ctDNA Surveillance May Improve Early Detection of Colon Cancer Recurrence, and Experts Say Guidelines Lag Behind
- The phase III FIND clinical trial showed that circulating tumor DNA (ctDNA)‑guided surveillance can help detect colorectal cancer recurrence months earlier than standard CT imaging and more than doubles the likelihood that recurrence is still treatable with surgery aimed at removing all the cancer.
- Earlier ctDNA detection led to smaller, fewer, and more surgically removable tumors, especially in the liver and lungs, even though overall recurrence rates were the same between nonmetastatic colon cancer patients with ctDNA‑guided surveillance or standard imaging.
- Dr. Nicholas Hornstein says expert practice is already ahead of guidelines, noting that “my clinical practice… leans on ctDNA more than the guidelines do,” particularly for treatment de‑escalation (less chemo) in stage II, and he engages in shared decision‑making with patients who are low‑risk stage III.
“Given I specialize in Colorectal Cancer, my clinical practice (and other expert practices) lean on ctDNA more than the guidelines do,” Dr. Nicholas Hornstein, medical oncologist at Northwell’s Lenox Hill Hospital, told SurvivorNet.
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What the FIND Trial Found
The results were striking:- Recurrence rates were similar between groups (18.0% vs. 18.6%).
- But patients monitored with ctDNA were twice as likely to receive curative‑intent treatment when recurrence occurred (48.1% vs. 23.6%).
- ctDNA detected recurrence 3.9 months earlier on average (9.5 vs. 13.4 months).
- When recurrence appeared in the liver or lungs, ctDNA‑guided patients had smaller, fewer, and more surgically removable tumors.
The takeaway from the trial is that ctDNA didn’t prevent recurrence, but it helped catch it earlier, when metastases were still operable — significantly increasing the chance of curative treatment.
The researchers concluded that ctDNA‑guided surveillance “improves the rate of curative-intent therapy for recurrence… through earlier detection of resectable metastases,” while noting that long‑term survival data are still maturing.
Expert Resources on Colorectal Cancer Patients
- Identifying KRAS Mutations To Personalize Colon Cancer Treatment
- How Is Rectal Cancer Treated Differently Than Colon Cancer?
- Why a Tailored Approach to Colon Cancer Treatment Matters
- SurvivorNet Guide: Treating Early-Stage Colon Cancer
- Chemotherapy Before Colon Cancer Surgery
- Chemotherapy for Stage Three Colon Cancer
How Experts Interpret the Findings
Dr. Hornstein says the FIND trial reinforces what many colorectal cancer specialists already see in practice, but he also emphasizes that ctDNA’s role in care extends beyond just surveillance.
He explains how ctDNA already shapes treatment decisions:
- Stage II: A negative ctDNA result is strong enough to justify de‑escalating treatment (less chemo) now.
- Low‑risk stage III: ctDNA results prompt a long shared decision‑making conversation with the colon cancer patient about how much chemotherapy is truly needed.
- High‑risk stage III: Dr. Hornstein still treats all patients aggressively regardless of ctDNA, given the high baseline risk.
Why He Says the Field Is Moving Faster Than Guidelines
Hornstein notes that many ctDNA trials — including the DYNAMIC‑III clinical trial and others — rely on assays designed 3–5 years ago, while newer, more sensitive ctDNA platforms are already in use today. This suggests that the FIND trial’s strong results may actually underestimate what next‑generation ctDNA can do.
Dr. Hornstein believes CIRCULATE‑North America will be the definitive clinical trial that sets U.S. standards for when to escalate or de‑escalate treatment based on ctDNA.
“NCCN hasn’t caught up,” Dr. Hornstein says, arguing that current guidelines undersell the strength of stage II ctDNA data.
Meanwhile, Dr. Hornstein says clinical trials enrolling ctDNA‑positive but radiographically occult patients — those with no visible disease on scans — are open to prove that acting on ctDNA can meaningfully change outcomes.
The FIND trial shows that ctDNA‑guided surveillance can double the chance that recurrent colorectal cancer is still curable.
Hornstein’s perspective adds that ctDNA isn’t just a surveillance tool; it’s already influencing real‑world treatment decisions, and the technology is advancing faster than guidelines can update.
The trial data and Dr. Hornstein’s expert insight point toward a future where ctDNA plays a key role across the entire colorectal cancer continuum: who needs treatment, how much treatment they need, and how early recurrence can be caught when cure is still possible.
Treatable and Curable If Caught Early
Colon cancer is very treatable and curable if caught early. Colon cancer screenings can involve at-home tests such as Cologuard, but a colonoscopy is more effective, according to SurvivorNet experts.
Surgery and chemotherapy are common approaches to colorectal cancer.
WATCH: Treating Early Stage Colon Cancer
“There are a lot of advances being made in colorectal cancer,” Dr. Heather Yeo, a surgical oncologist and colorectal surgeon at NewYork-Presbyterian/Weill Cornell, previously told SurvivorNet.
Colon cancer treatment is more targeted, meaning doctors often test for specific changes or genetic mutations that cause cancer growth.
“In colon cancer, we’re starting to look more and more at people’s biomarkers, so we’re starting to take the cancers, sequence them, understand where the different mutations are to figure out whether or not someone has a normal gene here or an abnormal gene,” Dr. Yeo explained.
“Those are the areas that people want to be able to target a little bit more. We’re getting close to more of what we would call precision medicine, meaning we can start looking at people’s genetic mutations and think about how they might respond to different drugs.”
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