Follow-up in colorectal cancer: cost-effectiveness analysis of established and novel concepts

Background: Follow-up programs in colorectal cancer have been under question recently due to their low efficacy. Some meta-analyses found a survival benefit and four randomized studies suggested the opposite. Therefore, this paper analyzes existing and proposed follow-up programs for costs and efficacy. Methods: One thousand and fifty-four colorectal cancer patients intensively followed-up in Ulm (endoscopy, chest radiography, abdominal ultrasound, computed tomography (CT) pelvis) were prospectively evaluated for recurrence, salvage surgery rate, survival and costs. Costs were compared among existing and proposed international follow-up programs retrieved by a MedLine search. Results: A total of 350/1054 colorectal cancer patients (33.2%) relapsed asymptomatically, as detected by follow-up. 56/350 (local 47%, distant 53%) recurrences were resectable (16%), 21/350 patients survived (6%). The efficacy of follow-up was 21/1054 patients (2%). Costs were, per patient, 2220 euros (colon) or 4851 euros (rectum). Costs in five randomized studies varied between 616 euros for minimal and 5049 euros for intensive follow-up. Four proposed follow-up concepts include risk-adaption, which claim to reduce costs by 50–60% and range between 889 (colorectal) and 5910 (high-risk, rectum) euros. The recommended German follow-up guideline costs 610 euros (low-risk, colorectal), 1120 euros (high-risk, colon) or 2252 euros (high-risk, rectum). Conclusion: Follow-up concepts for colorectal cancer should aim at the identification of curable patients with recurrence. Evidence-based concepts, including life quality tests, remain to be defined, but currently abdominal ultrasound, endoscopy and carcino-embryonic antigen (CEA) determination at 6-month intervals for 2 years and annual intervals for 3 years seem to identify this patient sub-group.