Informing metastatic colorectal cancer patients by quantifying multiple scenarios for survival time based on real‐life data

Abstract

Reported median overall survival (mOS) in metastatic colorectal cancer (mCRC) patients participating in systemic therapy trials has increased to over 30 months. It is uncertain whether trial results translate to real-life populations. Moreover, patients prefer presentation of multiple survival scenarios. Population-based data of all stage IV CRC patients diagnosed between 2008 and 2016 were obtained from the Netherlands Cancer Registry, which has a case ascertainment completeness surpassing 95%. We calculated the following percentiles (scenarios) of OS per year of diagnosis for the total population, and for treatment subgroups: 10th (best-case), 25th (upper-typical), 50th (median), 75th (lower-typical) and 90th (worst-case). Twenty-five percent of patients did not receive any antitumor treatment. From 2008 to 2016, mOS of the total population (n = 27275) remained unchanged at approximately 12 months. OS improved only for the upper-typical and best-case patients; by 4.2 to 29.1 months (P < .001), and by 6 to 62 months (P < .001), respectively. No clinically relevant change was observed among patients who received systemic therapy, with mOS close to 15 months and best-case scenario approximately 40 months. A clinically relevant improvement in survival over time was observed in patients who initially received metastasectomy and/or HIPEC only. In contrast to the wide belief based on trial data that mOS of mCRC patients receiving systemic therapy has improved substantially, improvement could not be demonstrated in our real-life population. Clinicians should consider quoting multiple survival scenarios based on real-life data instead of point estimates from clinical trials, when informing patients about their life expectancy.

Repeated centralized multidisciplinary team assessment of resectability, clinical behavior, and outcomes in 1086 Finnish metastatic colorectal cancer patients (RAXO): A nationwide prospective intervention study

“…These encouraging resection and/or LAT rates are in line with those from selected single-site series (11%–54%) and higher than in unselected single-site series (1%–30%) or in population-based series, also ours from Tampere and Turku university hospitals (12%–16%) ( appendix pp 2–4, 17 ). [ 5 , [16] , [17] , [18] ] Our apparently high rates are probably due to high action rates on resectability, including LAT (4%) for non-optimally fit and elderly patients. Resections and/or LAT were performed not just for upfront resectable, but especially for conversion opportunities (18%), that are usually reported in 28%–61% for single-site and 5%–16% for any single- or multisite metastases ( appendix pp 2–4 ).…”

“…Firstly, it is important to assess whether metastasectomy or LAT using various techniques, either upfront or after conversion therapy, are feasible, as long-term outcomes seem favourable after metastasectomy. [ 5 , [9] , [10] , [11] , [12] , [16] , [17] , [18] , [19] ] Secondly, technical resectability and conversion is difficult to assess, [20] and prone to be underestimated as shown for liver metastases by non-hepatobiliary surgeons and clinical oncologists compared with experienced hepatobiliary surgeons. [21] Whilst present guidelines suggest that patients should be evaluated at a multidisciplinary team (MDT) meeting to ensure proper assessment, [9] , [10] , [11] , [12] repeated or organ-specific assessments at a specialist cancer centre are far from standard practice worldwide for every patient, as was shown in recent trials.…”

An urgent call to raise the bar in oncology

“…However, systemic anticancer treatments often provide limited or no benefit to patients suffering from advanced cancer [ 123 ], lead to harm in the last weeks of life, reduce QOL, limit timely hospice care and increase risk of dying in the hospital with subsequently an increased risk of pathological grievance of bereaved [ 124 , 125 ]. Informing patients of treatment effects in daily practice by quoting point estimates, such as median OS achieved in highly selected patients from RCTs instead of using ‘real-life data’ (if available), could contribute to unrealistic patient expectations [ 126 ]. Accurately disclosing prognostic information does not negatively impact patient–physician relationships but may skew low-value life-prolonging care to comfort-oriented care [ 127 ].…”

Contribution of “complete response to treatment” to survival in patients with unresectable metastatic colorectal cancer: A retrospective analysis

“…Overall survival (OS) for patients with unresectable metastatic colorectal cancer with “best supportive care” (BSC) is 6 months [ 2 ]. In studies in the literature, the OS achieved with systemic therapy in patients with mCRC is approximately 2 years [ 3 , 4 ]. Accordingly, the fact that the comparison parameter is BSC in new randomized studies is unethical and patients with metastatic colorectal cancer are directed to systemic therapy [ 5 , 6 ].…”