Effect of specialist decision-making on treatment strategies for colorectal liver metastases

Jones, Rowan Pritchard; Vauthey, Jean Nicolas; Adam, René; Rees, Myrddin; Berry, David P.; Jackson, Richard; Grimes, Nathan; Fenwick, Stephen; Poston, Graeme J.; Malik, Hassan

doi:10.1002/bjs.8835

Cited by 127 publications

(77 citation statements)

References 28 publications

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“…All of the patients included in our study had LM and 30% had extrahepatic disease as well. Surgical resection of CRC LM is the preferred approach (27,28) but unfortunately many patients who are diagnosed with metastatic disease are found to be unresectable at the time of initial evaluation (29). Pathological characteristics of the primary tumor, including LNR, predict the extent of metastatic disease and may assist in identifying high risk patients.…”

Section: Discussionmentioning

confidence: 99%

Association of primary tumor lymph node ratio with burden of liver metastases and survival in stage IV colorectal cancer

Ahmad¹,

Reha²,

Saied³

et al. 2017

Hepatobiliary Surg. Nutr.

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Section: Discussionmentioning

confidence: 99%

Association of primary tumor lymph node ratio with burden of liver metastases and survival in stage IV colorectal cancer

Ahmad¹,

Reha²,

Saied³

et al. 2017

Hepatobiliary Surg. Nutr.

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“…A specialized MDT dedicated to the management of stage IV CRC is superior to that of a general CRC MDT [110,111] and should include surgeons specializing in colorectal surgery, hepatobiliary surgery and thoracic surgery, dedicated CRC medical and radiation oncologists, both imaging and interventional radiologists, and dedicated CRC surgical pathologists.…”

Section: The Critical Impact Of the Expertise Of The Team For Patientmentioning

confidence: 99%

Managing synchronous liver metastases from colorectal cancer: A multidisciplinary international consensus

Adam

Gramont

Figueras

et al. 2015

Cancer Treatment Reviews

471

413

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a b s t r a c tAn international panel of multidisciplinary experts convened to develop recommendations for managing patients with colorectal cancer (CRC) and synchronous liver metastases (CRCLM). A modified Delphi method was used. CRCLM is defined as liver metastases detected at or before diagnosis of the primary CRC. Early and late metachronous metastases are defined as those detected 612 months and >12 months after surgery, respectively. To provide information on potential curability, use of high-quality contrast-enhanced computed tomography (CT) before chemotherapy is recommended. Magnetic resonance imaging is increasingly being used preoperatively to aid detection of subcentimetric metastases, Contents lists available at ScienceDirectCancer Treatment Reviews j o u r n a l h o m e p a g e : w w w . e l s e v i e r h e a l t h . c o m / j o u r n a l s / c t r v and alongside CT in difficult situations. To evaluate operability, radiology should provide information on: nodule size and number, segmental localization and relationship with major vessels, response after neoadjuvant chemotherapy, non-tumoral liver condition and anticipated remnant liver volume. Pathological evaluation should assess response to preoperative chemotherapy for both the primary tumour and metastases, and provide information on the tumour, margin size and micrometastases. Although the treatment strategy depends on the clinical scenario, the consensus was for chemotherapy before surgery in most cases. When the primary CRC is asymptomatic, liver surgery may be performed first (reverse approach). When CRCLM are unresectable, the goal of preoperative chemotherapy is to downsize tumours to allow resection. Hepatic resection should not be denied to patients with stable disease after optimal chemotherapy, provided an adequate liver remnant with inflow and outflow preservation remains. All patients with synchronous CRCLM should be evaluated by a hepatobiliary multidisciplinary team.

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“…In addition, the multidisciplinary team process that patients go through once recurrent disease has been detected varies considerably. 82 …”

Section: Strengths and Weaknesses Of The Trialmentioning

confidence: 99%

A randomised controlled trial to assess the cost-effectiveness of intensive versus no scheduled follow-up in patients who have undergone resection for colorectal cancer with curative intent

Mant

Gray

Pugh

et al. 2017

Health Technol Assess

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Background Intensive follow-up after surgery for colorectal cancer is common practice but lacks a firm evidence base. Objective To assess whether or not augmenting symptomatic follow-up in primary care with two intensive methods of follow-up [monitoring of blood carcinoembryonic antigen (CEA) levels and scheduled imaging] is effective and cost-effective in detecting the recurrence of colorectal cancer treatable surgically with curative intent. Design Randomised controlled open-label trial. Participants were randomly assigned to one of four groups: (1) minimum follow-up (n = 301), (2) CEA testing only (n = 300), (3) computerised tomography (CT) only (n = 299) or (4) CEA testing and CT (n = 302). Blood CEA was measured every 3 months for 2 years and then every 6 months for 3 years; CT scans of the chest, abdomen and pelvis were performed every 6 months for 2 years and then annually for 3 years. Those in the minimum and CEA testing-only arms had a single CT scan at 12–18 months. The groups were minimised on adjuvant chemotherapy, gender and age group (three strata). Setting Thirty-nine NHS hospitals in England with access to high-volume services offering surgical treatment of metastatic recurrence. Participants A total of 1202 participants who had undergone curative treatment for Dukes’ stage A to C colorectal cancer with no residual disease. Adjuvant treatment was completed if indicated. There was no evidence of metastatic disease on axial imaging and the post-operative blood CEA level was ≤ 10 µg/l. Main outcome measures Primary outcome Surgical treatment of recurrence with curative intent. Secondary outcomes Time to detection of recurrence, survival after treatment of recurrence, overall survival and quality-adjusted life-years (QALYs) gained. Results Detection of recurrence During 5 years of scheduled follow-up, cancer recurrence was detected in 203 (16.9%) participants. The proportion of participants with recurrence surgically treated with curative intent was 6.3% (76/1202), with little difference according to Dukes’ staging (stage A, 5.1%; stage B, 7.4%; stage C, 5.6%; p = 0.56). The proportion was two to three times higher in each of the three more intensive arms (7.5% overall) than in the minimum follow-up arm (2.7%) (difference 4.8%; p = 0.003). Surgical treatment of recurrence with curative intent was 2.7% (8/301) in the minimum follow-up group, 6.3% (19/300) in the CEA testing group, 9.4% (28/299) in the CT group and 7.0% (21/302) in the CEA testing and CT group. Surgical treatment of recurrence with curative intent was two to three times higher in each of the three more intensive follow-up groups than in the minimum follow-up group; adjusted odds ratios (ORs) compared with minimum follow-up were as follows: CEA testing group, OR 2.40, 95% confidence interval (CI) 1.02 to 5.65; CT group, OR 3.69, 95% CI 1.63 to 8.38; and CEA testing and CT group, OR 2.78, 95% CI 1.19 to 6.49. Survival A Kaplan–Meier survival analysis confirmed no significant difference between arms (log-rank p = 0.45). The baseline-adjusted Cox proportional hazards ratio comparing the minimum and intensive arms was 0.87 (95% CI 0.67 to 1.15). These CIs suggest a maximum survival benefit from intensive follow-up of 3.8%. Cost-effectiveness The incremental cost per patient treated surgically with curative intent compared with minimum follow-up was £40,131 with CEA testing, £43,392 with CT and £85,151 with CEA testing and CT. The lack of differential impact on survival resulted in little difference in QALYs saved between arms. The additional cost per QALY gained of moving from minimum follow-up to CEA testing was £25,951 and for CT was £246,107. When compared with minimum follow-up, combined CEA testing and CT was more costly and generated fewer QALYs, resulting in a negative incremental cost-effectiveness ratio (–£208,347) and a dominated policy. Limitations Although this is the largest trial undertaken at the time of writing, it has insufficient power to assess whether or not the improvement in detecting treatable recurrence achieved by intensive follow-up leads to a reduction in overall mortality. Conclusions Rigorous staging to detect residual disease is important before embarking on follow-up. The benefit of intensive follow-up in detecting surgically treatable recurrence is independent of stage. The survival benefit from intensive follow-up is unlikely to exceed 4% in absolute terms and harm cannot be absolutely excluded. A longer time horizon is required to ascertain whether or not intensive follow-up is an efficient use of scarce health-care resources. Translational analyses are under way, utilising tumour tissue collected from Follow-up After Colorectal Surgery trial participants, with the aim of identifying potentially prognostic biomarkers that may guide follow-up in the future. Trial registration Current Controlled Trials ISRCTN41458548. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 32. See the NIHR Journals Library website for further project information.

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Effect of specialist decision-making on treatment strategies for colorectal liver metastases

Cited by 127 publications

References 28 publications

Association of primary tumor lymph node ratio with burden of liver metastases and survival in stage IV colorectal cancer

Association of primary tumor lymph node ratio with burden of liver metastases and survival in stage IV colorectal cancer

Managing synchronous liver metastases from colorectal cancer: A multidisciplinary international consensus

A randomised controlled trial to assess the cost-effectiveness of intensive versus no scheduled follow-up in patients who have undergone resection for colorectal cancer with curative intent

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