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Is Liver Surgery for CRC mets actually as succesful as claimed.?

peterz54's picture
peterz54
Posts: 343
Joined: Feb 2012

I'm having some difficulty with the statistics presented to show liver surgery as being so much better in terms of patient longevity than no surgery. here's why -

I have looked over many studies including studies in which Y Fong of MSKCC participited. In choosing patients fit for surgery it seems only the subset of patients who have good clinical scores (i.e. projected to live longer than average anyhow) are chosen. the survival curves are then compared to the overall population of Stage IV CRC patients.

maybe I overlooked something, but it seems that the proper way to do a comparison as to the efficacy of liver surgery for mCRC is to compare those chosen for surgery against a population of patients with the same clincal scores who did not undergo surgery. I have seen some recognition of selection bias as a weakness in the concluding remarks of a couple of studies but it doesn't seem to have been quantified or pursued seriously.

don't get me wrong, I am not claiming surgery is not a good choice, just for me that the conclusions and survival data are no longer as clear as they once were. therapy to make one's liver resectable still seems the best choice.

PhillieG's picture
PhillieG
Posts: 4885
Joined: May 2005

Performed Sept 21, 2004.
Roughly 65% of liver resected.
HAI pump installed.
Liver has been clear since resection.

Statistics provide a useful purpose but cancer is a very
complex disease and is very unique to each person:
Had I listened to my first oncologist and had surgery first, chemo later, how would I have fared?
Had I not had Avastin available to me how would I have fared?
Had I not done the HAI pump therapy how would I have fared?

I did participate in a Clinical Trial so now I'm a statistic I guess...

I know it's important to research things, I also know that having the right oncologist and what you do first
(as far as treatment goes) makes ALL of the difference in the world.
Best of luck with your research and decisions. I hope things go very well
-phil

peterz54's picture
peterz54
Posts: 343
Joined: Feb 2012

thanks. one reason for trying to be informed is that it becomes easier to understand the rationale of my wife's ONC and to judge whether she is any good or just going through the motions. I also have come to appreciate that the underlying biology is very complex and not very well understood and that the job of an oncologist can be unforgiving as they may deal with half a dozen cancers in varying stages.

Buckwirth's picture
Buckwirth
Posts: 1272
Joined: Jun 2010

Surgery is far more extensive than Fong and/or MSKCC, and has been well reviewed, though I agree in principal on questioning surgical assumptions of efficacy.

There are more than a few on this forum for whom any discussion of the statistics is an anathema, and these days I only step in with data if someone is posting something that is just plain false. Suffice it to say that surgery performed for single organ involvement stands a much better chance at being genuinely curative than any combination of chemotherapy, so if that option were open to me I would jump on it without any hesitation.

peterz54's picture
peterz54
Posts: 343
Joined: Feb 2012

thanks. my opinion is that it's foolish and inconsistent to ignore the data, or to cherrypick. afterall, we expect our doctors to be informed, so why shouldn't we be as well. I do know from personal experience that many doctors are not fully aware of all the information that is out there. maybe it's unrealistic to expect them to be. Also, much of the information on any subject does not carry equal weight due to limitations with study size and so on. And we also have the phenomena of doctors suffering from the same cognitive biases that the rest of us are subject to - another reason for peer review.

although I like to hear personal stories, as they can be of value in pointing out a direction to pursue, or to understand what is possible, I generally have an aversion to anyone making general claims based on their experience and nothing else. that's not much diifferent that people who say well my uncle smoked and drank all his life and he lived to be 98 yo. so what.

as for fong, I've gone beyong him. just threw him in as an example. I emailed him last week about the perceived weakness in these surgery studies but no reply.

My wife's problem is that she had 50% liver involvment (was symptomatic at dx) and a few lymph nodes involved. she went right into chemo as her colon tumor was not bleeding or obstructive. We get a PET/CT this week after 7th treatment to assess where she is at. total of twelve twelve treatments planned, which supposedly is well beyond optimum for ensuring liver viability for surgery. So i am just trying to help her weigh options in the unlikely case she becomes resectable.

appreciate the thoughts. keep the stats and critical thinking coming - this board is clearly in need...

p

PhillieG's picture
PhillieG
Posts: 4885
Joined: May 2005

I'm not sure there's anathema as far as stats go, I just can't stand them!
I admit, I had to look up "anathema" :-)

Seriously, this issue I have with statistics is that, at times, they're an over-generalization that can be misleading. Reading data on a study where the effectiveness is a gain of 6-9 months in one's life seems depressing at best and misleading. When I was first diagnosed, the "5 year survival rate" for stage IV CC was 6-8%. Not cheery, not promising, and too big of a generalization in my opinion.
The stats take into consideration the people who are in their 40s, good health (aside from cancer) and diagnosed as well as those in their 90s (bad heart, other organ issues). Not to knock being in one's 90s (my Mom is 92 and my Aunt is 94) but often when someone that age dies it wasn't necessarily because they had colon cancer.

On the other hand, they can provide important information to help people decide which route to take with treatment as there are plenty of routes as we know. It was also a driving force of being part of a Phase II clinical trial. There were some people who responded with "I'm not going to be a guinea pig" but I viewed it as "I'm going to be a test pilot!". I've always felt very strongly about being able to help others as far as sharing my cancer journey with them. Of course I hoped the trial worked (which it did apparently) but if it hadn't, at least they might have figured out what needed to be changed in order for it to work as hoped.

I think it's great you are doing all of this research for your wife's care, I'm happy to hear she is doing chemo first (I think when that's possible it's the way to go). As far as Fong goes, if you're not a patient of his I would doubt you'd get a response. It would amount to a freebie I think. I hope you discount other oncologists at Sloan Kettering. There are a handful of patients of Dr Kemeny's on here who have done very well with the HAI therapy and I see others there when I go for chemo which i am doing today as well as getting scan results. I am also meeting up with a guy who was deemed "inoperable" due to liver mets and has been under Kemeny's care for 6 months. he's getting scan results today too. They may be seeing if he's ready for surgery and HAI pump placement.

I know I can come off as confrontational as far as stats go. I understand research is important and statistics are how the results of research are given. I just have found that often when a person is first diagnosed and is just surfing the web to get info, they often find info that is not promising when there are many people who beat this or live with it for a long time. Choosing wisely is key, I can't stress that enough.

Maybe I'm just part of that small number who survives despite of the odds, or maybe not.*
the accuracy of my statement has a margin of error of +/- 3.7%

NOTE: I just met someone while waiting to see Dr K. She was dx in 2003, stage IV, liver and lung mets. Got with Dr K, did HAI Pump therapy and had been clear since 2007. In for her 6 month checkup now. I just met with Dr K and things are stable with me. I mentioned to her how some of her patients are on here and how everyone is doing very well. I also mentioned to her how many Oncs consider HAI therapy to be from the "Dinosaur Age". She's heard that too but very many if her patients are still here and are doing well or are cured... Go figure. I thanked her for ALL she's done and even gave her this cool iPad stylus as a gift. I said it was the LEAST I could do (at $1.65 it's probably true...)

ALSO: With stats, I began looking at the survivor/cured side of it. I always tried to look at them as "someone had to be in the group that did well, why not me". I'm realizing that I'm coming to this conversation NOT having to have made a major treatment decision in a very long time so my opinion/thoughts are biased and or skewed. It's a different ball game when you're in the middle of decision making. Stats are very important in helping make an informed decision. Personal (1st hand) recommendations can help too especially if they are from numerous people of different ages/sex/family history.
Please accept my apologies if I've been out of line.

peterz54's picture
peterz54
Posts: 343
Joined: Feb 2012

Thanks for your reply Phil

I am not trying to imply that anyone should throw in the towel and not imagine themselves as a survivor. A good mental outlook is important.

One point which is important to me, whether one uses the term statistics or research or clinical trials, is that decisions over time, changes in accepted theraapies, etc. are based on experience gained. We need to be informed about what the experience tells us so we can make decisions. Statistical techniques and graphs to help summarize experience gained, and so are just tools, but they are vital tools for oncologists and researchers. Imagine not having them. Or imagine not having the internet to tap into the NIH Library of Medicine as I do, or even to web sites like this..

At the same time we need to be careful in the use of the data, recognizing there could be hidden biases. Your example of the 5 year survival stat being 6 to 8% is telling. I quickly found out that there is a lag time, that this is an old stat and the more recent data is not out there (I think it's closer to 15% now). Yet many web sites provide out of date information like this. this lag time phenomena exists for more than just the 5 year stat but for current therapy recommendations, etc. as CRC treatment is moving fairly fast. so important to stay current and find out what's working, or not working, now...

Buckwirth's picture
Buckwirth
Posts: 1272
Joined: Jun 2010

Any reason you have PM's blocked? (This site calls them csn email, but the only email you might get is notice you have a message...)

When I PM you I get this message:

peterz54 does not accept private messages.

Just wondering, they can be useful for sharing information that might not be appropriate for the at-large forum.

Blake

edited for clarity on 3/23

here4lfe
Posts: 306
Joined: Jan 2010

It is a well-known problem, so you are right to question conclusions.

I like statistics, as long as the underlying assumptions are known. They give me a ball-park to play in, and the outliers offer the hope that i'll be one of them.

Best

tanstaafl's picture
tanstaafl
Posts: 1292
Joined: Oct 2010

Using only the median values can obscure great survival gains by a successful or "lucky" minority. e.g. if the median died in 24 months that's grim. However if 25% were cured and live 10-20-30 years more, the question becomes "am I one of the 25%" or "how do I join"? Biomarkers and testing are one set of tools. Advanced treatments are another.

New or unused technologies may expand a "lucky" minority from a few percent to the majority over time. The trick is to be a joiner on the right treatment's survival curve for one's situation, within one's own lifetime rather than waiting for "official" or "average" treatments.

herdizziness's picture
herdizziness
Posts: 3642
Joined: Apr 2010

*

pete43lost_at_sea's picture
pete43lost_at_sea
Posts: 3908
Joined: Nov 2010

I am a humble researcher, get as much health advice and then decide together.
Doing your homework and getting opinions will help you to make the best choice you.

Hugs,.Pete

Ps selection bias, of course, I bet they got the next grant, be skeptical. Why use relative stats, not absolutes. Often we are scammed as patients, doctors present treatment options advantages as relative stat, they present risks as absolute. They are selling their health service. Ask if the stats are relative or absolutes. Maybe our doctors should be honest, not play god. Many doctors are great, if you find a lemon report them to the AMA and tell them to get a job selling realestate.

Pps your researching reminds me of me. Keep on searching I have faith, the best answer is out their, we just have to recognise it when we see it and be bold, brave and decisive when it counts.

Buckwirth's picture
Buckwirth
Posts: 1272
Joined: Jun 2010

Do you have definitions for relative and absolute?

peterz54's picture
peterz54
Posts: 343
Joined: Feb 2012

i think they are using absolute when they go back to time of diagnosis. the issue is that we cannot derive relative stats properly. As I mentioned, they need to relate the success of those stage IV patients who go through surgery with a pool of Stage IV patients who share the same profile but do not go through surgery. And it's not just survival, but morbidity, surgical recovery time etc.

PatchAdams
Posts: 271
Joined: Nov 2011

CLICK FOR ARTICLE

Old info but very interesting numbers

Buckwirth's picture
Buckwirth
Posts: 1272
Joined: Jun 2010

that removes most, if not all, of the bias you are seeing in the other data:

Improved Survival in Metastatic Colorectal Cancer Is Associated With Adoption of Hepatic Resection and Improved Chemotherapy

From the abstract:

Results
Two thousand four hundred seventy patients with metastatic CRC at diagnosis received their primary treatment at the two institutions during this time period. Median overall survival for those patients diagnosed from 1990 to 1997 was 14.2 months, which increased to 18.0, 18.6, and 29.3 months for patients diagnosed in 1998 to 2000, 2001 to 2003, and 2004 to 2006, respectively. Likewise, 5-year overall survival increased from 9.1% in the earliest time period to 19.2% in 2001 to 2003. Improved outcomes from 1998 to 2004 were a result of an increase in hepatic resection, which was performed in 20% of the patients. Improvements from 2004 to 2006 were temporally associated with increased utilization of new chemotherapeutics. In the SEER registry, overall survival for the 49,459 identified patients also increased in the most recent time period.
PatchAdams
Posts: 271
Joined: Nov 2011

Thomas A. Aloia, MD and his team at M.D. Anderson 2006 Archives of Surgery

When colorectal cancer has spread to the liver only and nowhere else, removal or destruction of the liver tumors offers the best chance for a long term survival or cure.

The survival rate following HR (hepatic resection) of solitary colorectal liver metastasis exceeds 70% at 5 years. Radiofrequency ablation for solitary metastasis is associated with a markedly higher LR (local recurrence) rate and shorter recurrence-free and overall survival rates compared with HR, even when small lesions (3 cm) are considered.

After 5 years, more patients who had surgery were free of liver mets (92% vs. 60%). After 5 years, 50% of the surgical group were cancer-free.

Every method should be considered to achieve resection of solitary colorectal liver metastasis, including referral to a specialty center, extended hepatectomy, and chemotherapy.

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