title: Shifting trends in liver-directed management of patients with colorectal liver metastasis: a population-based analysis.
abstract: BACKGROUND
  We sought to evaluate population-based temporal trends in perioperative management, as well as short- and long-term outcomes associated with the operative management of colorectal liver metastasis (CRLM).
  
  
  METHODS
  Using Surveillance, Epidemiology and End Results-Medicare linked data, we identified 2,121 patients with operatively managed CRLM between 1991 and 2006. Clinicopathologic data, trends in operative management, and survival were examined.
  
  
  RESULTS
  Preoperative evaluation included computed tomography (CT; 66%), magnetic resonance imaging (MRI; 5%), and positron emission tomography (PET; 2%) with a temporal increase in the use of all 3 modalities over time (all P < .05). Patients undergoing hepatectomy only (n = 1,267; 60%) decreased over time, whereas the use of ablation alone (n = 668; 32%) and combined resection plus ablation (n = 186; 9%) increased (all P < .05). The use of both preoperative (10% to 16%) and adjuvant chemotherapy (35% to 47%) increased over time (P < .05). There was a marked temporal increase in patient comorbidities (>3 comorbidities: 1991-1995, 3%; 2003-2006, 12%; P < .001); however, perioperative complications (63%) and 30-day mortality (3%) did not change over time (both P > .05); 90-day mortality decreased from 9% to 7% over the study period (P = .007). Overall the 1-, 3-, and 5-year survivals were 74%, 42%, and 28% with no improvement over time (P = .19). On multivariate analysis, synchronous disease (hazard ratio [HR], 1.7) and use of ablation alone (HR, 1.2) were associated independently with a worse survival (both P < .05).
  
  
  CONCLUSIONS
  Most patients were evaluated with CT; PET was employed rarely. Although there was a temporal increase in chemotherapy utilization, only one half of patients received perioperative chemotherapy. Mortality associated with hepatic operations was low, but morbidity remained high with no temporal change despite an increased number of patient medical comorbidities.
authors.affiliation: Department of Surgery, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21287, USA.
authors.forename: Skye C
authors.initials: SC
authors.lastname: Mayo
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Heckman
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Shore
authors.forename: Hari
authors.initials: H
authors.lastname: Nathan
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Parikh
authors.forename: John F P
authors.initials: JF
authors.lastname: Bridges
authors.forename: Robert A
authors.initials: RA
authors.lastname: Anders
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Anaya
authors.forename: Natasha S
authors.initials: NS
authors.lastname: Becker
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D017115:Catheter Ablation; D015179:Colorectal Neoplasms / Q000473:pathology*; D015897:Comorbidity; D005260:Female; D006498:Hepatectomy / Q000639:trends*; D006801:Humans; D008113:Liver Neoplasms / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000556:secondary / Q000601:surgery*; D008297:Male; D012189:Retrospective Studies; D018426:SEER Program; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014481:United States
chemical_list: D000970:Antineoplastic Agents