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Reevaluating the Evidence for Intensive Postoperative Extracolonic Surveillance for Nonmetastatic Colorectal Cancer

Published:October 12, 2021DOI:https://doi.org/10.1016/j.jval.2021.07.017

      Highlights

      • A total of 3 recent trials (FACS, GILDA, and COLOFOL) failed to demonstrate a statistically significant survival advantage from intensive extracolonic surveillance for resected nonmetastatic colorectal cancer (CRC). This contrasts sharply with previous meta-analyses that found a moderate-to-large benefit from intensive follow-up. The recent evidence has been interpreted as demonstrating that extracolonic surveillance does not improve survival and, consequently, as indirect evidence that the increasingly common practice of metastasectomy may be less beneficial than previously thought.
      • This article leverages a modeling analysis to argue that the results of the trials have been misinterpreted. Given the large reduction in CRC recurrence rates over the last 30 years, the average 5-year survival benefit from intensive extracolonic surveillance would likely now be much smaller even if the benefit to patients who experience a recurrence was large. The trials were terribly underpowered to detect such a benefit. Overall, although very imprecise, the results of the 3 trials are consistent with a realistically sized survival benefit and thus should not motivate de novo skepticism about the efficacy of metastasectomy nor even risk-stratified extracolonic surveillance. Moreover, although the 5-year average benefit would be small, the predicted life-expectancy gain from the latter is comparable with CRC screening and thus would be clinically significant.
      • In the absence of experimental evidence, the true benefit of metastasectomy and consequently extracolonic surveillance remains unknown. Power analyses show that any future trial designed to compare surveillance regimens with respect to survival is practically guaranteed to be uninformative and thus would be ethically suspect. A moderate-to-large (n = 200-300) trial of salvage surgery (or of metastasectomy in particular) is needed to inform clinical practice in both cases.

      Abstract

      Objectives

      The FACS, GILDA, and COLOFOL trials have cast doubt on the value of intensive extracolonic surveillance for resected nonmetastatic colorectal cancer and by extension metastasectomy. We reexamined this pessimistic interpretation. We evaluate an alternative explanation: insufficient power to detect a realistically sized survival benefit that may be clinically meaningful.

      Methods

      A microsimulation model of postdiagnosis colorectal cancer was constructed assuming an empirically plausible efficacy for metastasectomy and thus surveillance. The model was used to predict the large-sample mortality reduction expected for each trial and the implied statistical power. A potential recurrence imbalance in the FACS trial was investigated. Goodness of fit between model predictions and trial results were evaluated. Downstream life expectancy was estimated and power calculations performed for future trials evaluating surveillance and metastasectomy.

      Results

      For all 3 trials, the model predicted a mortality reduction of ≤5% and power of <10%. The FACS recurrence imbalance likely led to a large relative bias (>2.5) in the hazard ratio for overall survival favoring control. After adjustment, both COLOFOL and FACS results were consistent with model predictions (P>.5). A 2.6 (95% credible interval 0.5-5.1) and 3.6 (95% credible interval 0.8-7.0) month increase in life expectancy is predicted comparing intensive extracolonic surveillance—routine computed tomography scans and carcinoembryonic antigen assays—with 1 computed tomography scan at 12 months or no surveillance, respectively. An adequately sized surveillance trial is not feasible. A metastasectomy trial should randomize at least 200 to 300 patients.

      Conclusions

      Recent trial results do not warrant de novo skepticism of metastasectomy nor targeted extracolonic surveillance. Given the potential for clinically meaningful life-expectancy gain and significant uncertainty, a trial of metastasectomy is needed.

      Keywords

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