Temple LKF et al. (2004) Use of surgery among elderly patients with stage IV colorectal cancer. J Clin Oncol 22: 3475–3484

In asymptomatic patients with stage IV colorectal cancer and unresectable metastases, the net benefit of resection of the primary tumor is unclear. Temple and colleagues have analyzed US practice patterns for stage IV colorectal cancer, using SEER–Medicare-linked data on a cohort of 9,011 patients presenting between 1991 and 1999.

The patients, all of whom were diagnosed with stage IV colon or rectal cancer at ≥ 65 years of age, were divided into two groups: those who received primary–cancer-directed surgery (CDS) within 4 months of diagnosis, and those who had not. The authors evaluated surgical practice patterns by analyzing the patient characteristics and the use of other treatment modalities in each group.

A total of 6,469 (72%) patients received primary–CDS. Patients were significantly less likely to undergo CDS if they had left-sided or rectal lesions or if they were black, aged >75 years, had low income, or were unmarried. Those who had received primary–CDS were significantly more likely to be treated with chemotherapy than patients in the no CDS group (47% vs 31%, P ≤0.001). Only 350 (3.9%) patients underwent metastasectomy.

Given the high surgical resection rate shown in the study, the authors propose that the practice merits systematic evaluation, in terms of symptom control, quality of life and survival. This is particularly important in the context of improved chemotherapy and endoluminal stenting now available.