South Australian Clinical Registry Research Articles

Survival outcomes of patients with resected colorectal liver metastases based on the tumour burden score

Background: The tumour burden score (TBS) is a novel prognostic model for patients undergoing hepatic resection of colorectal liver metastases based on the Metro-ticket paradigm. The aim of this study is to apply the TBS model to evaluate the survival outcomes in an Australian population. Method: All patients who had undergone curative-intent liver surgery for colorectal liver metastases from 2006 were identified from the South Australian Clinical Registry for Metastatic Colorectal Cancer. Preoperative imaging and postoperative pathology were calculated using the Pythagorean theorem whereby [TBS2 = (maximum tumour diameter)2 X number of liver lesions)2]. Patients were stratified into 3 groups; zone 1: TBS < 3, zone 2: TBS ⩾ 3 to 9, and zone 3: TBS >9. Results: A total of 510 patients met inclusion criteria. The overall 5-year survival was 52.3%. An incremental worsening of 5-year survival was noted as TBS increased. 5-year survival for preoperative CT TBS zones 1 [n = 210 (41.2%)], 2 [n = 282 (55.3%)] and 3 [ n = 18 (3.5%)] were 60.9%, 48.0% and 18.2% respectively; P < 0.001. 5-year survival for postoperative pathology TBS zones 1 [n = 143 (28.0%)], 2 [n = 339 (66.5%)] and 3 [n = 28 (5.5%)] were 64.8%, 47.6% and 44% respectively; P = 0.002. 5-year survival for imaging-based TBS and pathology-based TBS were comparable. Conclusion: The TBS model has good discriminatory ability for survival in patients undergoing hepatic resection of colorectal liver metastases. This model may facilitate patients selection for surgery and further systemic treatment.

Time from diagnosis to treatment of colorectal cancer in a South Australian clinical registry cohort: how it varies and relates to survival

ObjectivesSome early studies indicated lower survival with longer time from diagnosis to cancer treatment, but others showed the reverse. We investigated time to treatment of colorectal cancer and associations with...

Nonagenarian patients with metastatic colorectal cancer: Results from the South Australian metastatic colorectal cancer registry.

752 Background: With improved healthcare we now face an ageing population worldwide. More patients with metastatic colorectal cancer (mCRC) will present at advanced age. Patients with mCRC now have the potential of living longer due to surgery, chemotherapeutic agents and monoclonal antibodies. Australian data (2011) indicated 1.3% of the population are aged over 90 years*. Medical oncologists are now being referred patients in their 90’s and the optimal management for this group is unknown. Methods: The population based South Australian Clinical Registry for mCRC includes all patients with metastatic CRC diagnosed since the 1st February 2006. We examined cancer characteristics, treatments administered and outcomes for patients aged &gt; 90 years. Results: 130 patients of 4199 (3%) were aged 90 years or older. The median age was 92.1 years (range 90-104.8 years). 61% were female, 70% presented with synchronous disease. Organ involvement was as follows; 58% liver, 32% lung, 8% peritoneal and 7% bone. Primary site was: right 46%, left 28%, rectum 20%, unknown 6%. Only 4 patients had KRAS testing (all WT). 44.6% overall have had no surgery for their CRC primary. 24% of those with synchronous disease at diagnosis had resection of primary lesion and 3% had stoma formed for palliation. One patient had lung resection for metastasis. Only 4 patients received systemic therapy (age range 90-93). Lines of therapy delivered; one in 2 patients, two lines in one and 4 lines in one. Aside single agent 5FU, combination therapy (oxaliplatin/FU+/- bevacizumab) was given to two patients and cetuximab single agent in 2 (WT one, unknown one). The median survival overall was 3 months (95% CI 1.4-4.6 months). Two year survival was 10%. Conclusions: This analysis gives us some insight into the management of the very old. Female sex and right sided cancers are more frequent. Systemic therapy is rarely offered and the outlook is poor. Further research to understand whether active therapy is possible or warranted in this age group should be considered. *http://www.abs.gov.au/ausstats/abs@.nsf

Rural populations have equal surgical and survival outcomes in metastatic colorectal cancer.

Previous Australian studies have suggested poorer survival of patients with colorectal cancer in remote areas. To date no studies have assessed the geographic disparity in patients with metastatic disease. This retrospective cohort study looks at geographic differences in the surgical care and survival of patients with metastatic colorectal disease. The paper utilises data from the South Australian Clinical Registry for Metastatic Colorectal Cancer (SACRMCC). Data on patients' socio-economic status, primary and metastatic tumour characteristics, treatment and survival was extracted from the SACRMCC database. A binomial model analysis was used to identify geographical differences in the surgical treatment of patients and a Cox proportional hazards model was used to identify any geographic differences in survival. The findings showed no differences in the diagnosis of liver metastases or provision of liver surgery between geographic areas, however there was a reduced likelihood of liver surgery with increasing age. The median overall survival rate, from the date of diagnosis of metastatic disease, was 20.0 months and the distribution by geographic remoteness was 19.1 months, 20.2 months, 22.0 months and 20.4 months in Major Cities, Inner Regional, Outer Regional and Remote areas respectively. This was not statistically significant. Overall, there was no evidence of a geographical disparity in the diagnosis, surgical treatment or survival in metastatic colorectal cancer. This may be due to the shift toward centralising surgical care in South Australia. Nevertheless, there remains a need to improve the uptake of surgical care in the growing elderly population.

Colorectal Cancer Survival: An Analysis of Patients With Metastatic Disease Synchronous and Metachronous With the Primary Tumor

BackgroundWhether metastatic colorectal cancer (mCRC) that presents synchronously with the primary lesion behaves differently from mCRC that appears metachronously to the primary disease is not clear. Patients and MethodsThe South Australian Clinical Registry for mCRC collects data for patients diagnosed after February 2006. Data from 2502 patients, available on October 22, 2012, were analyzed according to stage at initial diagnosis (SAID) to compare outcomes between metachronous tumors (MTs) (stages I, II, III) and synchronous tumors (STs) (stage IV). Overall survival (OS) was calculated from the date of mCRC diagnosis. ResultsPatients with ST had more liver-only metastases, and patients with MT had more lung-only, non-lung and non-liver, and non-lung metastases. The median time to recurrence differed significantly according to SAID: stage I, 49.3 mo (n = 29), stage II, 25.2 mo (n = 346) and stage III, 18.4 mo (n = 497). The median OS was longer for patients with MT than for those with ST (19.0 vs.14.9 mo, P = .003). For patients who received any treatment for mCRC, the OS was longer for patients with MT than for those with ST (19.2 vs. 15.3 mo, P = .005). In patients who received only chemotherapy for mCRC, the median OS was longer for patients with MT than for those with ST (15.2 vs. 9.9 mo, P < .0001). No difference in OS between the MT and ST groups for patients who did not receive treatment for mCRC (1.6 vs. 2.6 mo; P = .95). ConclusionPatients with MT have a longer OS than those with ST, independent of treatment. Classification of patients according to whether they have metachronous or synchronous presentation of mCRC is prognostic. These results may add further support for population screening with the aim to reduce de novo metastatic disease.

A population‐based study of metastatic colorectal cancer in individuals aged ≥80 years

Life expectancy is increasing, and more patients are presenting with cancer at an advanced age (≥80 years). Optimal management for this group of patients has not been well defined. The South Australian Clinical Registry for Metastatic Colorectal Cancer (mCRC) collects data on all patients diagnosed since February 2006 in South Australia. The authors examined cancer characteristics, treatments administered, and outcomes for patients aged ≥80 years compared with patients aged <80 years. Data from 2314 patients were evaluable, and 29.2% of these patients were aged ≥80 years. The majority had moderately differentiated tumors. Poorly differentiated tumors were reported in fewer patients aged ≥80 years (20.1% vs 26.1%; P < .005). Overall, 28.1% of patients aged ≥80 years received chemotherapy, and 74.2% received single-agent fluoropyrimidines as first-line treatment. By comparison, 68.2% of patients aged <80 years received chemotherapy, 74.3% received combination chemotherapy, and 25.7% received single-agent fluoropyrimidine as first-line treatment. No treatment was received by 38.2% of patients aged ≥80 years compared with 11.4% of those aged <80 years. Participation in clinical trials was lower in patients aged ≥80 years (2% vs 13%). The median survival was worse for patients aged ≥80 years (8.2 months vs 19.2 months; P < .001), and the median survival of patients who received chemotherapy was 19.0 months for those aged ≥80 years and 22.3 months for those aged <80 years (P = .139). Patients who did not receive treatment had a poor median survival regardless of age (2.6 months for patients aged ≥80 years vs 2.7 months for patients aged <80 years). Patients aged ≥80 years were less likely to receive intervention for their metastatic colorectal cancer and had poorer survival. The survival of selected patients aged ≥80 years who received chemotherapy was similar to the survival of those aged <80 years despite the receipt of single-agent therapy. Patients aged ≥80 years with metastatic colorectal cancer are less likely to receive intervention for their disease and have poorer survival. Survival for selected patients aged ≥80 years who receive chemotherapy is similar to the survival of patients aged <80 years despite the receipt of single-agent therapy.

Survival Differences in Patients With Metastatic Colorectal Cancer and With Single Site Metastatic Disease at Initial Presentation: Results From South Australian Clinical Registry for Advanced Colorectal Cancer

Colorectal cancer is the third most common cancer in Australia. The median overall survival for metastatic colorectal cancer is nearly 2 years. However, there may be survival differences based on site of metastatic disease. Data was collected from the South Australian Registry for Advanced Colorectal Cancer. A total of 1207 patients with single site metastatic disease at initial diagnosis were subclassified into 6 subgroups: liver only (n = 780), pelvic only (n = 148), lung only (n = 142), lymph node only (n = 95), bone only (n = 32), and brain only (n = 10). Univariate and multivariate parametric survival analyses were performed. Median overall survival was 20.3 months for the whole group. The overall survival for lung-only metastases group was 41.1 months followed by liver- and pelvic-only disease groups (22.8 and 23.8 months, respectively). Patients with isolated bone-only and brain-only metastases had poor overall survival (5.1 and 5.7 months, respectively). On multivariate analysis, prognosis was superior for the lung-only group. Lung only group had the longest median overall survival. Bone and brain sites had a poor outlook. Site of metastatic disease at initial presentation may be prognostic.

Impact of age on choice of chemotherapy and outcome in advanced colorectal cancer

BackgroundAge is a major risk factor for development of sporadic colorectal cancer but elderly patients are underrepresented in clinical trials and are potentially offered chemotherapy less often. MethodsData were obtained from South Australian Clinical Registry for advanced colorectal cancer between 1st February 2006 and 9th September 2010. Patients who received chemotherapy were analysed to assess the impact of single versus combination chemotherapy and to assess the outcome in two age cohorts, age <70years and ⩾70years. ResultsOut of a total of 1745 patients in the database during this time period, 951 (54.5%) received systemic chemotherapy. 286 (30%) received first line therapy (median age 74years) with single agent fluoropyrimidine and 643 patients (68%) received first line combination chemotherapy (median age 64years). The median overall survival of patients receiving first line combination chemotherapy was 23.9months compared to 17.2months for those who received single agent fluoropyrimidine (p<0.001). Combination chemotherapy was given to 81% of patients aged <70years compared to 53% of those ⩾70years. There was no significant difference in median overall survival of patients receiving chemotherapy by age cohort, 21.3months for age <70years and 21.1months for age ⩾70years (p=0.4). ConclusionTreatment outcomes are comparable in both the elderly and younger patients. Patients who received initial combination chemotherapy were younger and had a longer median overall survival. In our study, age appeared to influence the treatment choices but not necessarily outcome.

An analysis of the effect of stage at diagnosis of bowel cancer on survival: Findings from the South Australian Clinical Registry (SACR) for metastatic colorectal cancer (mCRC).

3628 Background: Stage at diagnosis of CRC strongly correlates with prognosis. The impact of initial stage on outcome after development of metastatic (met) disease is not entirely clear. Methods: The SACR for mCRC collects data for mCRC patients (pts) diagnosed after Feb 1, 2006. Pts were grouped depending on stage at initial diagnosis to compare outcomes between metachronous and synchronous mCRC. Results: 1,878 mCRC pts are currently in the database. Median age was 73 yrs (range 17-105 yrs) with male preponderance (57%). Majority of pts had synchronous met disease (1206 pts; 64.2%) while the rest had St III (383; 20.4%), St II (n=254; 13.5%) and St I (n=24; 1.2%) disease at their initial diagnosis. Liver was the single most common met site (39%). Tumour grade was equally distributed by stage. Of the metachronous group, 61% pts had colon as primary site. St I, II and III was uniformly distributed among pts with colon or rectal metachronous mCRC. Median time to recurrence (TTR) was longer for St I pts as compared to St II pts (3.94 yrs vs. 2.0 yrs; p=0.04) and this trend was sustained between St II and St III pts (2.0 yrs vs. 1.52 yrs; p<0.001) as well. For stage III pts, the median TTR was similar for pts receiving neo-adjuvant or adjuvant treatment in comparison to those who had surgery alone (1.62 yrs v 1.38 yrs; p=0.59). 63% pts with metachronous mCRC from St I disease are still alive whereas the median survival was similar in pts with remaining metachronous and synchronous mCRC (St II – 1.36yrs, St III – 1.30 yrs, St IV – 1.22 yrs). Conclusions: In a large population based registry we found that pts presenting with St I CRC have a longer time to recurrence and a longer survival from time of recurrence as compared to pts presenting with St II, St III CRC, and synchronous mCRC. There was no difference observed in TTR or survival after recurrence when comparing stage II and III CRC and this was not affected by adjuvant chemotherapy use. mCRC pts initially presenting with stage II and III CRC had similar survival to those presenting with synchronous mCRC. Our findings are limited by the small number of patients that develop mCRC after an initial diagnosis of stage I CRC.

Impact of watching prior to commencement of chemotherapy for metastatic colorectal cancer (mCRC): Findings from the South Australian Clinical Registry (SACR) for mCRC.

e14139 Background: The role of chemotherapy in mCRC is firmly established and the option of watchful waiting (WW) has become an alternative rarely considered. Evidence from 2 pivotal studies is conflicting and of an era when only 5FU was available. Outcomes for mCRC have improved because of early detection through surveillance, surgery and more effective chemotherapy drugs. However, there may be a group of patients who are diagnosed early with low volume and asymptomatic disease that may be suitable for a WW plan. Methods: The SACR for mCRC collects data on all patients who have a diagnosis of mCRC established after 1/2/06. We examined cancer characteristics and outcomes of patients who were suitable for chemotherapy but had their treatment delayed by more than 3 months from diagnosis of metastatic disease. Results: Data from 417 mCRC patients who received chemotherapy as first intervention have been entered into the Registry to date. 41 (9.8%) of these patients had chemotherapy commencement delayed by more than 3 months from diagnosis. Median age was 76.7 yrs (range 38-87). Stage at diagnosis is as follows (n); I=2, II=8, III=25 and IV=6. For patients with initial stage I-III disease, median time to recurrence was 1.48 years (range 0.53-7.71). 30% and 32.4% had single site lung or liver metastasis respectively. Median delay from diagnosis of metastatic disease to chemotherapy was 5.32 months (range 3-28). Average number of lines of subsequent chemotherapy=1.4 (range 1-4) and 5 patients have received anti-EGFR Rx. The median survival for this group from diagnosis was 23.2 months. Survival is equivalent to that reported for the whole group (ASCO GI 2010, #472). Conclusions: WW is a controversial option. We found that almost 10% of all mCRC had a delay in the initiation of chemotherapy consistent with a WW approach. This group was older and was likely to have a single site of metastatic disease. The majority of these patients had metachronous mCRC and low volume disease, suggesting possible diagnosis by surveillance. Despite the treatment delay, the median survival was almost 2 years.

A population-based study of metastatic colorectal cancer (mCRC) in people age 80 or older: Findings from the South Australian Clinical Registry (SACR) for mCRC.

9082 Background: Life expectancy is increasing and more patients (pts) with mCRC are presenting at an advanced age (>80). Optimal management approach for this group of pts is not well defined as they are under-represented in clinical trials. Methods: The SACR for mCRC collects data on mCRC pts diagnosed after 1/2/2006. We examined cancer characteristics, treatment and outcome for pts aged >80 yrs. Comparison was made with pts <80 yrs. Results: Data from 1,878 eligible mCRC pts has been entered to date. 559 (30%) of these pts were aged ≥ 80. Key pt characteristics and treatments are reported in the table. Grade 3 differentiation was reported in lower proportion of pts ≥80 yrs than the younger group (18.4 % vs. 26.3 %, p < 0.001). Only 25% of pts >80 received chemotherapy (CT). Of these, 67% received single agent CT (mostly capecitabine) while 33% received combination CT as first line treatment. In comparison, 69% of pts <80 had CT, 75% of which received combination and 25% single agent (majority capecitabine) as their first line CT. Pts ≥ 80 had fewer liver resections, were less likely to receive radiotherapy or monoclonal antibodies and had lower recruitment in clinical trials. Median survival (MS) was 7.9 mths for >80 yrs vs. 19.6 mths for <80 yrs; p < 0.001. MS for pts treated with CT was 20 mths for >80 and 23 mths for <80, p = 0.127. Pts without any treatment had a poor survival regardless of their age (MS 2.9 mths >80 yrs vs. 3.4 mths <80 yrs). Conclusions: Older pts (≥ 80 yrs) were less likely to receive intervention for their mCRC and had poorer survival. However, survival for selected elderly pts, who received CT, was similar to those <80, despite most receiving single agent therapy. Patient characteristics and treatments. (<80 yrs) n = 1,319 (≥80 yrs) n = 559 Median age (range) 67 (17-79) 85 (80–105) Sex—M/F 799 (60%)/520 (40%) 272 (49%)/287 (51%) Synchronous primary 867 (66%) 339 (61%) Rectal primary 364 (28%) 113 (20%) Liver only metastatic site 540 (41%) 199 (36%) ≥3 metastatic sites 112 (8.5%) 48 (9%) Liver resections 213 (16%) 34 (6%) Surgery 753 (57%) 232 (41.5%) Monoclonal antibody 169 (13%) 11 (2%) Radiotherapy 263 (20%) 42 (7.5%) No treatment 156 (12%) 221 (39.5%)

A population-based study of metastatic colorectal cancer (mCRC) in people age 80 and older: Findings from the South Australian Clinical Registry (SACR) for mCRC.

514 Background: Life expectancy is increasing and more patients (pts) with mCRC are presenting at an advanced age (&gt;80). Optimal management approach for this group of pts is not well defined as they are under-represented in clinical trials. Methods: The SACR for mCRC collects data on mCRC pts diagnosed after 1/2/2006. We examined cancer characteristics, treatments administered and outcomes for pts aged &gt;80 yrs. Comparison was made with pts &lt;80 yrs. Results: Data from 1737 mCRC pts has been entered to date of which 522 (30%) pts were aged ≥ 80. Key patient characteristics and treatments are reported in the table. The majority had grade 2 tumours. Grade 3 differentiation was reported in lower proportion of pts ≥80 yrs than the younger group (18% v 26%, p &lt; 0.001). Only 23.6% of pts &gt;80 received chemotherapy (CT). Of these, 63% received single agent CT (mostly capecitabine) while 37% received combination CT as first line treatment. In contrast, 67% of pts &lt;80 received CT, 73% of which received combination CT and 27% single agent (majority capecitabine) as their first line CT. Pts aged ≥ 80 had fewer liver resections and were also less likely to receive radiotherapy or monoclonal antibodies. Median survival was 7.1 mths for &gt;80 yrs v 17.4 mths for &lt;80 yrs, p &lt; 0.001. Median survival for pts treated with chemotherapy was 19 mths for &gt;80 and 21.7 mths for &lt;80, p = 0.141. Pts without any treatment had a poor survival regardless of their age (median survival 2.9 mths &gt;80 yrs v 2.4 mths &lt;80 yrs). Conclusions: Older pts (≥ 80 yrs) were less likely to receive intervention for their mCRC and had poorer survival. However, survival for selected elderly pts, who received CT, was similar to those &lt;80, despite most receiving single agent therapy. [Table: see text] [Table: see text]

South Australian clinical registry for metastatic colorectal cancer

The aims of the South Australian Clinical Registry for Metastatic Colorectal Cancer are to record case outcomes according to site of recurrence and mode of clinical practice and to utilize the accumulated information for quality assurance activities. All patients who had a diagnosis of synchronous or metachronous metastatic colorectal cancer (CRC) after 1 February 2006 were eligible to be included in the registry. Data on patient details, disease characteristics, investigations, histopathology and treatment were collected. Disease-specific survival data were assessed using Kaplan-Meier product moment estimates and the log-rank test of equality was used for comparisons. 1544 patients have been entered as of 22 March 2010. In addition, 54.7% of primary CRCs were in the rectosigmoid area, 92.9% of them adenocarcinomas. Also, 52.6% of patients received chemotherapy and 15% had radiotherapy. Two hundred five patients underwent liver resection, nine had radiofrequency ablation and seven had selective internal radiotherapy. The overall 3-year survival from time of diagnosis of metastatic CRC was 29.5%. There was no significant survival difference between patients with synchronous and metachronous metastatic CRC. Patients with lung- or liver-only metastases have significantly improved survival if they underwent surgical resection. The treatment of patients with metastatic CRC continues to progress with modern medical and surgical developments. Important insights into the current patterns of care and clinical outcomes for metastatic CRC are provided by these data. In addition, this registry provides a feasible and useful database for the evaluation of current treatments established as best evidence in this population.