Skip to main content

Advertisement

SpringerLink
Log in

Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes

  • Healthcare Policy and Outcomes
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system.

Methods

Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998–2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery).

Results

Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65–75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39–1.97; >75 years: OR 3.84, 95 % CI 3.13–4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16–1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001).

Conclusions

The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64(1):9–29.

    Article  PubMed  Google Scholar 

  2. Poston GJ, Adam R, Alberts S, et al. OncoSurge: a strategy for improving resectability with curative intent in metastatic colorectal cancer. J Clin Oncol. 2005;23(28):7125–34.

    Article  PubMed  Google Scholar 

  3. Grothey A, Sargent D, Goldberg RM, Schmoll HJ. Survival of patients with advanced colorectal cancer improves with the availability of fluorouracil-leucovorin, irinotecan, and oxaliplatin in the course of treatment. J Clin Oncol. 2004;22(7):1209–14.

    Article  CAS  PubMed  Google Scholar 

  4. Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med. 2004;350(23):2335–42.

    Article  CAS  PubMed  Google Scholar 

  5. Van Cutsem E, Rivera F, Berry S, et al. Safety and efficacy of first-line bevacizumab with FOLFOX, XELOX, FOLFIRI and fluoropyrimidines in metastatic colorectal cancer: the BEAT study. Ann Oncol. 2009;20(11):1842–7.

    Article  PubMed  Google Scholar 

  6. Kirstein MM, Lange A, Prenzler A, Manns MP, Kubicka S, Vogel A. Targeted therapies in metastatic colorectal cancer: a systematic review and assessment of currently available data. Oncologist. 2014;19(11):1156–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Abdalla EK, Vauthey JN, Ellis LM, et al. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg. 2004;239(6):818–25. discussion 825–817.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Choti MA, Sitzmann JV, Tiburi MF, et al. Trends in long-term survival following liver resection for hepatic colorectal metastases. Ann Surg. 2002;235(6):759–66.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kopetz S, Chang GJ, Overman MJ, et al. Improved survival in metastatic colorectal cancer is associated with adoption of hepatic resection and improved chemotherapy. J Clin Oncol. 2009;27(22):3677–83.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Leporrier J, Maurel J, Chiche L, Bara S, Segol P, Launoy G. A population-based study of the incidence, management and prognosis of hepatic metastases from colorectal cancer. Br J Surg. 2006;93(4):465–74.

    Article  CAS  PubMed  Google Scholar 

  11. Abdalla EK, Adam R, Bilchik AJ, Jaeck D, Vauthey JN, Mahvi D. Improving resectability of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol. 2006;13(10):1271–80.

    Article  PubMed  Google Scholar 

  12. Engstrom PF, Arnoletti JP, Benson AB 3rd, et al. NCCN clinical practice guidelines in oncology: colon cancer. J Natl Compr Cancer Netw. 2009;7(8):778–831.

    PubMed  Google Scholar 

  13. Engstrom PF, Arnoletti JP, Benson AB 3rd, et al. NCCN clinical practice guidelines in oncology: rectal cancer. J Natl Compr Cancer Netw. 2009;7(8):838–81.

    Google Scholar 

  14. Ruers T, Punt C, Van Coevorden F, et al. Radiofrequency ablation combined with systemic treatment versus systemic treatment alone in patients with non-resectable colorectal liver metastases: a randomized EORTC Intergroup phase II study (EORTC 40004). Ann Oncol. 2012;23(10):2619–26.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Mayo SC, Heckman JE, Shore AD, et al. Shifting trends in liver-directed management of patients with colorectal liver metastasis: a population-based analysis. Surgery. 2011;150(2):204–16.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Maynard C, Chapko MK. Data resources in the Department of Veterans Affairs. Diabetes Care. 2004;27 Suppl 2:B22–6.

    Article  PubMed  Google Scholar 

  17. Anaya DA, Becker NS, Richardson P, Abraham NS. Use of administrative data to identify colorectal liver metastasis. J Surg Res. 2012;176(1):141–6.

    Article  PubMed  Google Scholar 

  18. Davila JA, Henderson L, Kramer JR, et al. Utilization of surveillance for hepatocellular carcinoma among hepatitis C virus-infected veterans in the United States. Ann Intern Med. 2011;154(2):85–93.

    Article  PubMed  Google Scholar 

  19. Walter LC, Lindquist K, Nugent S, et al. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150(7):465–73.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–9.

    Article  CAS  PubMed  Google Scholar 

  21. Fong Y, Cohen AM, Fortner JG, et al. Liver resection for colorectal metastases. J Clin Oncol. 1997;15(3):938–46.

    CAS  PubMed  Google Scholar 

  22. Boyko EJ, Koepsell TD, Gaziano JM, Horner RD, Feussner JR. US Department of Veterans Affairs medical care system as a resource to epidemiologists. Am J Epidemiol. 2000;151(3):307–14.

    Article  CAS  PubMed  Google Scholar 

  23. Perlin JB, Kolodner RM, Roswell RH. The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. Am J Manag Care. 2004;10(11 Pt 2):828–36.

    PubMed  Google Scholar 

  24. Berwick DM. Making good on ACOs’ promise: the final rule for the Medicare shared savings program. N Engl J Med. 2011;365(19):1753–6.

    Article  CAS  PubMed  Google Scholar 

  25. Kizer KW, Dudley RA. Extreme makeover: transformation of the veterans health care system. Annu Rev Public Health. 2009;30:313–39.

    Article  PubMed  Google Scholar 

  26. Manfredi S, Lepage C, Hatem C, Coatmeur O, Faivre J, Bouvier AM. Epidemiology and management of liver metastases from colorectal cancer. Ann Surg. 2006;244(2):254–9.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Anaya DA, Becker NS, Abraham NS. Global graying, colorectal cancer and liver metastasis: new implications for surgical management. Crit Rev Oncol Hematol. 2011;77(2):100–8.

    Article  PubMed  Google Scholar 

  28. Wildes TM, Kallogjeri D, Powers B, et al. The benefit of adjuvant chemotherapy in elderly patients with stage III colorectal cancer is independent of age and comorbidity. J Geriatr Oncol. 2010;1(2):48–56.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kohne CH, Folprecht G, Goldberg RM, Mitry E, Rougier P. Chemotherapy in elderly patients with colorectal cancer. Oncologist. 2008;13(4):390–402.

    Article  PubMed  Google Scholar 

  30. Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg. 1999;230(3):309–18. discussion 318–321.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Orcutt ST, Artinyan A, Li LT, et al. Postoperative mortality and need for transitional care following liver resection for metastatic disease in elderly patients: a population-level analysis of 4026 patients. HPB (Oxford). 2012;14(12):863–70.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Nojiri K, Nagano Y, Tanaka K, et al. Validity of hepatic resection of colorectal liver metastases in the elderly (75 years and older). Anticancer Res. 2009;29(2):583–8.

    PubMed  Google Scholar 

  33. Nagano Y, Nojiri K, Matsuo K, et al. The impact of advanced age on hepatic resection of colorectal liver metastases. J Am Coll Surg. 2005;201(4):511–6.

    Article  PubMed  Google Scholar 

  34. Adam R, Frilling A, Elias D, et al. Liver resection of colorectal metastases in elderly patients. Br J Surg. 2010;97(3):366–76.

    Article  CAS  PubMed  Google Scholar 

  35. Cummings LC, Payes JD, Cooper GS. Survival after hepatic resection in metastatic colorectal cancer: a population-based study. Cancer. 2007;109(4):718–26.

    Article  PubMed  Google Scholar 

  36. Kouri EM, Landrum MB, Lamont EB, Bozeman S, McNeil BJ, Keating NL. Location of cancer surgery for older veterans with cancer. Health Serv Res. 2012;47(2):783–93.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

This material is based on the work supported in part by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). Any opinions, findings, and conclusions expressed in this material are those of the authors and do not necessarily reflect those of the American Society of Clinical Oncology (ASCO), the Conquer Cancer Foundation, the Department of Veteran Affairs, or the United States Government.

Disclosure

Sonia T. Orcutt, Nader N. Massarweh, Linda T. Li, Avo Artinyan, Peter A. Richardson, Daniel Albo, and Daniel A. Anaya have no relevant financial disclosures or conflicts of interest to disclose.

Funding

This work was funded by a Conquer Cancer Foundation/ASCO Career Development Award (Daniel Anaya).

Author information

Authors and Affiliations

  1. Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA

    Sonia T. Orcutt MD & Daniel A. Anaya MD

  2. Veterans Affairs Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA

    Nader N. Massarweh MD, MPH & Peter A. Richardson PhD

  3. Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA

    Nader N. Massarweh MD, MPH, Linda T. Li MD, Avo Artinyan MD, MS, Daniel Albo MD, PhD & Daniel A. Anaya MD

  4. Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Peter A. Richardson PhD

Authors
  1. Sonia T. Orcutt MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nader N. Massarweh MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Linda T. Li MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Avo Artinyan MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Peter A. Richardson PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Daniel Albo MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Daniel A. Anaya MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniel A. Anaya MD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Orcutt, S.T., Massarweh, N.N., Li, L.T. et al. Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes. Ann Surg Oncol 24, 23–30 (2017). https://doi.org/10.1245/s10434-016-5351-8

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-016-5351-8

Keywords

Search

Navigation