Massachusetts Chapter of the American College of Surgeons

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The growing trend of no primary surgery in colorectal cancer
Thomas Peponis, Caitlin Stafford, James Cusack, Christy Cauley, Robert Goldstone, David Berger, Liliana Bordeianou, Hiroko Kunitake, Todd Francone, Rocco Ricciardi
Massachusetts General Hospital, Boston, MA

Background: In colorectal cancer (CRC), surgery of the primary site is commonly curative and often the first line of treatment. In this study, we sought to determine estimates of ‘no surgery’ on primary CRC while identifying reasons for ‘no surgery’.
Methods: We identified all patients with a histologic diagnosis of CRC from the National Cancer Database between 01/2004 through 12/2016. Then we identified patients who did not undergo surgery on the primary tumor and their characteristics. Kaplan-Meier and logistic regression analyses were used to evaluate specific factors associated with overall survival as related to ‘no surgery’.
Results: 1,208,878 patients with CRC were identified, 174,946 (14.5%) of whom had ‘no surgery’ of the primary cancer. Despite a steady incidence of CRC, the likelihood of ‘no surgery’ grew 170% over the study period. Metastatic disease was noted in 51.3% of the ‘no surgery’ cohort. 15,729 (9%) patients were not recommended to have surgery, 13,193 (7.5%) refused surgery, and only 2% underwent palliative surgery. On multivariable analysis, patients who were not recommended to have surgery were more likely to be older, uninsured, comorbid, and receive care at a single hospital. Ultimately, patients who did not have surgery had significantly lower overall survival.
Conclusion: A substantial proportion of patients with CRC do not have surgery. A considerable number of them receive care at a single hospital or are uninsured. Interventions aimed at expanding access and promoting second opinions at other cancer hospitals might reduce the growing rate of ‘no surgery’ in CRC.


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