Role of Surgery in Metastatic Colorectal Cancer

Colorectal cancer (CRC) is a relatively indolent disease that presents with limited or oligometastatic appearance in most patients, states Dirk Arnold, MD. A number clinical and treatment factors, including an optimal sequence for the various treatments that are approved, complicate treatment decisions in metastatic CRC. Ongoing clinical trials are assessing appropriate sequences for treatments, particularly chemotherapy and surgery.

Response to initial systemic therapy is a very strong indicator of a patient’s prognosis, explains Arnold, especially when considering an aggressive surgical approach. Patients who respond to systemic therapy may be candidates for debulking surgery, while individuals who do not respond may not benefit from surgery. When considering tumor burden and tumor heterogeneity, survival may be prolonged with systemic therapy if it can reduce some of that tumor burden, says Fortunato Ciardiello, MD. The removal of more visible masses by debulking may result in a higher likelihood that the disease can respond to therapy. However, clinical trials have yet to fully characterize this impact.

If debulking can offer a chemotherapy or systemic treatment-free interval, this could impact a patient’s overall survival, notes Arnold. Individuals without tumor burden and without evidence of disease following surgery could be spared further systemic therapy, which could prevent or delay the development of resistance against these therapies. However, identifying these patients is difficult. In many cases, treatment can be used in a perioperative approach, with upfront treatment followed by surgery and then additional systemic therapy.