Predicting Survival in Colorectal Liver Metastasis: Time for New Approaches
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EDITORIAL – HEPATOBILIARY TUMORS
Predicting Survival in Colorectal Liver Metastasis: Time for New Approaches Georgios Antonios Margonis, MD, PhD1, Nikolaos Andreatos, MD2, and Murray F. Brennan, MD1 Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; 2Department of Internal Medicine and Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 1
Prognostic models are important tools in forecasting survival outcomes. Prognostication facilitates patient– physician discussions and serves as a critical first step in identifying patient subgroups and potentially individuals with a markedly distinct prognosis. Although such prognostic stratification cannot directly predict treatment benefit, it can help to inform clinical decision-making. In trial design, by directing interventions toward appropriate high-risk groups, prognostic indicators can maximize the likelihood of a clinically meaningful trial. Accurate indices often can allow inclusion of patients most likely to benefit and help to reduce trial cohort size. One of the first prognostic models for patients with resectable colorectal liver metastasis (CRLM) was developed by Fong et al.1 in 1999. In a cohort of 1001 patients from the Memorial Sloan Kettering Cancer Center (MSKCC) treated between 1985 and 1998, the authors selected five independent, preoperatively available predictors of survival for incorporation into a clinical risk score (CRS). The weight assigned to each prognostic factor was deliberately the same (although the relative hazards of death varied somewhat between predictors), transforming the model into an easy-to-calculate, 0- to 5-point score. Importantly, the CRS successfully distributed patients across a wide range of outcomes, with 5-year survival rates ranging from 60% for patients with 0 points to 14% for patients with 5 points, thus helping to identify potentially
Ó Society of Surgical Oncology 2020 First Received: 5 June 2020 Accepted: 16 August 2020 G. A. Margonis, MD, PhD e-mail: [email protected]
actionable patient subgroups. The original publication discussed the possible importance of neoadjuvant chemotherapy for patients with high CRS, which currently is standard practice. This description of combined characteristics associated with poor survival can render a model clinically relevant even if the discriminatory ability as reflected by the concordance index (c-index) and area under the curve (AUC) is not high. The CRS remained a valuable clinical tool for two decades. With the advent of modern chemotherapy and broadened surgical indications for patients with CRLM, a number of reports appropriately began to question the discriminatory power of the CRS, with AUCs ranging from 0.53 to 0.68 in external validation cohorts.2 Although attempts to develop updated risk scores were made, gains in discriminatory ability were modest at best. A model recommended by Rees et al.3 reported a promising AUC of 0.8, but that decreased, ranging from 0.59 to 0.66 in the external validation.2 It slowly became accepted that the co
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