• DOI:10.1002/bjs.11789
• Corpus ID: 220487840

NICE Guidelines: management of colorectal cancer metastases

@article{Baum2020NICEGM,
  title={NICE Guidelines: management of colorectal cancer metastases},
  author={Michael J. Baum and Lesley Fallowfield and Vernon T Farewell and Fergus Macbeth and Tom Treasure},
  journal={British Journal of Surgery},
  year={2020},
  volume={107}
}

• M. Baum, L. Fallowfield, +2 authors T. Treasure
• Published 11 July 2020
• Medicine
• British Journal of Surgery

Editor The NICE recommendations to ‘consider’ surgical resection for colorectal cancer (CRC) metastases should worry those who value evidence-informing surgical practice1. There are no randomized controlled trials (RCT) of liver metastasectomy primarily due to liver surgeons’ opposition2. The effectiveness of peritoneal cytoreductive surgery (CRS) could not be deduced from the RCTs cited, because it was in both arms1. The evidence given supporting lung metastasectomy is poor: one retrospective observational study3 judged by NICE reviewers to have ‘high risk of selection bias’ and ‘very low quality’. Patients selected not to have metastasectomy (n = 57) had high rates of known adverse features: >3 metastases (67 per cent), bilateral (65 per cent), multi-lobe (77 per cent), multi-organ (37 per cent) and < 12 months since primary resection (49 per cent), far higher than in the 48 selected for metastasectomy: 4 per cent, 19 per cent, 10 per cent, 12⋅5 per cent and 33 per cent respectively. The full results of the PulMiCC RCT (n = 93) addressing this question have now been published and show no significant difference between lung metastasectomy and controls4. NICE recommended lung metastasectomy on the basis of the Committee’s ‘clinical experience’. Patients are offered metastasectomy in the widely held belief that without operation their 5-year survival would be < 5 per cent5. RCTs of local treatment of metastases (CLOCC6, SABR-COMET7 and PulMiCC4) show this to be mistaken. For example, survival without metastasectomy, in CLOCC and PulMiCC taken together, had a weighted combined estimate of 30 per cent (95 per cent c.i. (21 per cent, 40 per cent)) derived using a complementary log–log scale. Any putative survival benefit attributable to metastasectomy is probably much smaller than believed. CRC lung metastases are rarely symptomatic, or the cause of death; generally patients who have metastasectomy still die from progressive CRC. The research recommendation to compare two unproven treatments, surgery and SABR, would not test the effectiveness of either. The ‘experts’ appear to have steered NICE guidance, without evidence, towards their own practice and convictions.