Annals of Surgical Oncology

, Volume 23, Issue 11, pp 3602–3608 | Cite as

Prognostic Impact of Palliative Primary Tumor Resection for Unresectable Stage 4 Colorectal Cancer: Using a Propensity Score Analysis

  • Dai Shida
  • Tetsuya Hamaguchi
  • Hiroki Ochiai
  • Shunsuke Tsukamoto
  • Atsuo Takashima
  • Narikazu Boku
  • Yukihide Kanemitsu
Colorectal Cancer



The benefits that palliative resection of the primary tumor offers patients with unresectable stage 4 colorectal cancer, specifically with regard to overall survival, are controversial, and the issue is complicated by marked differences in patient backgrounds and characteristics.


The study enrolled 770 consecutive patients with unresectable stage 4 colorectal cancer referred to the divisions of surgery or gastrointestinal oncology at the National Cancer Center Hospital from 1997 to 2013. Of these patients, 429 (56 %) underwent palliative resection of the primary tumor, whereas 341 (44 %) did not. To lessen the effects of confounding factors between the groups, including age, year, severe symptoms, number of organs involved by metastases, primary tumor site, and carcinoembryonic antigen (CEA) value, propensity score analyses were used for regression adjustment, stratification, and matching, with overall survival as the primary end point.


The regression adjustment including the propensity score as a linear predictor in the model showed that palliative resection was associated with a significantly improved overall survival (hazard ratio [HR] 0.60; 95 % confidence interval [CI] 0.50–0.71; p < 0.01)]. Stratification analysis showed that in all five strata, palliative resection was associated with better overall survival (HR 0.43–0.73). Similarly, the propensity score-matched cohort (267 matched pairs) yielded an HR of 0.58 (95 % CI 0.48–0.70; p < 0.01).


The findings suggest that palliative resection of the primary tumor may be associated with improved overall survival. Further investigations such as prospective randomized trials are needed to confirm this result.


Colorectal Cancer Overall Survival Propensity Score Propensity Score Match Palliative Resection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank two statisticians, J. Mizusawa and T. Shibata, both at the Center for Research Administration and Support at the National Cancer Center, for their assistance. The authors also thank M. Moriya, Y. Shimada, T. Akasu, S. Fujita, and S. Yamamoto, all of whom served as former staff members in our divisions.

Conflict of interest

There are no conflicts of interest.


  1. 1.
    Watanabe T, Itabashi M, Shimada Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for treatment of colorectal cancer. Int J Clin Oncol. 2015;20:207–39.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Fakih MG. Metastatic colorectal cancer: current state and future directions. J Clin Oncol. 2015;33:1809–24.CrossRefPubMedGoogle Scholar
  3. 3.
    Tarantino I, Warschkow R, Worni M, et al. Prognostic relevance of palliative primary tumor removal in 37,793 metastatic colorectal cancer patients: a population-based, propensity score-adjusted trend analysis. Ann Surg. 2015;262:112–20.CrossRefPubMedGoogle Scholar
  4. 4.
    Ishihara S, Hayama T, Yamada H, et al. Prognostic impact of primary tumor resection and lymph node dissection in stage IV colorectal cancer with unresectable metastasis: a propensity score analysis in a multicenter retrospective study. Ann Surg Oncol. 2014;21:2949–55.CrossRefPubMedGoogle Scholar
  5. 5.
    Gresham G, Renouf DJ, Chan M, et al. Association between palliative resection of the primary tumor and overall survival in a population-based cohort of metastatic colorectal cancer patients. Ann Surg Oncol. 2014;21:3917–23.CrossRefPubMedGoogle Scholar
  6. 6.
    D’Agostino RB, Jr. Propensity scores in cardiovascular research. Circulation. 2007;115:2340–3.CrossRefPubMedGoogle Scholar
  7. 7.
    Zhu J, Sharma DB, Gray SW, Chen AB, Weeks JC, Schrag D. Carboplatin and paclitaxel with vs without bevacizumab in older patients with advanced non-small cell lung cancer. JAMA. 2012;307:1593–601.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Ferrand F, Malka D, Bourredjem A, et al. Impact of primary tumour resection on survival of patients with colorectal cancer and synchronous metastases treated by chemotherapy: results from the multicenter, randomised trial Federation Francophone de Cancerologie Digestive 9601. Eur J Cancer. 2013;49:90–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Hu CY, Bailey CE, You YN, et al. Time trend analysis of primary tumor resection for stage IV colorectal cancer: less surgery, improved survival. JAMA Surg. 2015;150:245–51.CrossRefPubMedGoogle Scholar
  10. 10.
    Faron M, Pignon JP, Malka D, et al. Is primary tumour resection associated with survival improvement in patients with colorectal cancer and unresectable synchronous metastases? A pooled analysis of individual data from four randomised trials. Eur J Cancer. 2015;51:166–76.CrossRefPubMedGoogle Scholar
  11. 11.
    Yun JA, Huh JW, Park YA, et al. The role of palliative resection for asymptomatic primary tumor in patients with unresectable stage IV colorectal cancer. Dis Colon Rectum. 2014;57:1049–58.CrossRefPubMedGoogle Scholar
  12. 12.
    Stillwell AP, Buettner PG, Ho YH. Meta-analysis of survival of patients with stage IV colorectal cancer managed with surgical resection versus chemotherapy alone. World J Surg. 2010;34:797–807.CrossRefPubMedGoogle Scholar
  13. 13.
    Anwar S, Peter MB, Dent J, Scott NA. Palliative excisional surgery for primary colorectal cancer in patients with incurable metastatic disease: is there a survival benefit? A systematic review. Colorectal Dis. 2012;14:920–30.CrossRefPubMedGoogle Scholar
  14. 14.
    Eisenberger A, Whelan RL, Neugut AI. Survival and symptomatic benefit from palliative primary tumor resection in patients with metastatic colorectal cancer: a review. Int J Colorectal Dis. 2008;23:559–68.CrossRefPubMedGoogle Scholar
  15. 15.
    Scheer MG, Sloots CE, van der Wilt GJ, Ruers TJ. Management of patients with asymptomatic colorectal cancer and synchronous irresectable metastases. Ann Oncol. 2008;19:1829–35.CrossRefPubMedGoogle Scholar
  16. 16.
    Tebbutt NC, Norman AR, Cunningham D, et al. Intestinal complications after chemotherapy for patients with unresected primary colorectal cancer and synchronous metastases. Gut. 2003;52:568–73.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    t Lam-Boer J, Mol L, Verhoef C, et al. The CAIRO4 study: the role of surgery of the primary tumour with few or absent symptoms in patients with synchronous unresectable metastases of colorectal cancer: a randomized phase III study of the Dutch Colorectal Cancer Group (DCCG). BMC Cancer. 2014;14:741.Google Scholar
  18. 18.
    Rahbari NN, Lordick F, Fink C, et al. Resection of the primary tumour versus no resection prior to systemic therapy in patients with colon cancer and synchronous unresectable metastases (UICC stage IV): SYNCHRONOUS: a randomised controlled multicentre trial (ISRCTN30964555). BMC Cancer. 2012;12:142.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Cotte E, Villeneuve L, Passot G, et al. GRECCAR 8: impact on survival of the primary tumor resection in rectal cancer with unresectable synchronous metastasis: a randomized multicentre study. BMC Cancer. 2015;15:47.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Ohhara Y, Suenaga M, Matsusaka S, et al. Comparison between three oxaliplatin-based regimens with bevacizumab in patients with metastatic colorectal cancer. Onco Targets Ther. 2015;8:529–537.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Dai Shida
    • 1
  • Tetsuya Hamaguchi
    • 2
  • Hiroki Ochiai
    • 1
  • Shunsuke Tsukamoto
    • 1
  • Atsuo Takashima
    • 2
  • Narikazu Boku
    • 2
  • Yukihide Kanemitsu
    • 1
  1. 1.Colorectal Surgery DivisionNational Cancer Center HospitalTokyoJapan
  2. 2.Gastrointestinal Medical Oncology DivisionNational Cancer Center HospitalTokyoJapan

Personalised recommendations