Letters to the Editor
Follow-Up Care of Patients with Fully Resected Colon Cancer
to the editor: I read with interest the article "Care of Cancer Survivors"1 in the February 15, 2005, issue of American Family Physician. I was surprised to see such a firm recommendation for aggressive follow-up of fully resected colon cancer with inaccurately documented references. The authors recommend carcinoembryonic antigen monitoring every three months for the first two years following treatment, and then every six months for the next three years; this is controversial and not a fully endorsed recommendation. According to my investigation, the National Comprehensive Cancer Network is the only medical group recommending routine carcinoembryonic antigen monitoring testing, and no major medical organization recommends routine computed tomography (CT) scanning as listed in the article.1 Also, the references listed in the article1 far from fully endorse routine aggressive follow-up with carcinoembryonic antigen monitoring testing and/or CT scanning.
The latest Cochrane article I could find is not from 2004, as noted in the article,1 but was last updated in 20022 and in no way firmly recommends aggressive follow-up. In its summary recommendations, it states: "Because of the wide variation in the follow-up programmes used in the included studies, it is not possible to infer from the data the best combination and frequency of clinic (or family practice) visits, blood tests, endoscopic procedures and radiological investigations to maximi[z]e the outcomes for these patients. Nor is it possible to estimate the potential harms or costs of intensifying follow-up for these patients."2
The other reference3 listed by the authors does not recommend aggressive follow-up with carcinoembryonic antigen monitoring and CT scanning either but discusses the limitations of present evidence in decision making.
A 2004 review article4 discusses the controversy around aggressive follow-up and compares the recommendations of individual organizations.
The primary listed reference from Cochrane presents a more balanced overall recommendation: "The results of this review support the general principle of clinical follow-up for patients with CRC [colorectal cancer] after curative treatment. The exact details of the optimal follow-up regimen still need clarification."2
REFERENCES
1. Sunga AY, Oeffinger KC, Hudson MM, Mahoney MC. Care of cancer survivors. Am Fam Physician 2005; 71:699-706.
2. Jeffery GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2002;(1):CD002200.
3. Renehan AG, Egger M, Saunders MP, O'Dwyer ST. Impact on survival of intense follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomized trial. BMJ 2002;324:813.
4. Pfister DG, Benson AB III, Somerfield MR. Clinical practice. Surveillance strategies after curative treatment of colorectal cancer. N Engl J Med 2004;350:2375-82.
in reply: We would like to thank Dr. Lawson for his remarks. Several of his comments are already addressed in our review.1 Specifically, with regard to surveillance following treatment for colorectal cancer, we stated "it is not possible to infer an optimal combination of tests or frequency of clinical follow-up for intensive colorectal cancer surveillance."1
We have cited general recommendations for follow-up of patients with colorectal cancer endorsed by the National Comprehensive Cancer Network (NCCN). The NCCN guidelines2 are in line with recommendations by the American Society of Clinical Oncology (ASCO) and the American Society of Colon and Rectal Surgeons (ASCRS). NCCN and ASCO recommend carcinoembryonic antigen (CEA) testing every three months for at least two years (ASCO recommends testing for at least two years; NCCN for two years, then every six months for three more years), whereas ASCRS recommends monitoring CEA levels a minimum of three times per year during the first two years of follow-up. A recent pooled analysis3 from 17 adjuvant randomized trials showed that more than 25 percent of recurrences occur beyond three years following surgery. Thus, we feel that a five-year follow-up, as recommended by NCCN, is favored.
Computed tomography (CT) remains a controversial modality of colorectal cancer surveillance and is not recommended routinely by any organization at this point. However, recent studies4,5 suggest that early asymptomatic recurrences can be detected by CT in the absence of CEA elevations. A significant number of these recurrences are amenable for curative resection, leading to an improved survival in comparison with unresectable patients.4,5 At this time, CT cannot be recommended routinely as a surveillance modality for colorectal cancer. CT scans should be obtained in the work-up of symptomatic patients or in the presence of elevated CEA and can be considered in patients at high risk of recurrence, such as those with stage III disease.
The importance of rigorous surveillance in colorectal cancer is based on the prospect of salvage surgery at the time of recurrence. Resection of isolated recurrences can lead to a five-year survival of about 30 percent,5 whereas five-year survivorship following chemotherapy in patients with unresectable recurrent disease is well below 10 percent. The ability to achieve a successful curative resection is highly compromised in the setting of symptomatic detection. This is supported by a study4 of 154 relapses seen in a randomized phase III study of adjuvant fluorouracil/leucovorin in patients with stage II and III disease. At the time of publication of this study, none of the patients with resected symptomatic recurrences were alive at five years, whereas 18.6 and 25.9 percent of those with resected CEA recurrences and resected CT recurrences, respectively, remained alive. Whether the implementation of an intensive surveillance schedule that includes frequent CT scans is affordable to society is yet to be determined and should be the subject of future cost-effectiveness analysis studies.
Finally, the publication year listed for the Cochrane review6 reference in the article was inadvertently changed; the correct publication year for this work is 2002.
REFERENCES
1. Sunga AY, Oeffinger KC, Hudson MM, Mahoney MC. Care of cancer survivors. Am Fam Physician 2005; 71:699-706.
2. National Comprehensive Cancer Network. The NCCN clinical practice guidelines in oncology. Accessed online June 13, 2005, at: http://www.nccn.org/professionals/physician_gls/default.asp.
3. Sargent DJ, Wieand S, Benedetti J, Labianca R, Haller DG, Shepherd LE, et al. Disease-free survival (DFS) vs. overall survival (OS) as a primary endpoint for adjuvant colon cancer studies: individual patient data from 12,915 patients on 15 randomized trials. J Clin Oncol 2004;22(14S):3502.
4. Chau I, Allen MJ, Cunningham D, Norman AR, Brown G, Ford HE, et al. The value of routine serum carcino-embryonic antigen measurement and computed tomography in the surveillance of patients after adjuvant chemotherapy for colorectal cancer. J Clin Oncol 2004;22:1420-9.
5. Tepper JE, O'Connell M, Hollis D, Niedzwiecki D, Cooke E, Mayer RJ. Analysis of surgical salvage after failure of primary therapy in rectal cancer: results from Intergroup Study 0114. J Clin Oncol 2003;21:3623-8.
6. Jeffery GM, Hickey BE, Hider P. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database Syst Rev 2002;(1):CD002200.
Nasal Irrigation to Treat Acute Bacterial Rhinosinusitis
to the editor: In the two-part article on acute bacterial rhinosinusitis (ABRS),1,2 the authors correctly identified the challenges in diagnosing acute bacterial rhinosinusitis. They noted that although up to 98 percent of physicians prescribe antibiotics for patients with rhinosinusitis, most cases are viral or allergic rather than bacterial, and that most patients really want recommendations for symptom relief.1
Nasal irrigation is an adjunctive therapy for ABRS and is noted to be "possibly effective" for the relief of sinus symptoms.2 We believe the potential benefits of nasal irrigation outweigh the negligible risks, and that it should be considered for more patients with rhinosinusitis, especially those with recurrent symptoms for whom effective medical treatment often is difficult. Nasal irrigation has been associated with decreased sinus symptom severity and recently was identified as "an important component in the management of most sinonasal conditions" that is "effective and underutilized."3
Nasal irrigation is an inexpensive, patient-controlled therapy that flushes the nasal cavity with saline solution, facilitating a wash of the structures within. Benefits from nasal irrigation may accrue from removal of nasal discharge and crusts, mucus thinning,3 and enhanced mucociliary clearance of nasal secretions. Nasal irrigation also may decrease mucosal inflammation osmotically.
Randomized controlled trials (RCTs) have assessed hypertonic saline nasal irrigation for several sinus-related conditions, including acute sinusitis (three studies), chronic sinus symptoms (two studies), and chronic sinusitis (three studies). Each reported improvement in sinus symptoms and on surrogate measures such as quality-of-life scales. None reported significant adverse events.
Our group recently reviewed the literature and assessed nasal irrigation for recurrent and chronic sinus symptoms in a RCT.4 We found significant improvement in quality-of-life scores and sinus symptoms, and decreased antibiotic and nasal spray use. Side effects were few, and patient satisfaction was high; reported adherence to daily nasal irrigation was 87 percent. Patients continued to note symptomatic improvement over 18 months.5 In a qualitative study,6 subjects reported that their use of nasal irrigation, especially at the onset of sinus symptoms, accounted for decreased medication use and physician visits, and may have prevented future episodes of rhinosinusitis.
Instructing patients is easy and brief. We present the rationale for hypertonic saline nasal irrigation as part of the treatment plan; if the patient is interested, we explain the technique with an illustrated patient handout (http://www.fammed.wisc.edu/research/projects/nasalirrigation.html). We recommend using nasal irrigation once daily from the onset of sinus symptoms until resolution. Nasal irrigation pots are available at most pharmacies.
The literature shows that even with the best clinical evaluation, we are likely to misdiagnose ABRS. Nasal irrigation can help reduce symptoms while the illness declares itself or resolves. Questions about exact salinity, pH, and frequency of nasal irrigation require further study. However, the data show that nasal irrigation is effective, safe, and tolerable for patients with sinonasal symptoms. Nasal irrigation should be considered for more patients with rhinosinusitis (including ABRS), especially those patients with recurrent and chronic symptoms who often have few effective treatment options.
REFERENCES
1. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. Am Fam Physician 2004;70:1685-92.
2. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part II. Treatment. Am Fam Physician 2004;70:1697-704.
3. Brown CL, Graham SM. Nasal irrigations: good or bad? Curr Opin Otolaryngol Head Neck Surg 2004;12:9-13.
4. Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract 2002;51:1049-55.
5. Rabago D, Pasic T, Zgierska A, Mundt M, Barrett B, Maberry R. The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms. Otolaryngol Head Neck Surg 2005;133:3-8.
6. Rabago D, Barrett B, Marchand L, Maberry R. Hypertonic saline nasal irrigation for chronic sinus symptoms: a qualitative study (Poster Presentation). Society of Teachers of Family Medicine Annual Conference 2005. Accessed online May 24, 2005, at: http://www.stfm.org/annualconf/an05/annual05web.pdf.
in reply: We thank Dr. Rabago and colleagues for their comments and agree that nasal irrigation is an adjunctive therapy that should be considered for patients with recurrent or chronic sinus symptoms. However, the focus of our review was acute bacterial rhinosinusitis. We reviewed the literature, which includes the articles cited by Dr. Rabago and colleagues, and found evidence that nasal irrigation was effective for relief of sinonasal symptoms in patients with chronic, frequent, recurrent sinusitis; recent intranasal or sinus surgery; allergic rhinitis; and age-related rhinitis. We found only two randomized controlled trials (RCTs) of nasal irrigation in adults.1,2 Contrary to the claim of Dr. Rabago and associates that all studies of nasal irrigation have shown a benefit, one RCT1 that included patients with colds and rhinosinusitis found no advantage of hypertonic saline nasal irrigation or normal saline nasal irrigation over observation. In another RCT,2 six groups of 50 patients with acute sinusitis received one of three antibiotics and either a nasal decongestant or nasal irrigation. The study2 found no differences among groups except for delayed radiologic healing in patients receiving cephradine (Velosef) plus a nasal decongestant. Although the findings of Dr. Rabago's research, as presented in his letter, are interesting, the relevance of the findings to acute bacterial rhinosinusitis are unclear.
Dr. Rabago states that no study has reported significant adverse events. However, in one study,1 32 percent of patients who used hypertonic saline nasal irrigation complained of burning, and only 44 percent stated they would use it again. Other potential adverse side effects include local irritation, itching, otalgia, otitis media, exacerbation of asthma or chronic obstructive pulmonary disease, and sinus pooling with subsequent draining.3
Furthermore, there is no consensus regarding a uniform protocol for nasal irrigation. Various reports are inconsistent about the superiority of hypertonic saline nasal irrigation, normal saline nasal irrigation, or Ringer's lactate solution irrigation.3 Different authors advocate buffered or nonbuffered solutions, and antimicrobial or xylitol additives.3 The importance of sterility is unknown. Multiple delivery methods and devices have been studied but not compared, including bottles or pots, bulb syringes, inhalers, and nebulizers.3
For these reasons, we rated nasal irrigation as "possibly effective." In 2000, the investigators of an evidence report prepared for the Agency for Health Care Policy and Research found insufficient evidence to assess the benefits.4 In 2005, the Academy of Allergology and Clinical Immunology and the European Rhinological Society did not recommend the use of nasal saline douche for acute rhinosinusitis, again because of a lack of evidence.5 Though this review was concerned with the treatment of adults with acute bacterial rhinosinusitis, it also should be noted that the American Academy of Pediatrics found insufficient evidence to recommend saline nasal irrigation in children in 2001.6
REFERENCES
1. Adam P, Stiffman M, Blake RL Jr. A clinical trial of hypertonic saline nasal spray in subjects with the common cold or rhinosinusitis. Arch Fam Med 1998;7:39-43.
2. Axelsson A, Grebelius N, Jensen C, Melin O, Singer F. Treatment of acute maxillary sinusitis. IV. Ampicillin, cephradine and erythromycin estolate with and without irrigation. Acta Otolaryngol 1975;79:466-72.
3. Brown CL, Graham SM. Nasal irrigations: good or bad? Curr Opin Otolaryngol Head Neck Surg 2004;12:9-13.
4. Lau J, Zucker D, Engels EA, Balk E, Barza M, Terrin N, et al. Diagnosis and treatment of acute bacterial rhinosinusitis. Evid Rep Technol Assess (Summ) 2005;124:1-3.
5. Fokkens W, Lund V, Bachert C, Clement P, Helllings P, Holmstrom M, et al. EAACI position paper on rhinosinusitis and nasal polyps executive summary. Allergy 2005;60:583-601.
6. Clinical practice guideline: management of sinusitis. Pediatrics 2001;108:798-808.
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