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List of all projects Quality assessment of multimodality treatment of patients with liver metastases of colorectal cancer in the Czech Comprehensive Cancer Centres

Coordinator Coordinator: Blaha Milan

Duration Duration: 2012–2015

Verifying the benefit of a multidisciplinary team-based approach in the comprehensive treatment of patients with liver metastases of colorectal cancer, evaluating the results in defined groups of patients according to selected parameters.


In the long term, the Czech Republic ranks among countries with the highest colorectal cancer incidence rates worldwide [1]. As much as 60% of CRC patients have liver metastases at the time of diagnosis or will develop them during treatment. Without treatment, patients survive less than one year on average. Patients treated chemotherapy or biochemotherapy – (B)CHMT – have been reported to survive for 12 to 24 months [2, 3]. Radical treatment (liver resection R0), which means a removal of liver tissue affected by the metastatic process, is considered an effective and potentially curative therapy. Radical treatment is essential for a subsequent administration of effective adjuvant (B)CHT, leading to 5-year survival in almost 60% of patients [4]. Studies focused on perioperative administration of CHMT have shown that survival increased by 10% in a three-year horizon [5]. At the time of project proposal (2011), only about 20% of patients were indicated for resection, mainly due to a technical unfeasibility, or the impossibility to maintain a sufficient volume of functional liver parenchyma [6]. Multimodal and personalised approach to each patient is an essential prerequisite for the successful treatment of CRC patients with liver metastases [7].

At the time of project proposal, adequate therapy was not provided to more than a half of CRC patients with liver metastases who were indicated for surgery in the Czech Republic [8]; moreover, there were no data to evaluate treatment effectiveness in this group of patients; many facilities did not apply decision mechanisms leading to the design of an optimal diagnostic and therapeutic process for a given patient; mechanisms for the evaluation of treatment outcomes and cost-effectiveness were not widely applied, and neither were methods for downstaging/downsizing [9].

It had been stated during a meeting at the Prague ONCO 2011 conference that CRC patients with synchronous or metachronous liver metastases have a chance of long-term survival only if the following requirements are met:

  1. care provided to these patients will be standardised and concentrated in specialised facilities (Comprehensive Cancer Centres - CCCs),
  2. a multidisciplinary team in the respective CCC will decide on the diagnostic and therapeutic process in a given patient,
  3. the above-mentioned combined procedures, including the perioperative administration of (B)CHMT will be monitored in terms of quality of care and treatment outcomes,
  4. data will be used from the Czech National Cancer Registry (CNCR) regarding the current and predicted incidence and prevalence rates of CRC patients, number of treated CRC patients with or without liver metastases in individual health care facilities in the Czech Republic, and possibly de-anonymised data from health care payers,
  5. clinical standard No. KKCCS0009 will be used for the diagnosis and treatment of patients with a secondary malignant tumour of liver, particularly in CRC (hereinafter referred to as “CS”) [10], which was developed by the Czech Surgical Society and other expert medical societies, in cooperation with the Czech National Reference Centre.

Project objectives:

  1. evaluating the effectiveness of multimodal therapy in CRC patients with liver metastases while monitoring quality indicators and treatment outcomes (proportion of resectability, safety of resection after a neoadjuvant (B)CHMT, early and late complications of resection, healing of the surgical wound, (B)CHMT hepatotoxicity, disease progression and other indicators), and comparing them with nationwide data acquired from the Czech National Cancer Registry,
  2. evaluating the benefit of neoadjuvant (B)CHMT in the groups of patients with primarily operable, primarily inoperable, and potentially resectable tumours, and comparing the percentage of resectability with published data,
  3. evaluating the use of CS in clinical practice,
  4. assessing the significance of measurement of selected molecular biomarkers including cell-free DNA (cfDNA) in samples of patients’ peripheral blood as a factor linked to treatment effectiveness [11]; serum biobanks in individual CCCs would be used for this purpose,
  5. monitoring the patients’ quality of life based on the Czech version of the EORTC QLQ - LMC21 questionnaire,
  6. assessing the treatment costs when CS is adhered to.

Other important information:

  • Expert guarantor: Prof Miroslav Ryska, MD, PhD
  • Funding: The project has been supported by the Internal Grant Agency of the Ministry of Health of the Czech Republic (IGA) within the programme “ Departmental Programme of Research and Development – MH III from 2010 to 2015”. The project is registered with the identifier NT13660.
  • Partners: four Comprehensive Cancer Centres in the Czech Republic (in Prague, Brno, Plzen, and Hradec Kralove; an overview of all centres is available at www.onconet.cz)
  • Brief overview of results: you can find more detailed information – in Czech language only – in the VaVaI information system

References

  1. Zavoral M, Suchánek S, Závada F et al. Colorectal cancer screening in Europe. World Journal of Gastroenterology 2009; 15(47): 5907–5915. doi: 10.3748/wjg.15.5907.
  2. Němeček R, Kocáková I, Kocák I a kol. Cetuximab a irinotekan v léčbě metastatického kolorektálního karcinomu – pilotní výsledky z Masarykova onkologického ústavu. [article in Czech language] Klinická onkologie 2009; 22(1): 27–33.
  3. Van Cutsem E, Nordlinger B, Adam R et al. Towards a pan-European consensus on the treatment of patients with colorectal liver metastases. European Journal of Cancer 2006; 42(14): 2212–2221. doi: 10.1016/j.ejca.2006.04.012.
  4. Abdalla EK, Vauthey JN, Ellis LM et al. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Annals of Surgery 2004; 239(6): 818–825.
  5. Nordlinger B, Sorbye H, Glimelius B et al. Perioperative FOLFOX4 chemotherapy and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC 40983): long-term results of a randomised, controlled, phase 3 trial. The Lancet Oncology 2013; 14(12): 1208–1215. doi: 10.1016/S1470-2045(13)70447-9.
  6. Kaczirek K, Tamandl D, Klinger M et al. Criteria for resectability of colorectal cancer liver metastases – an Austrian survey and current recommendations. European Surgery 2009; 41(5): 213–220. doi: 10.1007/s10353-009-0486-5.
  7. Nordlinger B, Van Cutsem E, Gruenberger T et al. Combination of surgery and chemotherapy and the role of targeted agents in the treatment of patients with colorectal liver metastases: recommendations from an expert panel. Annals of Oncology 2009; 20(6): 985–992. doi: 10.1093/annonc/mdn735.
  8. Ryska M, Pantoflíček J, Dušek L. Chirurgická léčba jaterních metastáz kolorektálního původu v České republice: současný celostátní survey. [article in Czech language] Rozhledy v chirurgii 2010; 89(2): 100–108.
  9. Třeška V, Skalický T, Sutnar A a kol. Chirurgická léčba jaterních metastáz kolorektálního karcinomu. [article in Czech language] Rozhledy v chirurgii 2009; 88(2): 69–74.
  10. Klinický stanard č. KKCCS0009 pro diagnostiku a léčbu pacientů se sekundárním zhoubným onemocněním jater, především u KRK. [text in Czech language] Národní referenční centrum, 2011.
  11. Lecomte T, Ceze N, Dorval E et al. Circulating free tumor DNA and colorectal cancer. Gastroentérologie Clinique et Biologique 2010; 34(12): 662–681. doi: 10.1016/j.gcb.2009.04.015.
  12. Blazeby JM, Fayers P, Conroy T et al. Validation of the European Organization for Research and Treatment of Cancer QLQ-LMC21 questionnaire for assessment of patient-reported outcomes during treatment of colorectal liver metastases. British Journal of Surgery 2009; 96(3): 291–298. doi: 10.1002/bjs.6471.
  13. Pawlik TM, Schulick RD, Choti MA. Expanding criteria for resectability of colorectal liver metastases. The Oncologist 2008; 13(1): 51–64. doi: 10.1634/theoncologist.2007-0142.
  14. Choti MA, Sitzmann JV, Tiburi MF et al. Trends in long-term survival following liver resection for hepatic colorectal metastases. Annals of Surgery 2002; 235(6): 759–766.


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