title: Surgical Referral for Colorectal Liver Metastases: A Population-Based Survey.
abstract: BACKGROUND
  Surgical resection is underutilized for patients with colorectal liver metastases (CLM). Although the causes of underutilization are poorly understood, provider attitudes towards surgical referral may be contributory. We sought to understand medical oncologists' perspectives on referral for CLM.
  
  
  METHODS
  Medical oncologists who treat colorectal cancer in the US state of Michigan were surveyed. We characterized respondents' attitudes regarding clinical and tumor-related contraindications to liver resection for CLM, as well as referral and treatment preferences using case-based scenarios. We then evaluated practice characteristics and treatment preferences between physicians.
  
  
  RESULTS
  A total of 112 eligible responses were received (46 % response rate). Nearly 40 % of respondents reported having no liver surgeons in their practice area. Commonly perceived contraindications to liver resection included extrahepatic disease (80.3 %), poor performance status (77.7 %), the presence of >4 metastases (62.5 %), bilobar metastases (43.8 %), and metastasis size >5 cm (40.2 %). Compared with high-referring physicians, low-referring physicians were just as likely to refer a patient with very low recurrence risk (89.3 vs. 98.3 %; p = 0.099), but much less likely to refer a patient with moderate risk (0 vs. 82.8 %; p < 0.001). High-referring physicians were more likely to consider resection for scenarios consistent with higher recurrence risk (31.0 vs. 10.7 %; p = 0.05).
  
  
  CONCLUSIONS
  We found wide variation in surgical referral patterns for CLM. Many felt that bilobar disease and tumor size were contraindications to liver-directed therapy despite a lack of supporting data. These findings suggest an urgent need to increase dissemination of evidence and guidance regarding management for CLM, perhaps through increased specialist participation in tumor boards.
authors.affiliation: Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Krell
authors.forename: Bradley N
authors.initials: BN
authors.lastname: Reames
authors.forename: Samantha
authors.initials: S
authors.lastname: Hendren
authors.forename: Timothy L
authors.initials: TL
authors.lastname: Frankel
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
authors.forename: Mathew
authors.initials: M
authors.lastname: Chung
authors.forename: David
authors.initials: D
authors.lastname: Kwon
authors.forename: Sandra L
authors.initials: SL
authors.lastname: Wong
mesh_terms: D015179:Colorectal Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000453:epidemiology / Q000556:secondary / Q000601:surgery*; D008824:Michigan / Q000453:epidemiology; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D010348:Patient Care Team; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011379:Prognosis; D012017:Referral and Consultation / Q000592:standards / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires