Predictors of surgical non-referral for colorectal liver metastases.
Surgical resection is the only curative option for patients with colorectal liver metastases (CRLM). The objective of our study was to identify factors associated with failure to refer patients with CRLM to a surgeon with oncologic and hepatobiliary expertise.



Data were retrospectively reviewed on 75 patients with CRLM treated at our institution. Patients were divided into referred and nonreferred groups for comparison. Quantitative assessment of association was tabulated using the odds ratio (OR). Statistical comparison was performed using the chi-square test and multiple regression models. Overall survival (OS) was calculated using the Kaplan-Meier method. Multivariate analysis was done using Cox regression.



Factors independently associated with lower surgical referral rates included age ≥ 65 y (OR 0.29, 95% confidence interval [CI] 0.09-0.89, P = 0.032), bilobar CRLM (OR 0.35, 95% CI 0.09-0.97, P = 0.048), and presence of >3 CRLM (OR 0.33, 95% CI 0.11-0.94, P = 0.044). The 5-y OS for referred patients was 33% compared with only 8% in patients who were not referred (P < 0.001). Factors independently associated with worse OS included age ≥ 65 y (hazard ratio [HR] 2.01, 95% CI 1.12-3.59, P = 0.019), bilobar hepatic metastases (HR 3.04, 95% CI 1.62-5.70, P < 0.001), and the presence of extrahepatic metastases (HR 2.11, 95% CI 1.02-4.16, P = 0.011). Referral to a surgeon was associated with improved OS (HR 0.42, 95% CI 0.24-0.74, P = 0.003).



Failure to refer CRLM patients for surgical evaluation is associated with aggressive biologic features that do not necessarily preclude resection. Determination of resectability should be made with input from appropriately trained surgical experts.
Department of Surgery, Roger Williams Medical Center, Providence, Rhode Island; Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.
Ali
A
Ahmad
Department of Surgery, Roger Williams Medical Center, Providence, Rhode Island; Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.
Jeffrey
J
Reha
Department of Surgery, Roger Williams Medical Center, Providence, Rhode Island; Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.
Ponnandai
P
Somasundar
Department of Surgery, Roger Williams Medical Center, Providence, Rhode Island; Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.
N Joseph
NJ
Espat
Department of Surgery, Roger Williams Medical Center, Providence, Rhode Island; Department of Surgery, Boston University School of Medicine, Boston, Massachusetts. Electronic address: skatz@chartercare.org.
Steven C
SC
Katz
D000230:Adenocarcinoma / Q000401:mortality / Q000556:secondary* / Q000601:surgery; D000368:Aged; D015179:Colorectal Neoplasms / Q000473:pathology*; D005260:Female; D013502:General Surgery; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012237:Rhode Island / Q000453:epidemiology
Colorectal cancer; Colorectal liver metastases; Multidisciplinary care; Surgical referral; Survival