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• W2080088515 abstract "In their review of Pulmonary Resection in Metastatic Colorectal Cancer, Pfannschmidt et al.1Pfannschmidt J, Hoffman H, Dienemann H. Factors influencing outcome of pulmonary metastasectomy for colorectal cancer. J Thorac Oncol. In press.Google Scholar consider carcinoma embryonic antigen (CEA) as an adverse feature in the prognosis of patients who have had pulmonary metastasectomy for colorectal cancer, a consistent finding in multivariable analyses of clinical case series.2Saito Y Omiya H Kohno K et al.Pulmonary metastasectomy for 165 patients with colorectal carcinoma: a prognostic assessment.J Thorac Cardiovasc Surg. 2002; 124: 1007-1013Abstract Full Text Full Text PDF PubMed Scopus (284) Google Scholar, 3Kanemitsu Y Kato T Hirai T et al.Preoperative probability model for predicting overall survival after resection of pulmonary metastases from colorectal cancer.Br J Surg. 2004; 91: 112-120Crossref PubMed Scopus (129) Google Scholar Kanemitsu et al.3Kanemitsu Y Kato T Hirai T et al.Preoperative probability model for predicting overall survival after resection of pulmonary metastases from colorectal cancer.Br J Surg. 2004; 91: 112-120Crossref PubMed Scopus (129) Google Scholar published a predictive model on the basis of 313 patients operated on between 1989 and 1998. Their five prognostic factors were primary histology, hilar or mediastinal lymph node involvement, number of metastases, preoperative CEA level, and extrathoracic disease. However, CEA was not statistically significant in the most recent Memorial Sloane Kettering report.4Onaitis MW Petersen RP Haney JC et al.Prognostic factors for recurrence after pulmonary resection of colorectal cancer metastases.Ann Thorac Surg. 2009; 87: 1684-1688Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar They found that in patients younger than 65 years, female sex, apparent disease free interval (DFI) less than 1 year, and number of metastases more than three to be predictive of recurrence and went on to make an explicit recommendation: “medical management alone should be considered standard for patients who have both three or more pulmonary metastases and less than 1 year DFI.” This contradiction prompts a consideration of the role of CEA in the surveillance of patients with colorectal cancer and in the selection of patients for surgery and of the limitations of multivariate analysis as a basis for clinical decision making. First, to deal briefly with the statistical issue, the failure to find a “p value” does not mean that CEA would have had no bearing on outcome. If at the case selection stage, there was a clinical policy (explicit or unstated) to avoid operating on patients with high CEA, the range of CEA data will have been curtailed at the input stage; there is a point at which it cannot then emerge as a prognostic factor. Other factors will then come to the fore. It should also be remembered that there is a limit to the number of factors that will emerge as significant and an inevitable degree of variation in their apparent ranking. The contradiction merits attention for surgeons who have to make decisions about how to use CEA in their selection of patients.5Utley M Treasure T The use of scoring systems in selecting patients for lung resection: work-up bias comes full-circle.Thorac Surg Clin. 2008; 18: 107-112Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Treasure T Utley M Berrisford R A risk model for lung resection: data from the European Thoracic Database Project.Eur J Anaesthesiol. 2008; 25: 613-619Crossref PubMed Scopus (2) Google Scholar In the systematic review by Fiorentino et al.,7Fiorentino F Hunt I Teoh K et al.Pulmonary metastasectomy in colorectal cancer: a systematic review and quantitative synthesis.J R Soc Med. 2010; 103: 60-66Crossref PubMed Scopus (98) Google Scholar approximately a third of 51 included publications reported the preoperative CEA in a way that could be used in the analysis (Figure 1). Approximately half of these patients in the operated series had an increased CEA in the earlier era falling to approximately a third more recently. This illustrates the point alluded to above; there may have been a conscious avoidance of metastasectomy for patients with high CEA. The knowledge provided in earlier reports might quite rightly have altered the practice, and hence the case mix, for later reports. When CEA and survival data were available, these showed (Figure 2) an evident and consistent relationship: patients with increased CEA have consistently worse survival. This suggests that the importance of a raised CEA as an adverse prognostic feature for survival should not be forgotten just because it now features less prominently in the input data set.FIGURE 2Five-year survival according to elevation of carcinoma embryonic antigen (CEA).View Large Image Figure ViewerDownload (PPT) In the course of developing the PulMiCC trial,8Treasure T Fallowfield L Farewell V et al.Pulmonary metastasectomy in colorectal cancer: time for a trial.Eur J Surg Oncol. 2009; 35: 686-689Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 9Treasure T, Lees B, Fallowfield L. An exemplar trial in metastasectomy: PulMiCC (Pulmonary Metastasectomy in Colorectal Cancer). J Thorac Oncol. In press.Google Scholar we discovered that gastroenterologists and thoracic surgeons were at cross purposes in the use of CEA in patients with recurrence of colorectal cancer. While as thoracic surgeons we were interpreting CEA as an adverse feature,3Kanemitsu Y Kato T Hirai T et al.Preoperative probability model for predicting overall survival after resection of pulmonary metastases from colorectal cancer.Br J Surg. 2004; 91: 112-120Crossref PubMed Scopus (129) Google Scholar some gastroenterologists were using the CEA measurement as a surveillance tool: when CEA became increased, this prompted a computed tomography scan and possible referral to thoracic surgery if this revealed pulmonary metastases. The practice may have stemmed in part from a philosophy of care of colorectal cancer in which routine CEA testing was used to prompt “second look” surgery to deal with local recurrence10Northover J Houghton J Lennon T CEA to detect recurrence of colon cancer.JAMA. 1994; 272: 31Crossref PubMed Scopus (43) Google Scholar and was at least temporally related to the growth in hepatic metastasectomy for colorectal cancer.11Stangl R Altendorf-Hofmann A Charnley RM et al.Factors influencing the natural history of colorectal liver metastases.Lancet. 1994; 343: 1405-1410Abstract PubMed Scopus (655) Google Scholar CEA measurement was then shown to be not cost effective, because although it picked up asymptomatic patients earlier, it made no impact on survival.10Northover J Houghton J Lennon T CEA to detect recurrence of colon cancer.JAMA. 1994; 272: 31Crossref PubMed Scopus (43) Google Scholar, 12Virgo KS Wade TP Longo WE et al.Surveillance after curative colon cancer resection: practice patterns of surgical subspecialists.Ann Surg Oncol. 1995; 2: 472-482Crossref PubMed Scopus (53) Google Scholar, 13Virgo KS Vernava AM Longo WE et al.Cost of patient follow-up after potentially curative colorectal cancer treatment.JAMA. 1995; 273: 1837-1841Crossref PubMed Scopus (121) Google Scholar From the thoracic surgeons' viewpoint, it would seem reasonable to obtain a CEA measurement, and if it is high, it should go in the balance pan adding weight against metastasectomy. It is critical that the statistical findings are used appropriately in surgical decision making. To rather stretch the point, but to illustrate the point, here is a wry observation on misunderstanding the statistical findings. Although the distribution of hemoglobin measurements is significantly different in populations of males and females, measuring the hemoglobin is a poor way of discovering the sex of a patient in front of you." @default.
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• W2080088515 title "Carcinoma Embryonic Antigen: Its Place in Decision Making for Pulmonary Metastasectomy in Colorectal Cancer" @default.
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