Clinicians' attitudes towards management of metastatic colorectal adenocarcinoma

Management of asymptomatic primary tumours in stage IV colorectal cancer: Review of outcomes

AIM: To compare outcomes for patients presenting with stage IV colorectal cancer and an asymptomatic primary tumour, undergoing primary tumour resection (PTR) plus palliative chemotherapy vs primary chemotherapy up-front.

METHODS: A literature search was conducted using MEDLINE and EMBASE. The primary outcome was overall survival. Secondary outcomes included perioperative mortality, morbidity and delayed surgical intervention rates in patients undergoing PTR and subsequent complication rates in patients with an un-resected primary tumour. Tertiary outcomes included impact on systemic treatment and identification of prognostic factors relevant for survival in this cohort.

RESULTS: Twenty non-randomised studies met the inclusion criteria. Eleven studies included comparative overall survival data. Three studies showed an overall survival advantage for PTR, 7 studies showed no statistically significant advantage, and 1 study showed a significant worsening in survival in the surgical group. The perioperative mortality rate ranged from 0% to 8.5%, and post-operative morbidity rate from 10% to 35%, mainly minor complications that did not preclude subsequent chemotherapy. The rate of delayed primary-tumour related symptoms, most commonly obstruction, in patients with an un-resected primary tumour ranged from 3% to 46%. The strongest independent poor prognostic factor was extensive hepatic metastases, in addition to poor performance status, M1b stage and non-use of modern chemotherapy agents.

CONCLUSION: Based on the current literature, both PTR and up front chemotherapy appear appropriate initial management strategies, with a trend towards an overall survival advantage with PTR. The procedure has a low post-operative mortality, and most complications are transient and minor. The results of recruiting randomised trials are eagerly anticipated.

Changing management and survival in patients with stage IV colorectal cancer

BACKGROUND

Patients with metastatic colorectal cancers have poor outcomes. Yet recent developments in the use of chemotherapy and surgery have promised improvements in survival. The aim of this study was to compare the treatment and survival for all patients presenting with stage IV colorectal cancer managed over the last 20 years at a tertiary referral center and to define independent predictors for survival.

METHODS

A cohort of patients with stage IV colorectal cancer treated from 1989 through 1995 served as a historical control for comparison with prospective cohorts treated from 1996 through 2002 or from 2003 through 2009. The Kaplan Meier technique was used to calculate overall survival. The Cox proportional hazards model was used to determine independent predictors of survival.

RESULTS

A total of 313 patients with stage IV colorectal cancer were analyzed. Two-year overall survival was significantly higher in the 2003 to 2009 cohort (40.3%; 95%CI, 28.6-51.8%) than in either the 1989 to 1995 cohort (20.6%, 95%CI, 13.5- 28.6%) or the 1996 to 2002 cohort (19.3%; 95%CI, 12.8-26.9%). Significant independent predictors for overall survival included surgical resection with anastomosis (hazard ratio, 0.507; 95%CI, 0.371-0.692), surgical resection with stoma (0.578; 0.401-0.833), ASA score 3 (1.493; 1.150-1.941) or score 4 (2.532; 1.505-4.258), receiving palliative chemotherapy (0.64; 0.457-0.885), and receiving palliative radiotherapy (0.543; 0.352-0.835).

CONCLUSIONS

In this analysis of overall survival for patients with stage IV colorectal cancer treated from 1989 through 2009, significant improvements were noted only in the last 7 years. Improvements may be related to more widespread use of palliative chemotherapy, newer chemotherapy agents, surgical excision of the primary tumor, and lower postoperative mortality.