Colorectal cancer survivorship program at a single tertiary centre :– Has service provision changed after Covid-19?

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Rachael Menadue, Lea Tiffany, Shriranshini Satheakeerthy, Aditya Sakalkale, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5518160/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Jul, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Surveillance after colorectal cancer (CRC) resection is an important aspect of survivorship care. This study aimed to assess whether there were any changes to post-operative surveillance in non-metastatic CRC patients, pre and post-COVID pandemic in Victoria. Methods All CRC patients (stage I-III) who underwent curative surgery at Western Health, Victoria, Australia were included. Surveillance included a three-monthly clinical review and carcinoembryonic antigen (CEA) up to 18 months, and CT imaging and colonoscopy at 12 months following surgical resection. Results Between 2019-2022, 380 patients were identified. Stage III patients had the highest uptake with regards to clinical reviews, CEA testing and 12-month CT (83.3%, 60.3% and 85.5% respectively) while Stage I patients had the lowest (52.7%, 35.7% and 75.5% respectively) (p<0.05). Colonoscopy surveillance was low regardless of stage (66.3%, 59.8% and 59.7% of Stage I, II and III respectively). Uptake of CEA, clinic reviews and colonoscopy did not vary during our study period. More patients underwent 12-month CT following the COVID pandemic (87.0%) compared to pre-COVID (73.1%) or during COVID (76.0%, p<0.05). There was no difference in 18-month mortality and overall recurrence during our study timelines. Conclusion Patients with earlier stage CRC had lower rates of adherence to surveillance protocols, particularly with regard to CEA monitoring and colonoscopic surveillance. Adherence to surveillance and surveillance patterns were not meaningfully altered by the intra or post COVID-19 era. Colorectal Cancer Surveillance Survivorship follow-up COVID adherence Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Colorectal cancer (CRC) remains the most common digestive tract malignancy in Australia, and the second leading cause of cancer death [1]. Surveillance following curative resection for CRC is an essential aspect of survivorship care, as patients remain at risk of developing recurrence, most commonly within the first two years of surgery [2]. The incidence of CRC is increasing, with over 17,000 new cases diagnosed annually in Australia, resulting in more patients entering follow-up surveillance programs [1]. The COVID-19 pandemic has led to significant disruptions in colorectal cancer care within Australia, with increasing clinical and health economic demands on our healthcare system. We sought to analyse the changes in CRC surveillance provision over the last few years in order to better inform our future provision of services. This study therefore aimed to assess the overall level of adherence of patients to surveillance follow-up post-surgery for non-metastatic CRC at a tertiary referral centre between January 2019 and December 2022. Methods A retrospective analysis was undertaken to evaluate all patients who underwent curative resection for colorectal adenocarcinoma at Western Health between 2019 and 2022. Western Health, located in metropolitan Victoria, Australia, serves a population of approximately one million. Patients were excluded from the study if they did not participate in follow-up care, had their care transferred to another institution, or did not require surveillance as decided by the CRC multidisciplinary team. Patients were identified using our prospective CRC registry (ACCORD). Patient data from the hospital Electronic Medical Records (EMR) were reviewed by two independent health practitioners to ensure data concordance. Follow-up data was recorded for the first 18-month period following CRC resection and adherence to our institutional surveillance protocol was assessed. Patients’ clinical and sociodemographic characteristics were recorded, including age, gender and type of operation performed. Tumour characteristics including the American Joint Committee on Cancer (AJCC) stage were recorded for all patients. Our surveillance protocol (Figure 1) required patients to have three-monthly outpatient reviews, either in-person or by telehealth. Reviews were conducted either in a specialist-led colorectal surgical or medical oncology clinic. All patients of Non-English-Speaking Backgrounds (NESB) were provided with an interpreter during their clinic appointment. Serum CEA was required three-monthly. Requests for CEA were completed on physical blood request forms, by providers directly linked to our hospital network. CT scans and colonoscopy were due 12 months after surgery and were requested to be completed within our own institution, Except in those cases were a complete colonoscopy was not obtained prior to surgery, in which case a colonoscopy within 12 months was indicated. A grace period of six weeks before and after a due date for a clinical review or investigation was deemed acceptable with a previous study at our institution [25]. Descriptive data was used for patient demographics, cancer characteristics and primary procedure. Pearson Chi-Squared test, ANOVA, MANOVA (with post-hoc testing) as well as Kruskal-Wallis test (with post-hoc testing) were used as appropriate when comparing categorical variables and rates of compliance with follow-up metrics. An alpha of <0.05 was deemed statistically significant. Approval from Western Health Human Research Ethics Committee was obtained (WH/95334/QA2023.22). Results 451 patients were assessed for eligibility. 71 patients were subsequently excluded from the analysis (Figure 2); 4 declined follow-up (n=4), 53 were transferred to another public or private institution (n=53), 8 were deceased (n=8), 6 were deemed to be exempt from intensive surveillance by the multidisciplinary team (n=6). All follow up was assessed until the time of drop out, transfer or death. A final total of 380 patients (stage I,II and III) were identified, of whom 213 were male and 167 were female. Of the 380 patients, the majority suffered from colonic cancer (70.8%). 103 patients presented with Stage I colorectal cancer, 129 with Stage II and 148 with Stage III. The most commonly performed primary procedures were anterior resections, n=149 (39.2%). 109 CRC patients (Stages I,II and III) were treated in 2019, 90 in 2020, 101 in 2021 and 80 in 2022. Provision is defined as the proportion of patients who adhered to surveillance metric. [TABLE 1] Clinical reviews Overall provision of clinical reviews (in person as well as telehealth) for Stage I, II and III CRC were 52.7%, 63.2% and 83.5% respectively. Patients who had Stage III CRC consistently had the highest provision at all time-points at 83.5% (p<0.05) (Figure 3 and Table 2). Stage III patients were more likely to have their surveillance with clinic reviews in comparison with Stages I and II (Chi2, p<0.05). Serial CEA Overall provision with serial three-monthly CEA levels for Stage I, II and III CRC were low at 35.7%, 49.4% and 60.3% respectively. Patients with Stage III CRC demonstrated the highest adherence (p<0.05), with a mean compliance rate of 60.3% across all time-points. There was better provision of serial CEA levels amongst Stage III patients compared to Stages I and II (p<0.05)(Figure 4). CT and Colonoscopy In total, 272 patients completed their CT scan at 12-months after surgical resection (79.5%). Similar rates were seen across the 3 stages of CRC (p=0.06). Completion of colonoscopy at 12 months was 61.7% with 209 patients successfully undergoing the procedure within the recommended time-period. Overall CRC Outcomes There was an overall CRC recurrence rate of 15.4% in the first 18 months of surveillance, with Stage III patients being the most likely to experience recurrence at 30.4% (p<0.05), compared to 8.5% of Stage II and 6.8% of Stage I CRC. [TABLE 2] Impact of COVID pandemic The COVID pandemic resulted in several lockdowns in the state of Victoria, Australia from 2020 to 2021. There were 116 patients in the pre-COVID group, 102 patients during COVID and 162 patients in the post-COVID. There was a higher proportion of patients who presented with Stage III CRC after COVID compared to earlier time periods; post COVID 47.5%, compared to before COVID 35.3% and during COVID 29.4% ( p<0.05 ) . More patients underwent a 12-month CT following the COVID pandemic (87.0% compared to pre-COVID 73.1% or during COVID 76.0%) ( p<0.05 ). Provision of CEA, clinic reviews and colonoscopy were not statistically different across the COVID timelines. 18-month mortality and overall recurrence were also not statistically significant across the COVID timelines. Discussion Colorectal cancer surveillance is an essential aspect of survivorship care. Current Australian national guidelines recommend that those who undergo resection for colorectal cancer with curative intent, and who are fit for further intervention, should receive intensive follow-up [ 3 ]. Some systematic reviews and meta-analyses have noted an overall survival benefit with intensive surveillance protocols [ 10 , 11 ]. However, a recent, updated systematic review by Jeffery et al, which included over 13,000 patients, did not find any improvement in overall survival, disease-free survival or relapse-free survival with intensive CRC surveillance regimens [ 12 ]. This finding is in keeping with analysis of data from the National Cancer Database [ 13 ]. Nevertheless, current Australian guidelines recommend intensive surveillance for suitable patients who undergo resection for colorectal cancer with curative intent [ 3 ]. Surveillance typically involves a combination of clinical evaluation and investigations including serial serum carcinoembryonic antigen (CEA) measurement, computed tomography (CT) scans and colonoscopy. Such regimens are often time and resource intensive for healthcare systems. Due to increasing demand on health networks and variation in patient background demographics and understanding of the importance of surveillance follow up, adherence to these guidelines can be highly variable [ 4 ]. This study aimed to identify if colorectal cancer surveillance at our institution changed due to the pandemic and how a subsequent increase in clinical demand might have impacted our surveillance provision. Approximately 50% of our patients completed serial serum CEA tests. Additionally, colonoscopy provision at 12-months was lower than previously published Australian data [ 14 , 15 ]. CT scans performed at the 12-month period had the greatest provision of all the investigations. We found that Stage III patients had the highest rates of compliance to the surveillance protocol for all tests; clinical review reached 90% uptake. This may be explained by the fact that higher stage patients who also had medical oncology treatment and separate oncology follow-up, were more likely to have multiple survivorship review requests by the multidisciplinary team and/or had a better understanding of the importance of surveillance take up. There was a change in how clinical follow-up was offered during the pandemic, similar to many other health institutions within Australia. Patients during the pandemic were offered ‘telehealth’ (mainly telephone) appointments and this has continued to the present day. There is evidence in the literature that the disruptions caused by the pandemic have led to reductions in screening, diagnostic, and treatment services for colorectal cancer both nationally and internationally [ 22 ]. From our study, we have shown that adherence to our CRC surveillance were largely unaffected by the COVID pandemic, however the uptake of telehealth versus in-person reviews in our centre is not currently known. Our study also showed that a greater proportion of our patients presented as Stage III cancers after COVID. This is no different to other national and international data where in particular screening colonoscopies and patient presentation of symptoms were impacted by the pandemic [ 23 , 24 , 26 ]. There are several learning points from this study. There are still barriers with regards to institutional workflows and patient characteristics which has led to the variation in survivorship care between different cancer stages despite having a clear surveillance protocol within our hospital institution. We have shown that certain aspects of surveillance protocol adherence have the potential for high uptake such as in-person clinical reviews. Within our institution, we plan to introduce a nurse–led cancer surveillance program, utilising patient tracking software which aims to reduce duplication of requests, streamline workflows, and ensure more timely survivorship follow up. Utilising nursing staff roles to incorporate tasks previously undertaken by medical staff has been suggested to help with expediting healthcare delivery in cancer care, as well as aiding with healthcare cost reduction [ 17 , 18 ]. Nurse-led clinics for patients with other malignancies, such as breast, lung and prostate, have been reported to be successful with patients [ 19 , 20 ]. In the Australian context, Moloney et al. was able to achieve overall compliance of 97.4% and high patient satisfaction with a nurse-led CRC surveillance program over a 10 year period [ 21 ]. Our study has several limitations. It is a retrospective and as such, results were dependent on the quality of the original raw data. However, as we have a CRC prospectively maintained registry, we have ensured that all patients treated within our institution during the project timeframe have been included. Although the sample size was relatively small, and patients were only followed-up for an 18-month period, we have identified information that we can use to address certain areas in our future practice. Finally, while we examined surveillance provision, it did not examine factors that may have contributed to these results. Survivorship care is an essential aspect of colorectal cancer treatment. Within our institution, patients with different cancer stages had different surveillance program provision. Further work is required to identify how we can improve on our survivorship care for these patients. Declarations Author Contribution: Conceptualization: Justin Yeung, Rachael Menadue; Methodology: Matthew Wei, Rachael Menadue, Lea Tiffany, Shriranshini Satheakeerthy; Formal analysis and investigation: Lea Tiffany, Shriranshini Satheakeerthy; Writing - original draft preparation: Matthew Wei, Shriranshini Satheakeerthy; Writing - review and editing: Shriranshini Satheakeerthy, Justin Yeung, Aditya Sakalkale; Supervision: Justin Yeung, Ian Faragher, Fiona Reid. Acknowledgments Gabriel Lirios, Deyan Momirovski, Alec Leos Disclosure Statement Nil competing or conflicting interests to declare. No funding received. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approval from Western Health Human Research Ethics Committee was obtained (WH/95334/QA2023.22). References AIHW. Australian Institute of Health and Welfare 2021. Cancer in Australia 2021. 2021;Cat. no. CAN 117(Cancer Series No. 114). Meyerhardt JA, Mangu PB, Flynn PJ, Korde L, Loprinzi CL, Minsky BD, et al. Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer: American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol. 2013;31(35):4465–70. Lee P, Beale P, Gilmore A, Party CCACCGW. Health professionals performing follow-up and suggested follow-up schedule. 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JAMA Network Open, 3(8), e2017267. DOI: 10.1001/jamanetworkopen.2020.17267 Pellegrino SA;Chan S;Simons K;Kinsella R;Gibbs P;Faragher IG;Deftereos I;Yeung JM; (no date) Patterns of surveillance for colorectal cancer: Experience from a single large tertiary institution, Asia-Pacific journal of clinical oncology. U.S. National Library of Medicine. Available at: https://pubmed.ncbi.nlm.nih.gov/33079492/ (Accessed: 4 July 2024). Chen MZ, Tay YK, Teoh WM, Kong JC, Carne P, D'Souza B, Chandra R, Bui A; Melbourne Colorectal Collaboration. Melbourne colorectal collaboration: a multicentre review of the impact of COVID-19 on colorectal cancer in Melbourne, Australia. ANZ J Surg. 2022;92(5):1110–1116. doi: 10.1111/ans.17603. Epub 2022 Apr 8. PMID: 35393720; PMCID: PMC9111459. Tables Tables 1 to 2 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 22 Jul, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 25 Apr, 2025 Reviews received at journal 09 Mar, 2025 Reviewers agreed at journal 20 Feb, 2025 Reviewers invited by journal 26 Jan, 2025 Editor assigned by journal 26 Jan, 2025 Submission checks completed at journal 18 Dec, 2024 First submitted to journal 25 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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4","display":"","copyAsset":false,"role":"figure","size":321141,"visible":true,"origin":"","legend":"\u003cp\u003eSerial CEA (%) by stage of Colorectal Cancer\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5518160/v1/67107d060f1631a330013fb4.png"},{"id":87757267,"identity":"39556792-2e1c-4106-8dfe-43552e8a89b5","added_by":"auto","created_at":"2025-07-28 16:10:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1185627,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5518160/v1/2a427684-6923-48c1-bd81-7d2995e57d2e.pdf"},{"id":72291066,"identity":"9aea200c-c1ca-43bd-99a4-09d7e45bc9d8","added_by":"auto","created_at":"2024-12-24 17:25:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20938,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5518160/v1/52e5ccc990aa91b581ac9fa8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Colorectal cancer survivorship program at a single tertiary centre :– Has service provision changed after Covid-19?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColorectal cancer (CRC) remains the most common digestive tract malignancy in Australia, and the second leading cause of cancer death [1]. Surveillance following curative resection for CRC is an essential aspect of survivorship care, as patients remain at risk of developing recurrence, most commonly within the first two years of surgery [2]. The incidence of CRC is increasing, with over 17,000 new cases diagnosed annually in Australia, resulting in more patients entering follow-up surveillance programs [1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic has led to significant disruptions in colorectal cancer care within Australia, with increasing clinical and health economic demands on our healthcare system. We sought to analyse the changes in CRC surveillance provision over the last few years in order to better inform our future provision of services.\u003c/p\u003e\n\u003cp\u003eThis study therefore aimed to assess the overall level of adherence of patients to surveillance follow-up post-surgery for non-metastatic CRC at a tertiary referral centre between January 2019 and December 2022.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective analysis was undertaken to evaluate all patients who underwent curative resection for colorectal adenocarcinoma at Western Health between 2019 and 2022. Western Health, located in metropolitan Victoria, Australia, serves a population of approximately one million.\u0026nbsp;Patients were excluded from the study if they did not participate in follow-up care, had their care transferred to another institution, or did not require surveillance as decided by the CRC multidisciplinary team.\u003c/p\u003e\n\u003cp\u003ePatients were identified using our prospective CRC registry (ACCORD). Patient data from the hospital Electronic Medical Records (EMR) were reviewed by two independent health practitioners to ensure data concordance. Follow-up data was recorded for the first 18-month period following CRC resection and adherence to our institutional surveillance protocol was assessed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients’ clinical and sociodemographic characteristics were recorded, including age, gender and type of operation performed. Tumour characteristics including the American Joint Committee on Cancer (AJCC) stage were recorded for all patients.\u003c/p\u003e\n\u003cp\u003eOur surveillance protocol (Figure 1) required patients to have three-monthly outpatient reviews, either in-person or by telehealth. Reviews were conducted either in a specialist-led colorectal surgical or medical oncology clinic. All patients of Non-English-Speaking Backgrounds (NESB) were provided with an interpreter during their clinic appointment.\u003c/p\u003e\n\u003cp\u003eSerum CEA was required three-monthly. Requests for CEA were completed on physical blood request forms, by providers directly linked to our hospital network. CT scans and colonoscopy were due 12 months after surgery and were requested to be completed within our own institution,\u0026nbsp;Except in those cases were a complete colonoscopy was not obtained prior to surgery, in which case a colonoscopy within 12 months was indicated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA grace period of six weeks before and after a due date for a clinical review or investigation was deemed acceptable with a previous study at our institution [25].\u003c/p\u003e\n\u003cp\u003eDescriptive data was used for patient demographics, cancer characteristics and primary procedure.\u0026nbsp;Pearson Chi-Squared test, ANOVA, MANOVA (with post-hoc testing) as well as\u0026nbsp;Kruskal-Wallis test (with post-hoc testing) were used as appropriate when comparing categorical variables and rates of compliance with follow-up metrics. An alpha of \u0026lt;0.05 was deemed statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproval from Western Health Human Research Ethics Committee was obtained (WH/95334/QA2023.22).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e451 patients were assessed for eligibility. 71 patients were subsequently excluded from the analysis (Figure 2); 4 declined follow-up (n=4), 53 were transferred to another public or private institution (n=53), 8 were deceased (n=8), 6 were deemed to be exempt from intensive surveillance by the multidisciplinary team (n=6). All follow up was assessed until the time of drop out, transfer or death.\u0026nbsp;A final total of 380 patients (stage I,II and III) were identified,\u0026nbsp;of whom\u0026nbsp;213 were male and 167 were female.\u003c/p\u003e\n\u003cp\u003eOf the 380 patients, the majority suffered from colonic cancer (70.8%). 103 patients presented with Stage I colorectal cancer, 129 with Stage II and 148 with Stage III. The most commonly performed primary procedures were anterior resections, n=149 (39.2%).\u0026nbsp;109 CRC patients (Stages I,II and III) were treated in 2019, 90 in 2020, 101 in 2021 and 80 in 2022.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProvision is defined as the proportion of patients who adhered to surveillance metric.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[TABLE 1]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical reviews\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOverall provision of clinical reviews (in person as well as telehealth) for Stage I, II and III CRC were 52.7%, 63.2% and 83.5% respectively. Patients who had Stage III CRC consistently had the highest provision at all time-points at 83.5% (p\u0026lt;0.05) (Figure 3 and Table 2). Stage III patients were more likely to have their surveillance with clinic reviews in comparison with Stages I and II (Chi2, p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSerial CEA\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOverall provision with serial three-monthly CEA levels for Stage I, II and III CRC were low at 35.7%, 49.4% and 60.3% respectively. Patients with Stage III CRC demonstrated the highest adherence (p\u0026lt;0.05), with a mean compliance rate of 60.3% across all time-points. There was better provision of \u0026nbsp;serial CEA levels amongst Stage III patients compared to Stages I and II (p\u0026lt;0.05)(Figure 4).\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCT and Colonoscopy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 272 patients completed their CT scan at 12-months after surgical resection (79.5%). Similar rates were seen across the 3 stages of CRC (p=0.06). Completion of colonoscopy at 12 months was 61.7% with 209 patients successfully undergoing the procedure within the recommended time-period.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOverall CRC Outcomes\u003cbr\u003e\u003c/em\u003eThere was an overall CRC recurrence rate of 15.4% in the first 18 months of surveillance, with Stage III patients being the most likely to experience recurrence at 30.4% (p\u0026lt;0.05), compared to 8.5% of Stage II and 6.8% of Stage I CRC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[TABLE 2]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImpact of COVID pandemic\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe COVID pandemic resulted in several lockdowns in the state of Victoria, Australia from 2020 to 2021.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were 116 patients in the pre-COVID group, 102 patients during COVID and 162 patients in the post-COVID. There was a higher proportion of patients who presented with Stage III CRC after COVID compared to earlier time periods; post COVID 47.5%, compared to before COVID 35.3% and during COVID 29.4% (\u003cem\u003ep\u0026lt;0.05\u003c/em\u003e) .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore patients underwent a 12-month CT following the COVID pandemic (87.0% compared to pre-COVID 73.1% or during COVID 76.0%) (\u003cem\u003ep\u0026lt;0.05\u003c/em\u003e). Provision of CEA, clinic reviews and colonoscopy were not statistically different across the COVID timelines. 18-month mortality and overall recurrence were also not statistically significant across the COVID timelines.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eColorectal cancer surveillance is an essential aspect of survivorship care. Current Australian national guidelines recommend that those who undergo resection for colorectal cancer with curative intent, and who are fit for further intervention, should receive intensive follow-up [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Some systematic reviews and meta-analyses have noted an overall survival benefit with intensive surveillance protocols [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, a recent, updated systematic review by Jeffery et al, which included over 13,000 patients, did not find any improvement in overall survival, disease-free survival or relapse-free survival with intensive CRC surveillance regimens [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This finding is in keeping with analysis of data from the National Cancer Database [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nevertheless, current Australian guidelines recommend intensive surveillance for suitable patients who undergo resection for colorectal cancer with curative intent [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurveillance typically involves a combination of clinical evaluation and investigations including serial serum carcinoembryonic antigen (CEA) measurement, computed tomography (CT) scans and colonoscopy. Such regimens are often time and resource intensive for healthcare systems. Due to increasing demand on health networks and variation in patient background demographics and understanding of the importance of surveillance follow up, adherence to these guidelines can be highly variable [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to identify if colorectal cancer surveillance at our institution changed due to the pandemic and how a subsequent increase in clinical demand might have impacted our surveillance provision.\u003c/p\u003e \u003cp\u003eApproximately 50% of our patients completed serial serum CEA tests. Additionally, colonoscopy provision at 12-months was lower than previously published Australian data [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. CT scans performed at the 12-month period had the greatest provision of all the investigations.\u003c/p\u003e \u003cp\u003e We found that Stage III patients had the highest rates of compliance to the surveillance protocol for all tests; clinical review reached 90% uptake. This may be explained by the fact that higher stage patients who also had medical oncology treatment and separate oncology follow-up, were more likely to have multiple survivorship review requests by the multidisciplinary team and/or had a better understanding of the importance of surveillance take up.\u003c/p\u003e \u003cp\u003eThere was a change in how clinical follow-up was offered during the pandemic, similar to many other health institutions within Australia. Patients during the pandemic were offered \u0026lsquo;telehealth\u0026rsquo; (mainly telephone) appointments and this has continued to the present day. There is evidence in the literature that the disruptions caused by the pandemic have led to reductions in screening, diagnostic, and treatment services for colorectal cancer both nationally and internationally [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. From our study, we have shown that adherence to our CRC surveillance were largely unaffected by the COVID pandemic, however the uptake of telehealth versus in-person reviews in our centre is not currently known.\u003c/p\u003e \u003cp\u003eOur study also showed that a greater proportion of our patients presented as Stage III cancers after COVID. This is no different to other national and international data where in particular screening colonoscopies and patient presentation of symptoms were impacted by the pandemic [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are several learning points from this study. There are still barriers with regards to institutional workflows and patient characteristics which has led to the variation in survivorship care between different cancer stages despite having a clear surveillance protocol within our hospital institution. We have shown that certain aspects of surveillance protocol adherence have the potential for high uptake such as in-person clinical reviews. Within our institution, we plan to introduce a nurse\u0026ndash;led cancer surveillance program, utilising patient tracking software which aims to reduce duplication of requests, streamline workflows, and ensure more timely survivorship follow up.\u003c/p\u003e \u003cp\u003eUtilising nursing staff roles to incorporate tasks previously undertaken by medical staff has been suggested to help with expediting healthcare delivery in cancer care, as well as aiding with healthcare cost reduction [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Nurse-led clinics for patients with other malignancies, such as breast, lung and prostate, have been reported to be successful with patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the Australian context, Moloney et al. was able to achieve overall compliance of 97.4% and high patient satisfaction with a nurse-led CRC surveillance program over a 10 year period [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study has several limitations. It is a retrospective and as such, results were dependent on the quality of the original raw data. However, as we have a CRC prospectively maintained registry, we have ensured that all patients treated within our institution during the project timeframe have been included. Although the sample size was relatively small, and patients were only followed-up for an 18-month period, we have identified information that we can use to address certain areas in our future practice. Finally, while we examined surveillance provision, it did not examine factors that may have contributed to these results.\u003c/p\u003e \u003cp\u003eSurvivorship care is an essential aspect of colorectal cancer treatment. Within our institution, patients with different cancer stages had different surveillance program provision. Further work is required to identify how we can improve on our survivorship care for these patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Justin Yeung, Rachael Menadue; Methodology: Matthew Wei, Rachael Menadue, Lea Tiffany, Shriranshini Satheakeerthy; Formal analysis and investigation: Lea Tiffany, Shriranshini Satheakeerthy; Writing - original draft preparation: Matthew Wei, Shriranshini Satheakeerthy; Writing - review and editing: Shriranshini Satheakeerthy, Justin Yeung, Aditya Sakalkale; Supervision: Justin Yeung, Ian Faragher, Fiona Reid.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGabriel Lirios, Deyan Momirovski, Alec Leos\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNil competing or conflicting interests to declare. No funding received. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approval from Western Health Human Research Ethics Committee was obtained (WH/95334/QA2023.22).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAIHW. Australian Institute of Health and Welfare 2021. Cancer in Australia 2021. 2021;Cat. no. CAN 117(Cancer Series No. 114).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyerhardt JA, Mangu PB, Flynn PJ, Korde L, Loprinzi CL, Minsky BD, et al. 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A Review of the Impact of the COVID-19 Pandemic on Colorectal Cancer Screening: Implications and Solutions. Pathogens. 2021;10(11):1508. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/pathogens10111508\u003c/span\u003e\u003cspan address=\"10.3390/pathogens10111508\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34832663; PMCID: PMC8619517.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRottoli M, Gori A, Pellino G, Flacco ME, Martellucci C, Spinelli A, Poggioli G; COVID\u0026ndash;Colorectal Cancer (CRC) Study Group. Colorectal Cancer Stage at Diagnosis Before vs During the COVID-19 Pandemic in Italy. 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DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2020.17267\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2020.17267\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePellegrino SA;Chan S;Simons K;Kinsella R;Gibbs P;Faragher IG;Deftereos I;Yeung JM; (no date) Patterns of surveillance for colorectal cancer: Experience from a single large tertiary institution, Asia-Pacific journal of clinical oncology. U.S. National Library of Medicine. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/33079492/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/33079492/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (Accessed: 4 July 2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen MZ, Tay YK, Teoh WM, Kong JC, Carne P, D'Souza B, Chandra R, Bui A; Melbourne Colorectal Collaboration. Melbourne colorectal collaboration: a multicentre review of the impact of COVID-19 on colorectal cancer in Melbourne, Australia. ANZ J Surg. 2022;92(5):1110\u0026ndash;1116. doi: 10.1111/ans.17603. Epub 2022 Apr 8. PMID: 35393720; PMCID: PMC9111459.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 2 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Colorectal Cancer, Surveillance, Survivorship, follow-up, COVID, adherence ","lastPublishedDoi":"10.21203/rs.3.rs-5518160/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5518160/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003cbr\u003e\nSurveillance after colorectal cancer (CRC) resection is an important aspect of survivorship care. This study aimed to assess whether there were any changes to post-operative surveillance in non-metastatic CRC patients, pre and post-COVID pandemic in Victoria. \u003cbr\u003e\n\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nAll CRC patients (stage I-III) who underwent curative surgery at Western Health, Victoria, Australia were included. Surveillance included a three-monthly clinical review and carcinoembryonic antigen (CEA) up to 18 months, and CT imaging and colonoscopy at 12 months following surgical resection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\n Between 2019-2022, 380 patients were identified. Stage III patients had the highest uptake with regards to clinical reviews, CEA testing and 12-month CT (83.3%, 60.3% and 85.5% respectively) while Stage I patients had the lowest (52.7%, 35.7% and 75.5% respectively) (p\u0026lt;0.05). Colonoscopy surveillance was low regardless of stage (66.3%, 59.8% and 59.7% of Stage I, II and III respectively). Uptake of CEA, clinic reviews and colonoscopy did not vary during our study period. More patients underwent 12-month CT following the COVID pandemic (87.0%) compared to pre-COVID (73.1%) or during COVID (76.0%, p\u0026lt;0.05). There was no difference in 18-month mortality and overall recurrence during our study timelines.\u003cbr\u003e\n\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cbr\u003e\n Patients with earlier stage CRC had lower rates of adherence to surveillance protocols, particularly with regard to CEA monitoring and colonoscopic surveillance. Adherence to surveillance and surveillance patterns were not meaningfully altered by the intra or post COVID-19 era.\u003c/p\u003e","manuscriptTitle":"Colorectal cancer survivorship program at a single tertiary centre :– Has service provision changed after Covid-19?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-24 17:17:23","doi":"10.21203/rs.3.rs-5518160/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-25T23:39:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-10T00:22:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168913123913147212450575992922852007699","date":"2025-02-21T04:52:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-26T16:33:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-26T16:31:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-18T09:42:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-11-25T08:03:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"21929b17-03ae-49f4-8f4e-a4a9bc655b97","owner":[],"postedDate":"December 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-28T16:08:32+00:00","versionOfRecord":{"articleIdentity":"rs-5518160","link":"https://doi.org/10.1007/s00520-025-09762-6","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-07-22 15:57:58","publishedOnDateReadable":"July 22nd, 2025"},"versionCreatedAt":"2024-12-24 17:17:23","video":"","vorDoi":"10.1007/s00520-025-09762-6","vorDoiUrl":"https://doi.org/10.1007/s00520-025-09762-6","workflowStages":[]},"version":"v1","identity":"rs-5518160","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5518160","identity":"rs-5518160","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}