title: Risk-stratified intensive follow up for treated colorectal cancer - realistic and cost saving?
abstract: OBJECTIVE
  Intensive follow-up post surgery for colorectal cancer (CRC) is thought to improve long-term survival principally through the earlier detection of recurrent disease. This paper aims to calculate the additional resource and cost implications of intensive follow up post-CRC resection, examine the possibility of risk-stratifying this follow up to those at highest risk of recurrence and investigating the impact that population screening might have on the future cost and outcomes of follow up.
  
  
  METHODS
  Two follow-up regimens were constructed: the 'standard' follow-up protocol used the principles of the British Society of Gastroenterology (BSG) guidelines whilst the 'intensive' follow-up protocol used the most intensive arm of the follow up after colorectal surgery (FACS) trial. Using ONS data, the number of CRC diagnosed in a given year was calculated for 2003 and projected for 2016 based on the population of England and Wales. The resource requirements and costs of follow up over a 5-year period were then calculated for the two time periods. Risk stratifying entry to follow up and the introduction of population CRC screening were then considered.
  
  
  RESULTS
  For the 2003 cohort, an intensive follow-up program would detect 853 additional resectable recurrences over 5 years with 795 fewer subjects requiring palliative care. An additional 26 302 outpatient appointments, 181 352 CEA tests and 79 695 CT scans over 5 years would be required to achieve this. The cost of investigating subjects who would never develop detectable recurrences was pound15.6 million. The cost per additional resectable recurrence was pound18 077, a figure also found for a nonscreened population in 2016. An identical intensive follow-up policy with biennial FOBT screening in 2016 saw the cost per additional resectable recurrence rise to pound36 255.
  
  
  CONCLUSIONS
  Intensive follow up will detect considerably more resectable recurrences but at considerable cost and it is unclear if such follow up will be achievable in an already over-stretched NHS. If population-based CRC screening increases the number of Dukes A cancers this may offer the possibility of risk-stratifying future follow up to those at highest risk of recurrence; minimizing tests on those who will never have recurrent disease and better utilizing our scarce resources.
authors.affiliation: Department of Surgery, James Cook University Hospital, Middlesborough, Cleveland, UK. dmacafee@doctors.org.uk
authors.forename: D A L
authors.initials: DA
authors.lastname: Macafee
authors.forename: D K
authors.initials: DK
authors.lastname: Whynes
authors.forename: J H
authors.initials: JH
authors.lastname: Scholefield
mesh_terms: D015331:Cohort Studies; D003082:Colectomy / Q000009:adverse effects / Q000379:methods; D015179:Colorectal Neoplasms / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis* / Q000401:mortality; D009367:Neoplasm Staging; D012308:Risk Management / Q000191:economics*; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D006113:United Kingdom