How surgical experts evaluate patients with clinical evidence of recurrence of rectal carcinoma: No consensus

Introduction: The optimal evaluation of patients with clinically suspected recurrence of rectal carcinoma is not known. Many testing modalities are available and their costs are significant. We documented the intensity of the extent-of-disease workup recommended by colorectal surgeons when their own patients with rectal carcinoma develop clinical evidence of recurrence.

Methods: A custom-designed questionnaire was mailed to all 1,795 members of the American Society of Colon and Rectal Surgeons (ASCRS). Subjects were asked which laboratory tests and imaging studies they would order for one of their generally healthy patients with a rising serum CEA level following potentially curative low anterior resection of a T3N0M0 adenocarcinoma of the rectum (and no adjuvant therapy). The second vignette described a generally healthy patient with multiple potentially resectable pulmonary nodules following potentially curative low anterior resection of a T3N0M0 adenocarcinoma of the rectum (and no adjuvant therapy). We measured the variability of practice patterns among surgeons and estimated the effects of physician age, US Census Region, health maintenance organization (HMO) penetration rate, and type of recurrence on the intensity of the evaluation.

Results: Of the 566 questionnaires completed (33%), 347 (61%) were evaluable. Nonevaluability was usually due to lack of rectal cancer patient follow-up in surgeons' practices. The tests most frequently recommended for the scenario involving elevated CEA level were: CT (92%), repeat CEA level (87%), and colonoscopy (87%). The tests most frequently recommended for the scenario involving pulmonary nodules were: CT of chest (90%), CT of abdomen/pelvis (74%), CEA level (55%), CBC (55%), and colonoscopy (55%). The effects on workup intensity of physician age, US Census Region, HMO penetration rate, and type of recurrence were small.

Conclusions: This is the first empirical data on this subject for a large sample of an international society of highly credentialed experts. The lack of consensus for most tests in current practice is likely due to multiple factors, including the lack of evidence supporting any particular strategy, variations in the quality of medical insurance held by patients in a particular surgeon's practice, and cultural determinants.