Some patients will present with symptoms of recurrent disease; recurrence may also be discovered during surveillance in the post-treatment period. Prompt referral for management by a multidisciplinary team is recommended to achieve the best outcomes for anyone with recurrent disease.

Re-biopsy should be considered if feasible. Perform molecular and immunological biomarker testing to inform further therapies (or, if available, blood samples for circulating tumour DNA [ctDNA] molecular testing).

After surgery, residual disease is most often defined on pathological assessment of the resected specimen with involved microscopic margin. In selected cases, patients may be treated with reoperation or postoperative radiation therapy and/or chemotherapy or curative intent ablative therapy.

After radiation therapy, definitive chemo-radiation or ablative therapy, residual disease should be monitored by serial imaging and treated appropriately.

Some patients will have metastatic disease on initial presentation or develop metastases after a previous cancer diagnosis. Access to the best available therapies, including clinical trials, as well as treatment overseen by a multidisciplinary team, are crucial to achieving the best outcomes for anyone with metastatic disease.

Signs and symptoms will depend on the type of cancer initially diagnosed and the location of metastatic disease. They may be discovered by the patient or by surveillance in the post-treatment period.

Managing metastatic disease

Managing metastatic disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate. Patients should have access to clinical trials if eligible. From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A and B, and in the special population groups section should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Many people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

Oligometastatic disease refers to a small number of metastases. In some situations, specialised treatment can be used to improve long-term control. Appropriate cases should be referred to centres with expertise in this area.