title: Patterns of referral and resection among patients with liver-only metastatic colorectal cancer (MCRC).
abstract: BACKGROUND
  Rates of metastatectomy vary among patients with liver-only metastatic colorectal cancer (MCRC). This study describe predictors of referral to a hepatobiliary surgeon (HBS) and hepatic resection in a population-based setting.
  
  
  METHODS
  Patients referred to the British Columbia Cancer Agency (BCCA) with synchronous or relapsed MCRC isolated to the liver in 2002-2004 were identified. Classification of tumor burden as "high" or "low" was based on prognostic features defined by LiverMetSurvery registry. Metastases larger than 5 cm, bilobar, or more than 3 metastases were classified as high tumor burden. Multivariate logistic regression models were used to identify predictors of HBS referral and subsequent metastatectomy. Overall survival was calculated by the Kaplan-Meier method.
  
  
  RESULTS
  Of 618 patients with isolated hepatic metastasis, 148 (24%) were referred to a HBS and 99 (16%) underwent resection. Advanced age was the most common reason for not referring 64 patients (10%) with ECOG performance status 0/1 and low tumor burden. In multivariate analysis, variables associated with referral were younger age (P < .001), ECOG performance status 0/1 (P < .002), chemotherapy for metastatic disease (P = .007), 1-3 metastasis (P < .001), and unilobar disease (P < .001). Median patient survival was 0.99 years (95% confidence interval [95% CI], 0.89-1.10 years) among nonreferred, 1.83 years (95% CI, 1.37-2.31 years) if referred but not resected, and 3.85 years (95% CI, 2.90-4.80 years) if resected.
  
  
  CONCLUSIONS
  A significant proportion of patients are not referred to a HBS because of advanced chronological age. Resection of hepatic metastases was associated with improved overall survival irrespective of initial tumor burden.
authors.affiliation: Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada.
authors.forename: Doran
authors.initials: D
authors.lastname: Ksienski
authors.forename: Ryan
authors.initials: R
authors.lastname: Woods
authors.forename: Caroline
authors.initials: C
authors.lastname: Speers
authors.forename: Hagen
authors.initials: H
authors.lastname: Kennecke
mesh_terms: D000368:Aged; D001661:Biliary Tract Neoplasms / Q000453:epidemiology / Q000556:secondary / Q000601:surgery*; D001662:Biliary Tract Surgical Procedures; D001955:British Columbia / Q000453:epidemiology; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000453:epidemiology / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D012017:Referral and Consultation; D015996:Survival Rate; D016896:Treatment Outcome