively; 22 (27.5%) patients developed multisite distant recurrences. Recurrences occurred within the first 5 years of completion of therapy in 96 (88.1%) cases. Twelve (11%) patients received salvage therapy with curative intent. Six patients (0.9%) had a metachronous colorectal primary tumors. Conclusions: Colorectal cancer recurs most commonly in the first 5 years after therapy. Multisite distant recurrence and isolated liver metastases predominate. Recurrences are often asymptomatic and most commonly manifest as elevated CEA. Regular clinical evaluation, CEA testing, colonoscopy, and symptom-based cross-sectional imaging detect up to three-quarters of patients with recurrences, but the overall salvageability remains low.