What is the recommended follow-up assessment for a patient with a history of gastric cancer who has undergone surgery and adjuvant chemotherapy?

Follow-Up Assessment After Surgery and Adjuvant Chemotherapy for Gastric Cancer

For advanced gastric cancer patients after radical resection and adjuvant chemotherapy, follow-up visits should occur every 3 months for the first 2 years, then every 6 months until 5 years, with each visit including clinical history, physical examination, tumor markers (CEA and CA19-9), performance status assessment, weight monitoring, and chest/abdominal/pelvic CT scans every 6 months. 1

Follow-Up Schedule Based on Disease Stage

Advanced Gastric Cancer (Post-Radical Resection with Adjuvant Chemotherapy)

• Years 1-2: Visit every 3 months 1
• Years 3-5: Visit every 6 months 1
• Beyond 5 years: Annual visits 1

Early-Stage Gastric Cancer (If Applicable)

• Years 1-3: Visit every 6 months 1
• Years 4-5: Annual visits 1
• Beyond 5 years: Annual visits 1

Components of Each Follow-Up Visit

Mandatory Assessments at Every Visit

• Clinical history and physical examination to detect new symptoms or symptom deterioration 1
• Blood chemistry including CEA and CA19-9 tumor markers 1
• Helicobacter pylori (HP) detection as HP infection directly impacts prognosis 1
• Performance status monitoring (ECOG or Karnofsky scale) 1
• Weight monitoring to detect nutritional decline or disease progression 1

Imaging Studies

• Chest, abdominal, and pelvic CT scans every 6 months during the first 5 years, particularly important for patients with abnormal CEA levels 1
• Annual chest, abdominal, and pelvic enhanced CT after 5 years 1
• Annual gastroscopy to assess anastomotic status and detect local recurrence, though anastomotic recurrence is rare 1
• PET/CT or MRI as alternative imaging modalities when indicated 1

Critical Context and Rationale

The primary objective of this intensive follow-up is early detection of local recurrence, metastasis, or secondary malignancy that may be amenable to curative-intent treatment, thereby improving overall survival and quality of life 1. However, it is important to note that large-scale evidence supporting the optimal follow-up strategy is still lacking 1.

The more intensive schedule for advanced gastric cancer (every 3 months initially) reflects the higher risk of recurrence in this population compared to early-stage disease 1. The postoperative follow-up schedule is similar regardless of whether patients received neoadjuvant therapy prior to surgery 1.

Important Caveats and Exceptions

When to Modify or Discontinue Routine Follow-Up

• Patients with poor performance status who are unsuitable for antitumor treatment in the event of recurrence should not undergo routine intensive follow-up 1
• Symptom-driven visits are more appropriate for patients with significant comorbidities or declining functional status 1

Symptom-Driven Assessment

• Any new symptoms or symptom deterioration warrant immediate evaluation regardless of scheduled follow-up timing 1
• When symptoms occur, perform directed history, physical examination, blood tests, and radiological investigations if the patient is a candidate for palliative chemotherapy or radiotherapy 1

Divergence in Guidelines

There is notable divergence between Asian and Western guidelines. The Chinese Society of Clinical Oncology (CSCO) recommends structured, intensive follow-up with specific imaging intervals 1, while European (ESMO) guidelines state there is no evidence that regular intensive follow-up improves outcomes and recommend symptom-driven visits for most cases 1.

In clinical practice, the more intensive CSCO approach is justified for advanced gastric cancer patients after adjuvant chemotherapy because these patients have higher recurrence risk and may benefit from early detection of potentially resectable recurrences, which can improve survival and quality of life 1. The goal is to identify candidates for salvage surgery or aggressive local therapy, not merely to document progression.

Special Considerations

Helicobacter Pylori Testing

• HP detection should be routine at follow-up visits as HP infection has direct prognostic implications 1
• Eradication therapy should be considered if HP is detected

Gastroscopy Findings

• Any anastomotic abnormalities require adequately sized biopsies to rule out local recurrence 1
• The primary purpose is anastomotic assessment, not routine surveillance for new primary tumors

Elevated Tumor Markers

• Abnormal CEA levels should trigger more frequent or comprehensive imaging, particularly chest, abdominal, and pelvic CT scans 1