Should pulmonary metastases from colorectal cancer be resected ?

1. Should pulmonary metastases from colorectal cancer be resected? Tom Treasure MD MS FRCS FRCPClinical Operational Research UnitUCL (Department of Mathematics)London http://www.ctsnet.org/home/ttreasure

2. My starting point: If I get colorectal cancer • I would be grateful for your skill to control the primary cancer • I’d hope for a cure BUT • If you fail to cure me ... I will want to know the evidence base for any further treatment offered

6. Reported series with 40% 5 year survival • not a random sample • are from an unknown denominator • with great variation amongst individuals Antony Gormley’s “Field”

8. A solitary nodule – what is it? • Colorectal metastasis • Primary lung cancer • Something else • Clinical context • Smoking history • Radiological review (Lindell Radiology 2007) • Tissue diagnosis • If intraoperative diagnosis work up with NSCLC in mind

10. Evaluation • Patient • Age • Sex • Symptoms • FEV1 • Cancer • Date of primary CRC resection (interval) • Stage of primary at CRC resection • Present control/status (including PET) • Number of metastases • Carcinoma embryonic antigen (CEA)

13. When not to offer metastactomy? • Short interval – how short? • Multiple metastases – how many? • Raised CEA – mixed messages! N=378 1998 to 2007 Duke MSK-CC Annals Thoracic Surgery 2009;87:1685

14. When not to offer metastactomy? • Short interval – NOT < 12 months • Multiple metastases – NOT > 3 • Raised CEA – the CEA paradox N=378 1998 to 2007 Duke MSK-CC Annals Thoracic Surgery 2009;87:1685

16. JAMA 1994;272:31 JTO 2010;5:S179

18. Where is the evidence? • 51 surgical follow up studies • 3504 patients • 1960s to 2000s

20. Survival averages 40%... in selected patients Evidence based on * Practice 146 ESTS members ** Multiple no obstacle 85% <12 months alright 93% Synchronous alright 73% • 60% solitary metastasis • 36 months interval * JRSM 2010;103:60 ** JTO 2008;3:1257

21. A thought experiment ... One Met Many Mets Increasing interval between the primary resection and the metastasectomy J Thorac Oncol 2010; 5(6 Suppl 2):S200-S202

22. Modelling outcomes on Thames Cancer Registry data Arch Surg 1992; 127:1403 J Thorac Cardiovasc Surg 1996; 112:867 “Better out than in” Utley et al. Proceedings of the 33rd International Conference on Operational Research Applied to Health Services

23. Modelling with Thames Cancer Registry data Survival Time following resection of primary

24. Proportion of patients still alive 5 yr survival 75% - 10% Dukes A Dukes B Dukes C unknown Dukes D Months Thanks to South Thames Cancer Registry, UK

25. Proportion of patients still alive J Thorac Cardiovasc Surg. 1996 Oct;112(4):867-74

26. Proportion of patients still alive

27. Modelling outcomes on Thames Cancer Registry data Arch Surg 1992; 127:1403 J Thorac Cardiovasc Surg 1996; 112:867 “Better out than in” Utley et al. Proceedings of the 33rd International Conference on Operational Research Applied to Health Services

28. Modelling outcomes on Thames Cancer Registry data Arch Surg 1992; 127:1403 J Thorac Cardiovasc Surg 1996; 112:867 “Better out than in” Utley et al. Proceedings of the 33rd International Conference on Operational Research Applied to Health Services

32. Two closing thoughts • Belief is more powerful than evidence • But trials can bring a surprise

33. Blalock 1944 • Ranks 13th of 293 unique cited papers • Cited by 14/51 index papers • (High five 31,30,27,22,22)

34. New England J Medicine 1944; 231:261-267

35. Annals of Thoracic Surgery 1980;30:378

38. 2007 MD Anderson 2008 New York collected 2009 Boston 2007 MSK-CC N = 100, 385, 121, 208

39. And finally: thank you for you interest! If I get colorectal cancer • I would be grateful for your skill to control the primary cancer • I’d hope for a cure BUT • If you fail, please do NOT use up the rest of my days in unavailing therapies.