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Treatment of Stage IV Colon Cancer in the US: A Patterns of Care Analysis

Treatment of Stage IV Colon Cancer in the US: A Patterns of Care Analysis. Xiang Gao 1 , Amanda Kahl 2 , Paolo Goffredo 1 , Imran Hassan 1 , Mary Charlton 2 1 University of Iowa, Department of Surgery; 2 University of Iowa, College of Public Health NAACCR/IACR Combined Annual Conference 2019.

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Treatment of Stage IV Colon Cancer in the US: A Patterns of Care Analysis

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  1. Treatment of Stage IV Colon Cancer in the US: A Patterns of Care Analysis Xiang Gao1, Amanda Kahl2 ,Paolo Goffredo1, Imran Hassan1, Mary Charlton2 1University of Iowa, Department of Surgery; 2University of Iowa, College of Public Health NAACCR/IACR Combined Annual Conference 2019

  2. Disclosures • The authors have nothing to disclose

  3. Background - Colon Cancer • 3rd most common cancer diagnosis • 3rd leading cause of cancer-related deaths • Lifetime risk • Men: 1 in 22 • Women: 1 in 24 • Stage IV 5-year survival: 14% • 77-90% present with unresectable disease Source: American Cancer Society. https://www.cancer.org/cancer/colon-rectal-cancer.html

  4. Background - SEER POC 2014

  5. Background - Stage IV Treatment Tumor resection, metastasectomy, neo/adjuvant chemotherapy Chemotherapy + biologics, then re-evaluate Chemotherapy + biologics Chemotherapy + biologics Colon resection if: imminent risk of obstruction, significant bleeding, perforation, or other significant tumor symptoms

  6. Objective Examine the patient, tumor, and hospital factors associated with treatment regimens in stage IV colon cancer.

  7. Methods - Study Population • Patients aged >20 years • Diagnosed in 2014 • Stage IV colon- first and only cancer • Sampling proportionate to registry size • Connecticut, New Jersey, Iowa, Detroit, Kentucky, Louisiana, Atlanta, California, Hawaii, New Mexico, Seattle, Utah • Oversampling of racial minorities

  8. Methods - Treatment Variables Treatment variables: • Primary tumor resection (PTR, yes/no) • Radiation (yes/no) • Chemotherapy • Targeted biologic agents Treatment groups: • Resection plus chemotherapy • Chemotherapy only • Given within 7 weeks of diagnosis • Resection only • No treatment

  9. Methods - Additional Variables • Charlson Index • SEER Registry region: • Northeast: Connecticut, New Jersey • North Central: Iowa, Detroit • South: Kentucky, Louisiana, Atlanta • West: California, Hawaii, New Mexico, Seattle, Utah

  10. Methods - Statistical Analysis • Treatment patterns by SEER region • Chi-square tests • Patient, tumor, hospital/region characteristics by treatment • Multinomial logistic regression • Patient, tumor, hospital/region characteristics by treatment with chemotherapy only as reference group • Overall survival • Kaplan-Meier • Cox proportional hazards

  11. Results SEER 18 Registry POC patients diagnosed with stage IV colon cancer in 2014 (N=1445) Exclude histologies that are not malignant neoplasm, carcinoma, adenocarcinona, mucinous adenocarcinoma, or signet ring cell carcinoma N=38 Stage IV adenocarcinoma of colon (N=1407)

  12. Results - Overall Population Surgery to metastasis 28%

  13. Results - Patterns of Treatment by Region

  14. Results - Univariable Analysis by Treatment Group Patient Demographics Age at diagnosis Sex Race Insurance status Marital status Hospital/registry characteristics Registry Region Hospital bed size Residency program status Clinical characteristics Charlson Index Perforation Obstruction Treatment variables PTR and chemotherapy sequence Surgery to metastasis Radiation Chemotherapy VEGF inhibitor EGFR inhibitor Tumor characteristics Histology Grade T, N, M stages KRAS, BRAF status MSI

  15. Results - Multinomial Regression Factors associated with PTR + Chemotherapy (vs chemotherapy only)

  16. Results- Results - Multinomial Regression Factors associated with PTR only (vs chemotherapy only)

  17. Results - Multinomial Regression Factors associated with no treatment (vs chemotherapy only)

  18. Results - Kaplan Meier Overall Survival Median survival PTR + Chemotherapy: >24 months Chemotherapy Only: 14 months PTR only: 5 months No treatment:2 months

  19. Results - Cox Proportional Hazards Adjusted for: Age, sex, race, insurance status, marital status, Charlson Index, SEER region, hospital bed size, hospital residency status, tumor histology, grade, T, N, and M stages, KRAS, BRAF, MSI, perforation, obstruction, surgery to metastasis

  20. Summary PTR + Chemo • Node positive • Lower metastatic burden • + perforation • + obstruction • Married • Small, non-academic hospitals PTR only • Advanced T, N • Lower metastatic burden • + perforation • + obstruction • Older • Medicaid • Small hospitals No treatment • Unknown genetic markers • Older • African American 57% of patients received PTR (+/- chemotherapy)

  21. Conclusions • Resection is frequently used in treatment of stage IV colon cancer • Resection should be reserved to severe symptoms or curative intent • Variation in treatment patterns by hospital factors • Support for guideline implementation may be particularly beneficial in small, non-academic hospitals • Variation in treatment patterns by race, insurance status, age • Efforts that identify/address barriers to care, patient education

  22. Thank you

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