Frequency of unplanned surgical intervention in patients with stage IV colorectal cancer receiving palliative chemotherapy: An analysis of SEER-Medicare.

640 Background: Patients (pts) with synchronous stage IV colorectal cancer commonly begin palliative chemotherapy while the primary tumor remains. Single institution series report low rates of surgical intervention, but this has not been examined nationally. The present study utilizes a large national dataset to examine the natural history of unplanned surgical intervention in stage IV colorectal cancer pts on palliative chemotherapy. Methods: SEER-Medicare was queried for pts with metastatic colorectal cancer (1998-2009) who underwent resection or diversion (ICD9 procedure/CPT). The cohort was separated into 3 groups: elective (surgery on admission without urgent/emergent flag), urgent (surgery not on day of admission but within hospitalization or with urgent flag) and emergent (emergent flag). Pts who underwent any procedure for curative intent (elective colorectal surgery, liver directed therapy or surgery for pulmonary metastases) at any time were excluded. Demographics, tumor grade and comorbidities were analyzed for effect on intervention rate. Time to event for either urgent or emergent surgical intervention or censorship by death, were measured. Conditional analyses were performed to determine the risk of surgical intervention at 6 months, 1 and 2 years post diagnosis. Results: 3,992 pts met inclusion criteria. Median age=73; 53% male. White 79%, black 11% and other 10%. The overall intervention rate was 6%; 35% emergent, 65% urgent. At 42 months, 90% of the pts had died. The probability of requiring unplanned surgery between 6-12 months was 2.5%; 12-24 months=1.9%, and >24 months=0.8%. Charlson comorbidity score of 1 was a significant predictor of surgical intervention (HR 1.64 [1.24, 2.19]). Sex, age and race had no influence on the likelihood of surgical intervention. Conclusions: This study represents a large series of stage IV colorectal cancer pts and the frequency of unplanned surgery in pts receiving palliative chemotherapy. Pts treated with palliative chemotherapy are unlikely to require urgent or emergent surgery, and therefore prophylactic surgery to reduce the risk of perforation or obstruction should not be routinely performed.

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Stage IV colorectal cancer: An NCDB analysis of the surgical treatment of peritoneal carcinomatosis versus liver metastases.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.e15067 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. e15067-e15067

Author(s):

Samer A Naffouje ◽

George I. Salti

Keyword(s):

Colorectal Cancer ◽

Liver Metastases ◽

Peritoneal Carcinomatosis ◽

Surgical Intervention ◽

Stage Iv ◽

Current Treatment ◽

Surgical Approaches ◽

Curative Intent ◽

Stage Iv Colorectal Cancer ◽

Significant Difference

e15067 Background: Traditionally, peritoneal carcinomatosis (PC) secondary to colorectal cancer (CRC) was perceived as a terminal disease, for which the only palliation was offered. With the emergence of new surgical approaches such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), surgical intervention in select patients with ‘curative’ intent was made possible. In this study, we compared the outcomes of the surgical intervention on stage IV CRC patients with isolated liver metastases (LM) to those with PC only. Methods: The National Cancer Database (NCDB) for CRC was analyzed excluding patients with PMP. Patients with isolated LM or with PC were identified, then divided into 2 treatment groups per the current treatment of each scenario: LM patients treated with surgery±chemotherapy (LM group), and PC patients treated with surgery+chemo±HIPEC (PC group). Results: 21,829 patients were identified; 18,932 fell in the LM group, and 2,897 in the PC group. Mean age in the LM and PC groups was 62.94±13.54 vs. 59.59±13.73. No significant difference was noted in the 30-day readmission rates (6.0% vs. 6.6%; p = 0.103). LM group had higher rates of 30- and 90-day mortality (4.3% vs. 0.3% and 8.6% vs. 1.8%, respectively; p < 0.0001), but a slightly shorter hospitalization (7.70±8.64 vs. 7.92±7.07; p = 0.024) Median overall survival was not different between the groups (27.3 vs. 25.36 months; p = 0.214). Conclusions: Surgery with systemic and IP chemotherapy can be a viable treatment option in stage IV CRC patients with PC with comparable short-term and survival outcomes to the widely accepted liver resection in patients with isolated LM.

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Frequency of unplanned surgery in patients with stage IV colorectal cancer receiving palliative chemotherapy with an intact primary: An analysis of SEER‐Medicare

Journal of Surgical Oncology ◽

10.1002/jso.25508 ◽

2019 ◽

Vol 120 (3) ◽

pp. 407-414 ◽

Cited By ~ 1

Author(s):

Patrick D. Lorimer ◽

Benjamin M. Motz ◽

Russell C. Kirks ◽

Yimei Han ◽

James T. Symanowski ◽

...

Keyword(s):

Colorectal Cancer ◽

Palliative Chemotherapy ◽

Stage Iv ◽

Stage Iv Colorectal Cancer

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Response of the primary tumor in symptomatic and asymptomatic stage IV colorectal cancer to combined interventional endoscopy and palliative chemotherapy

BMC Cancer ◽

10.1186/1471-2407-9-218 ◽

2009 ◽

Vol 9 (1) ◽

Cited By ~ 3

Author(s):

Silke Cameron ◽

Diana Hünerbein ◽

Tümen Mansuroglu ◽

Thomas Armbrust ◽

Jens-Gerd Scharf ◽

...

Keyword(s):

Colorectal Cancer ◽

Primary Tumor ◽

Palliative Chemotherapy ◽

Stage Iv ◽

Interventional Endoscopy ◽

Stage Iv Colorectal Cancer ◽

Asymptomatic Stage

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Conditional survival analysis of stage IV colorectal cancer patients living >24 months.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.3566 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. 3566-3566

Author(s):

Nadia Dawn Ali ◽

Shadi Zandieh ◽

Kristen Donohue ◽

Chunxia Chen ◽

Dirk Moore ◽

...

Keyword(s):

Colorectal Cancer ◽

Overall Survival ◽

Median Overall Survival ◽

Survival Curve ◽

Stage Iv ◽

Conditional Survival ◽

Prognostic Information ◽

Curative Intent ◽

Cancer Management ◽

Stage Iv Colorectal Cancer

3566 Background: The overall survival of patients with stage IV colorectal cancer (both in unresectable and resectable settings) has been increasing over recent decades due to improvements in chemotherapy, liver surgery and other liver-directed therapies. As a result of more patients living longer, there is a need to refine prognostic information to more accurately predict survival to assist multi-disciplinary cancer management teams in treatment decisions but also for patient quality of life. Methods: We performed a retrospective analysis of all patients with stage IV colorectal cancer seen at Rutgers Cancer Institute of New Jersey between Jan 1, 2005 to March 10, 2015 by ICD-9 code (N = 318 patients). This included patients who were deemed unresectable and patients who were resected with curative intent. Our study population was patients with documented survival for > 24 months (N = 158). Variables gathered included patient demographics, disease related (primary location, KRAS status, metastasis location, interval to metastases) and treatment related (chemotherapy regimens, radiation and surgery) data. Survival curve estimates are conditional on having survived 24 months. Results: Complete data was available for 125 patients (75 were resected for cure and 50 were not). Median overall survival of resected patients was not reached. The median overall survival of non-resected patients was 75.9 months. Univariate and multivariate analysis for surgery and non-surgery groups was performed. No statistically significant covariates were found beyond surgical resectability. The conditional survival probabilities of living 1, 2 or 3 years longer after 24 months of survival are 91.7%, 71.6% and 51.6% respectively in the patients with unresectable disease, and 98.1%, 92.2% and 88.8% in patients who were able to be resected with curative intent. Conclusions: These results indicate that patients who survive 24 months with stage IV colorectal cancer have an excellent prognosis. For patients who are unresectable and survive 24 months, this study suggests that they may benefit from resection of remaining metastatic sites if feasible. For resected patients this information may propose a possible benefit from repeat metastasectomy.

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Outcome of Primary Tumor in Patients With Synchronous Stage IV Colorectal Cancer Receiving Combination Chemotherapy Without Surgery As Initial Treatment

Journal of Clinical Oncology ◽

10.1200/jco.2008.20.9817 ◽

2009 ◽

Vol 27 (20) ◽

pp. 3379-3384 ◽

Cited By ~ 248

Author(s):

George A. Poultsides ◽

Elliot L. Servais ◽

Leonard B. Saltz ◽

Sujata Patil ◽

Nancy E. Kemeny ◽

...

Keyword(s):

Colorectal Cancer ◽

Metastatic Disease ◽

Combination Chemotherapy ◽

Primary Tumor ◽

Initial Treatment ◽

Infusion Pump ◽

Stage Iv ◽

Prophylactic Surgery ◽

Hepatic Artery Infusion ◽

Stage Iv Colorectal Cancer

Purpose The purpose of this study was to describe the frequency of interventions necessary to palliate the intact primary tumor in patients who present with synchronous, stage IV colorectal cancer (CRC) and who receive up-front modern combination chemotherapy without prophylactic surgery. Patients and Methods By using a prospective institutional database, we identified 233 consecutive patients from 2000 through 2006 with synchronous metastatic CRC and an unresected primary tumor who received oxaliplatin- or irinotecan-based, triple-drug chemotherapy (infusional fluorouracil, leucovorin, and oxaliplatin; bolus fluorouracil, leucovorin, and irinotecan; or fluorouracil, leucovorin, and irinotecan) with or without bevacizumab as their initial treatment. The incidence of subsequent use of surgery, radiotherapy, and/or endoluminal stenting to manage primary tumor complications was recorded. Results Of 233 patients, 217 (93%) never required surgical palliation of their primary tumor. Sixteen patients (7%) required emergent surgery for primary tumor obstruction or perforation, 10 patients (4%) required nonoperative intervention (ie, stent or radiotherapy), and 213 (89%) never required any direct symptomatic management for their intact primary tumor. Of those 213 patients, 47 patients (20%) ultimately underwent elective colon resection at the time of metastasectomy, and eight patients (3%) underwent this resection during laparotomy for hepatic artery infusion pump placement. Use of bevacizumab, location of the primary tumor in the rectum, and metastatic disease burden were not associated with increased intervention rate. Conclusion Most patients with synchronous, stage IV CRC who receive up-front modern combination chemotherapy never require palliative surgery for their intact primary tumor. These data support the use of chemotherapy, without routine prophylactic resection, as the appropriate standard practice for patients with neither obstructed nor hemorrhaging primary colorectal tumors in the setting of metastatic disease.

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Surgery of the Primary Tumour in Stage IV Colorectal Cancer with Unresectable Metastases

European Oncology & Haematology ◽

10.17925/eoh.2012.08.01.27 ◽

2012 ◽

Vol 08 (01) ◽

pp. 27 ◽

Cited By ~ 1

Author(s):

Ninos Ayez ◽

Wijnand J Alberda ◽

Henk M Verheul ◽

Jacobus W Burger ◽

Johannes H de Wilt ◽

...

Keyword(s):

Colorectal Cancer ◽

Primary Tumour ◽

Stage Iv ◽

Prophylactic Surgery ◽

Stage Iv Colorectal Cancer ◽

Limited Life ◽

Number Of Patients ◽

Unresectable Metastases

Since patients with incurable metastatic colorectal cancer (CRC) only have a relatively limited life expectancy, and resection of the primary tumour is accompanied by both morbidity and mortality, it is under debate whether resection of the primary tumour has an effect on survival or quality of life. The rationale behind the resection strategy is that prophylactic surgery prevents future complications. With current new chemotherapy regimens, a relatively low number of patients with metastatic CRC require surgery for their primary tumour. Many studies concerning the management of incurable stage IV CRC have been performed and most studies suggest a survival benefit for patients undergoing surgical resection of the primary tumour compared with those who received palliative treatment. However, in stage IV CRC with unresectable metastases, the role of a palliative resection of the primary tumour has never been assessed properly. Because randomised clinical trials are lacking, it is difficult to draw conclusions from the present literature.

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Factors Influencing Survival in Stage IV Colorectal Cancer: The Influence of DNA Ploidy

ISRN Gastroenterology ◽

10.1155/2013/490578 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 5

Author(s):

Ioannis D. Xynos ◽

Nicolaos Kavantzas ◽

Smaro Tsaousi ◽

Michalis Zacharakis ◽

George Agrogiannis ◽

...

Keyword(s):

Colorectal Cancer ◽

Palliative Chemotherapy ◽

Dna Ploidy ◽

Performance Status ◽

Prognostic Significance ◽

Stage Iv ◽

Dna Index ◽

Risk Of Death ◽

Stage Iv Colorectal Cancer ◽

Mild Anaemia

Objective. To evaluate the prognostic significance of microscopically assessed DNA ploidy and other clinical and laboratory parameters in stage IV colorectal cancer (CRC). Methods. 541 patients with histologically proven stage IV CRC treated with palliative chemotherapy at our institution were included in this retrospective analysis, and 9 variables (gender, age, performance status, carcinoembryonic antigen, cancer antigen 19-9, C-Reactive Protein (CRP), anaemia, hypoalbuminaemia, and ploidy (DNA Index)) were assessed for their potential relationship to survival. Results. Mean survival time was 12.8 months (95% confidence interval (CI) 12.0–13.5). Multivariate analysis revealed that DNA indexes of 2.2–3.6 and >3.6 were associated with 2.94 and 4.98 times higher probability of death, respectively, compared to DNA index <2.2. CRP levels of >15 mg/dL and 5–15 mg/dL were associated with 2.52 and 1.72 times higher risk of death, respectively. Hazard ratios ranged from 1.29 in patients mild anaemia (Hb 12–13.5 g/dL) to 1.88 in patients with severe anaemia (Hb < 8.5 g/dL). Similarly, the presence of hypoalbuminaemia (albumin < 5 g/dL) was found to confer 1.41 times inferior survival capability. Conclusions. Our findings suggest that patients with stage IV CRC with low ploidy score and CRP levels, absent or mild anaemia, and normal albumin levels might derive greatest benefit from palliative chemotherapy.

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