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Practice Patterns for the Management of Hepatic Metastases from Colorectal Cancer: A Mixed Methods Analysis

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Purpose

The optimal management of colorectal cancer liver metastases (CRC-LM) has changed during the past two decades. However, clinical practice lags behind best evidence recommendations. We sought to characterize the gap between current practice and best evidence for the management of these patients and to identify barriers that hamper effective utilization of metastasectomy.

Methods

A mixed-methods approach was used. A survey was mailed to all general surgeons (GS) and medical oncologists (MO) in Ontario, Canada. Domains examined included: physician/practice characteristics, indications for hepatectomy, use of multi-modality therapy and referral patterns. Physician focus groups were conducted that explored issues relating to access to care.

Results

The survey was mailed to 942 physicians with a response rate of 68 % (n = 348; GS n = 295, 69 %; MO n = 53, 63 %). Current practice patterns demonstrated that 97 % of physicians refer patients with low tumor burden (e.g., solitary CRC-LM), but referral rates for hepatectomy decreased as the tumor burden increased. Physicians still consider extrahepatic disease as a strong contraindication to metastasectomy. Barriers to care included: economic, time, and resource constraints; lack of physician engagement, local medical expertise, and high-quality guidelines. Multidisciplinary cancer conferences were identified as an enabler of clinical care and a potential platform for the acquisition of new medical knowledge.

Conclusions

Current management of CRC-LM does not reflect best evidence. Patients who may benefit from surgery are not being referred for metastasectomy. We have identified an evidence-practice gap at the level of physician, which should be targeted with novel quality improvement strategies.

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Acknowledgment

The authors thank Marina Englesakis, J. Charles Victor, Julie Takata, Jackie Zhai, Meagan Wiebe, and Harden Huang for their contribution to this work. This project was funded by Colon Cancer Canada and the Ministry of Health and Long-Term Care of Ontario, Academic Enrichment Fund, Innovation Fund.

Disclosures

There are no financial disclosures from any authors.

Author information

Authors and Affiliations

  1. Division of General Surgery, University Health Network, University of Toronto, Toronto, ON, Canada

    Alice C. Wei MD, Lakhbir Sandhu MD, Katharine S. Devitt MSc, Anna R. Gagliardi PhD, David R. Urbach MD & Steve Gallinger MD

  2. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Alice C. Wei MD, Anna R. Gagliardi PhD, Erin D. Kennedy MD, David R. Urbach MD, Steve Gallinger MD & Nancy N. Baxter MD

  3. Division of General Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada

    Erin D. Kennedy MD

  4. Department of Surgery and the Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada

    Nancy N. Baxter MD

Authors
  1. Alice C. Wei MD
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  2. Lakhbir Sandhu MD
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  3. Katharine S. Devitt MSc
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  4. Anna R. Gagliardi PhD
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  5. Erin D. Kennedy MD
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  6. David R. Urbach MD
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  7. Steve Gallinger MD
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  8. Nancy N. Baxter MD
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Corresponding author

Correspondence to Alice C. Wei MD.

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Wei, A.C., Sandhu, L., Devitt, K.S. et al. Practice Patterns for the Management of Hepatic Metastases from Colorectal Cancer: A Mixed Methods Analysis. Ann Surg Oncol 20, 1567–1574 (2013). https://doi.org/10.1245/s10434-012-2698-3

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  • DOI: https://doi.org/10.1245/s10434-012-2698-3

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