Survival Benefit Confirmed With Palliative Resection in mCRC

Palliative care involving initial treatment with surgical resection of the primary tumor followed by systemic treatment yielded a 4.7-month OS benefit in patients with mCRC compared with the same treatments administered in the reverse order.

Palliative care involving initial treatment with surgical resection of the primary tumor followed by systemic treatment yielded a 4.7-month overall survival (OS) benefit in patients with metastatic colorectal cancer (mCRC) compared with the same treatments administered in the reverse order, according to a retrospective analysis presented at the European Society for Medical Oncology (ESMO) 16th World Congress on Gastrointestinal Cancer in Barcelona, Spain.

Overall, the analysis showed vast differences in OS based on initial treatment in patients presenting with stage 4 mCRC, with local curative treatment faring the best, according to lead author Jorine ’t Lam-Boer, MS, of the department of surgery at Radboud University Medical Center in Nijmegen, The Netherlands.

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Bendell is the director of GI Cancer Research Program at Sarah Cannon Research Institute.

According to ’t Lam-Boer, controversy remains regarding the benefit of surgical resection of the primary tumor prior to treatment in stage 4 colorectal cancer. Some studies have shown an extension of OS, but these positive data are offset by reports of morbidity and mortality following surgery. Moreover, all the available data are from retrospective studies.

’t Lam-Boer and colleagues’ retrospective, population-based study used data from patients presenting with stage 4 colorectal cancer enrolled in the Netherlands National Cancer Registries database from 2008 to 2011. Patients were stratified according to treatment received: curative treatment, palliative treatment, or best supportive care (BSC). The group receiving palliative care was further divided according to whether the first treatment administered involved resection of the primary tumor or systemic therapy.

A total of 10,593 patients were identified by the researchers; however, 2360 patients did not meet the inclusion criteria and were excluded from the study. Among the remaining 8233 patients, 1510 (18.3%) received local curative treatment for metastasis and 2304 patients (28%) received BSC only. The median OS for patients receiving local curative treatment was 43.7 months compared with 2.1 months in patients receiving BSC. Among patients in the palliative treatment group, 1908 (23.2%) were initially treated with resection of the primary tumor, which was followed by systemic therapy in 949 patients (49.7%). The remaining 2511 patients in the palliative group initially received systemic treatment, followed by resection of the primary tumor in 145 patients (5.8%).

Clinical Pearls

• Palliative care involving initial treatment with surgical resection of the primary tumor followed by systemic treatment yielded a 4.7-month overall survival (OS) benefit in patients with metastatic colorectal cancer (mCRC) compared with the same treatments administered in the reverse order.
• Data came from a retrospective, population-based study that used data from 8233 patients presenting with stage 4 colorectal cancer enrolled in the Netherlands National Cancer Registries database from 2008 to 2011.

Multivariate analysis showed that primary resection was performed more often in patients aged <75 years, patients with colon cancer, and patients with a single site of metastasis.

Overall survival was significantly improved in the group of patients initially treated with resection compared with those initially treated with systemic therapy: 16.6 months versus 11.9 months, respectively.

Cox regression analysis demonstrated that resection was independently associated with improved OS (HR = 0.38; 95% CI: 0.34-0.43).

Thomas Seufferlein, MD, from the department of internal medicine at Universit&auml;tsklinikum in Ulm, Germany discussed the relevance of these results to clinical practice and the role of surgical resection in stage 4 disease.

&ldquo;That&rsquo;s exactly the tricky point—should the primary tumor be resected in stage 4 disease? There are retrospective data suggesting, &lsquo;yes,&rsquo; but these data are seriously biased, in my opinion. The data from this analysis also suggest support for resection, but they are also retrospective data. Therefore, prospective data are really needed to resolve this question.&rdquo;

No external funding for this analysis was reported.