Primary Tumor Resection and Patients With Asymptomatic Colorectal Cancer and Nonresectable Metastases: Results of Recent Randomized Trials
Mené entre 2012 et 2019 sur 196 patients atteints d'un cancer colorectal métastatique (âge médian : 65 ans ; 57 % d'hommes), cet essai randomisé de phase III évalue l'efficacité, du point de vue de la mortalité à 60 jours, d'une chimiothérapie à base de fluoropyrimidine avec bévacizumab, dispensée seule ou suivie d'une résection tumorale primaire
The role of up-front surgery for primary colorectal cancer (CRC) in patients who have nonresectable metastases has been long debated. Small retrospective studies have demonstrated an association between primary tumor resection (PTR) and longer survival. However, without random assignment to resection vs not receiving resection, it is impossible to eliminate patient-selection biases. Advocates also argue that PTR may prevent obstruction, bleeding, and other complications during chemotherapy. Thus, PTR has been common clinical practice even in the setting of unresectable metastatic disease.Two large randomized clinical trials, both published in 2021, offer important data supporting the use of chemotherapy alone in this setting. In a multicenter trial from the Japanese Colorectal Oncology Group, Kanemitsu et al tested the hypothesis that PTR followed by chemotherapy is superior to chemotherapy alone. A total of 165 patients who had unresectable stage IV asymptomatic CRC were randomly assigned to chemotherapy alone (84 patients) or PTR plus chemotherapy (81 patients). With a median follow-up of 22.0 months, the median overall survival was 26.7 months in the group that received chemotherapy alone and 25.9 months in the group that received PTR plus chemotherapy (hazard ratio, 1.10; 95% CI, 0.76-1.59; P = .69). Three postoperative deaths occurred in the group that received PTR plus chemotherapy. PTR was associated with more frequent and severe chemotherapy-related nonhematologic adverse events. The authors concluded that PTR should no longer be considered a standard of care for patients with CRC who have asymptomatic primary tumors and synchronous unresectable metastases.
JAMA Surgery , éditorial, 2020