Shifting trends in liver-directed management of patients with colorectal liver metastasis: a population-based analysis

Abstract

Background: We sought to evaluate population-based temporal trends in perioperative management, as well as short- and long-term outcomes associated with the operative management of colorectal liver metastasis (CRLM).

Methods: Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 2,121 patients with operatively managed CRLM between 1991 and 2006. Clinicopathologic data, trends in operative management, and survival were examined.

Results: Preoperative evaluation included computed tomography (CT; 66%), magnetic resonance imaging (MRI; 5%), and positron emission tomography (PET; 2%) with a temporal increase in the use of all 3 modalities over time (all P < .05). Patients undergoing hepatectomy only (n = 1,267; 60%) decreased over time, whereas the use of ablation alone (n = 668; 32%) and combined resection plus ablation (n = 186; 9%) increased (all P < .05). The use of both preoperative (10% to 16%) and adjuvant chemotherapy (35% to 47%) increased over time (P < .05). There was a marked temporal increase in patient comorbidities (>3 comorbidities: 1991-1995, 3%; 2003-2006, 12%; P < .001); however, perioperative complications (63%) and 30-day mortality (3%) did not change over time (both P > .05); 90-day mortality decreased from 9% to 7% over the study period (P = .007). Overall the 1-, 3-, and 5-year survivals were 74%, 42%, and 28% with no improvement over time (P = .19). On multivariate analysis, synchronous disease (hazard ratio [HR], 1.7) and use of ablation alone (HR, 1.2) were associated independently with a worse survival (both P < .05).

Conclusion: Most patients were evaluated with CT; PET was employed rarely. Although there was a temporal increase in chemotherapy utilization, only one half of patients received perioperative chemotherapy. Mortality associated with hepatic operations was low, but morbidity remained high with no temporal change despite an increased number of patient medical comorbidities.

Fig 1

Flow diagram of patient selection within SEER–Medicare database, 1973–2006.

Fig 2

(A) Temporal trends in liver-directed operations and perioperative medical management for patients with CRLM. (B) Trends in Elixhauser medical comorbidities and perioperative complications and 30-day mortality for patients with CRLM undergoing hepatectomy, ablation, or both.

Fig 3

Overall survival of operatively managed patients from the time of the liver-directed operation, stratified by time period. There was no improvement in survival over time (P = .19). Overall median survival 28 months.

Fig 4

Overall survival from the time of the liver-directed operation stratified by resection alone, ablation alone, and combined resection plus ablation. Medians months of survival: resection alone (30 months), ablation alone (23 months), and resection plus ablation (34 months).