Stage II Colon Cancer: Towards an Individualized Approach
Like many oncologists, the sight of a stage II colon cancer patient on my schedule draws a sigh. I know the discussion will be long and the concepts confusing even to the statistically literate; and at the end of the day, I will have to leave it up to the
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Stage II Colon Cancer: Towards an Individualized Approach Blase N. Polite
Introduction Like many oncologists, the sight of a stage II colon cancer patient on my schedule draws a sigh. I know the discussion will be long and the concepts confusing even to the statistically literate; and at the end of the day, I will have to leave it up to the patient to make the decision because neither guidelines nor data in the vast majority of the cases clearly point to the correct answer of whether they should or should not receive chemotherapy. The problem is that stage II colon cancer is a wastebasket of likely different cancers biologically with SEER 5-year survival rates ranging from 66 % in stage IIA cancers to 37 % for stage IIC disease [1]. In this chapter, I will present the current state of science for stage II colon cancer with the hopes of allowing the practitioner to better risk stratify patients and thereby select those who are most likely to benefit or not benefit from adjuvant chemotherapy. I will conclude with my recommendations for specific cases with the strength of that recommendation based on the science.
Search Strategy PICO table Pt population Pts with stage 2 colon cancer
Intervention Chemo
Comparators Observation
Outcomes studied Disease free survival, overall survival
B.N. Polite, MD, MPP Section of Hematology/Oncology, University of Chicago Biological Science Division, Chicago, IL, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery, Difficult Decisions in Surgery: An Evidence-Based Approach, DOI 10.1007/978-3-319-40223-9_16
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I searched the PubMed data base using the following MeSH terms: Colonic Neoplasms/drug therapy, Colonic neoplasms/pathology, Colonic neoplasms/surgery, chemotherapy/adjuvant, gene expression, DNA mismatch repair, fluorouracil, oxaliplatin, irinotecan, meta-analysis, randomized controlled trials. References of relevant articles were searched for missed studies. I also reviewed major abstracts relevant to these topics presented at the ASCO annual meeting and ASCO GI s ymposium from 2012 to 2015. Finally, I cross checked my references with those in the UpToDate article entitled “Adjuvant chemotherapy for resected stage II colon cancer.” [2]
Results Non-risk Stratified Patients Table 16.1 lists the most relevant studies which have attempted to answer the utility of chemotherapy in stage II colon cancer. While not a perfect study, only the QUASAR trial [3] comes close to being a truly randomized trial of stage II colon cancer patients with reasonable power to answer the question of a chemotherapy benefit. All the other studies are either underpowered or are pooled subset analyses of randomized trials. Most of these are very well done scientifically, including a meta-analysis done by the Cochrane group [4], but suffer from biases inherent in pooled analysis. To this mix we also add registry data which are the weakest of all the study ty
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