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Omission of Adjuvant Chemotherapy Is Associated With Increased Mortality in Patients With T3N0 Colon Cancer With Inadequate Lymph Node Harvest

Wells, Katerina O. M.D., M.P.H.; Hawkins, Alexander T. M.D.; Krishnamurthy, Devi M. M.D.; Dharmarajan, Sekhar M.D.; Glasgow, Sean C. M.D.; Hunt, Steven R. M.D.; Mutch, Matthew G. M.D.; Wise, Paul M.D.; Silviera, Matthew L. M.D.

Diseases of the Colon & Rectum: January 2017 - Volume 60 - Issue 1 - p 15–21
doi: 10.1097/DCR.0000000000000729
Original Contributions: Colorectal/Anal Neoplasia

BACKGROUND: Adjuvant chemotherapy for T3N0 colon cancer is controversial. National guidelines recommend its use in patients with stage II with high-risk features, including lymph node harvest of less than 12, yet this treatment is underused.

OBJECTIVE: The purpose of this study was to demonstrate that the use of adjuvant chemotherapy in patients with T3N0 adenocarcinoma with inadequate lymph node harvest is beneficial.

DESIGN: This was a retrospective population-based study of patients with resected T3N0 adenocarcinoma of the colon.

SETTINGS: The National Cancer Database was queried from 2003 to 2012.

PATIENTS: A total of 134,567 patients with T3N0 colon cancer were included in this analysis.

MAIN OUTCOME MEASURES: The use of chemotherapy, short-term outcomes, and overall survival was evaluated. Clinicopathologic factors associated with omission of chemotherapy were also analyzed.

RESULTS: Inadequate lymph node harvest was observed in 23.3% of patients, and this rate decreased over the study period from 46.8% in 2003 to 12.5% in 2012 (p < 0.0001). Overall 5-year survival for patients with T3N0 cancer was 66.8%. Inadequate lymph node harvest among these patients was associated with lower overall 5-year survival (58.7% vs 69.8%; p < 0.001). The use of adjuvant chemotherapy among patients with T3N0 cancer after inadequate lymph node harvest was only 16.7%. In a multivariable analysis, factors associated with failure to receive chemotherapy included advanced age (OR = 0.44 (95% CI, 0.43–0.45)), increased comorbidities (OR = 0.7 (95% CI, 0.66–0.76)), and postoperative readmission (OR = 0.78 (95% CI, 0.67–0.91)). Patients with inadequate lymph node harvest who received adjuvant chemotherapy had improved 5-year survival (chemotherapy, 78.4% vs no chemotherapy, 54.7%; p < 0.001). Even when controlling for all of the significant variables, the administration of chemotherapy remained a predictor of decreased mortality (HR = 0.57 (95% CI, 0.54–0.60); p < 0.001).

LIMITATIONS: This study was limited by its retrospective, population-based design.

CONCLUSIONS: Patients with T3N0 colon cancer with inadequate lymph node harvest who receive adjuvant chemotherapy have increased overall survival. Despite this survival benefit, a fraction of these patients receive adjuvant chemotherapy. Barriers to chemotherapy are multifactorial.

Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri

Financial Disclosure: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Los Angeles, CA, April 30 to May 4, 2016.

Correspondence: Katerina O. Wells, M.D., M.P.H., Department of Surgery, Division of Colon and Rectal Surgery, Baylor University Medical Center, 3409 Worth St. Suite 640, Dallas, TX 75246. E-mail:

© 2017 The American Society of Colon and Rectal Surgeons