Disclosures: Jarnagin reports no relevant financial disclosures. Wei reports personal fees from Celgene, Ethicon, Ipsen, Paradigm Medical Communications, Physicians Education Resource and Shire, as well as nonfinancial support from Bayer and Intuitive Surgical outside the submitted work.
October 23, 2020
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Many patients with colorectal liver metastases not referred for resection, despite benefit

Disclosures: Jarnagin reports no relevant financial disclosures. Wei reports personal fees from Celgene, Ethicon, Ipsen, Paradigm Medical Communications, Physicians Education Resource and Shire, as well as nonfinancial support from Bayer and Intuitive Surgical outside the submitted work.
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Resection of colorectal liver metastases, often performed in conjunction with chemotherapy, can substantially extend survival — a fact that has been acknowledged for about 20 years.

Yet, only about 15% of eligible patients are referred for metastasectomy, according to a viewpoint published in JAMA Surgery.

William R. Jarnagin, MD, FACS, chief of the hepatopancreatobiliary service at Memorial Sloan Kettering Cancer Center.

“For metastatic colon cancer to the liver, the best results are obtained with a combination of resection and chemotherapy,” William R. Jarnagin, MD, FACS, chief of the hepatopancreatobiliary service at Memorial Sloan Kettering Cancer Center, told Healio. “Chemotherapy alone generally does not cure people with this disease. Other modalities like ablations and radioembolization may offer some benefit, but again, the likelihood of cure with these modalities is very low.”

Jarnagin, who wrote the viewpoint with Alice C. Wei, MD, MSc, FRCSC, FACS, co-director of surgical initiatives for the David M. Rubenstein Center for Pancreatic Cancer Research, said that depending on several factors, complete resection can result in long-term survival rates (up to 10 years and beyond) as high as 50% to 60% among the lowest-risk patients.

“Even among patients who have more advanced disease, up to 10% to 20% are cured when surgery is part of the treatment,” Jarnagin said. “So, it’s clearly better than any other single modality.”

Jarnagin spoke with Healio about possible reasons for the low rate of referral for surgical resection and discussed how this rate might be increased.

Question: What about this topic attracted your interest?

Answer: An analysis of SEER data showed a very high proportion of patients who seemed as though they would benefit from resection but did not get it. We speculated on the reasons why this may have been the case. Some of it involves certain biases on the part of treating oncologists, who may have a different interpretation of the data or an incomplete understanding of what’s possible with surgery. Another possibility is that some patients don’t have access to centers that do advanced hepatobiliary surgery. It’s probably a combination of factors.

Q: What are some of the misunderstandings regarding what is possible with surgery?

A: Liver surgery is a fairly new field that has evolved tremendously since the 1980s. At that time, it was associated with substantial morbidity and mortality. I think many people remember this from their training, when liver surgery was associated with high risk. Also, if they practice in areas where liver surgery is still not done on a regular basis, the outcomes may not be as good as they should be. At major centers that do these operations frequently, morbidity and mortality rates are low, and the long-term results are far better than they were even 10 years ago. So, if practitioners aren’t exposed to this or aren’t seeing it regularly in their practices, they may not be as likely to refer patients for surgery as clinicians with a difference experience.

Q: Is increased clinician education necessary to clear up these misconceptions?

A: It would certainly help for people to be aware of the results that we now expect routinely these days with liver resection. The surgical treatment of metastatic colon cancer in particular has evolved to the point where experienced surgeons are performing far fewer major resections. The surgeries we do now are very often parenchymal-sparing, which are much safer for patients. So, I think if people were educated about that and had a better understanding of how perioperative outcomes have changed, they would be more likely to refer patients for evaluations. However, even oncologists who are fully aware of these outcomes may not have access to surgeons who were trained to do these sorts of operations.

Q: Is there a lack of trained surgeons to perform this operation?

A: I’m aware of manpower staffing issues in hepato-pancreatico-biliary surgery. However, over the past several years, many formal training programs have been established throughout the United States and Canada that train physicians specifically in hepatobiliary and pancreatic surgery. Over time, therefore, more and more specialty-trained surgeons will entire practice, but many of these surgeons practice in metropolitan areas or in large centers. So, more remote areas might be underserved.

Q: Would some patients be poor candidates for resection of liver metastases?

A: Yes. However, at many referral centers, these patients are seen by both oncologists and surgeons right at the initial visit. The discussion often revolves around whether or not surgery is feasible. If it is not at that time, what is the likelihood that surgery will ever be possible? Many times — and we’re seeing this more and more —patients with very advanced disease respond so well to treatment that they ultimately are candidates for surgery. These are patients who never would have been considered likely candidates, but they are having an operation either in one stage to remove all the cancer or having all disease treated in two stages. This evolution is the result of the availability of more active chemotherapeutic agents and advances in surgical technique. Things have evolved to the point where there are a lot of potential options for patients.

For more information:

William R. Jarnagin, MD, FACS, can be reached at 1275 York Ave., New York, NY 10065; email: jarnagiw@mskcc.org.