Original article
13142
Palliative surgical intervention in metastatic colorectal
carcinoma: a prospective analysis of quality of life
W. J. Tan*, M. H. Chew*, I. B. H. Tan†, J. H. Law‡, R. Zhao‡, S. Acharyya§, Y. L. Mao*,
L. G. Fernandez*, C. T. Loi* and C. L. Tang*
*Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore, †Department of Medical Oncology, National Cancer Centre
Singapore, Singapore, Singapore, ‡Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore and §Centre for Qualitative
Medicine, DUKE NUS Graduate Medical School, Singapore, Singapore
Received 23 April 2015; accepted 10 July 2015; Accepted Article online 6 October 2015
Abstract
Aim Quality of life (QOL) was assessed after palliative
surgery for incurable metastatic colorectal cancer (CRC).
Method Newly diagnosed patients with incurable meta-
static CRC who were offered elective palliative surgical
intervention were included. The European Organization
for Research and Treatment of Cancer QLQ-C30 and
QLQ-CR29 questionnaire was used for the assessment
of QOL at baseline and at 3 and 6 months after surgery.
Generalized estimating equations were used to estimate
the mean change in the QOL score from baseline.
Results Twenty-four patients formed the study group.
Sixteen underwent resection of the primary tumour and
eight had a proximal diversion or bypass. The Global
Health (GH) score and Social Functioning (SF) score
improved at 3 and 6 months after intervention respec-
tively (GH +11, P = 0.021; SF +15, P = 0.005). Mean
anxiety scores were markedly improved from the base-
Introduction
Colorectal cancer (CRC) is the second most common
cancer in women and the third most common in men
[1]. Among such patients close to 20% present with
metastatic disease [2]. While a few may be amenable to
curative resection of the primary tumour and the metas-
tases, in most patients it is unresectable. Prognosis for
this group of patients is particularly grim with an esti-
mated 5-year survival of less than 10% [3]. Surgery is
mainly reserved for patients with sufficiently severe
symptoms due to the primary tumour to justify the sig-
nificant risk of morbidity and mortality [4,5].
Correspondence to: Dr Min Hoe Chew, Department of Colorectal Surgery,
Singapore General Hospital, 20 College Road, Academia, Singapore 169856,
Singapore.
E-mail: chew.min.hoe@sgh.com.sg
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 357–363
doi:10.1111/codi.
line of 51 to 71 (P = 0.004, 3 months) and 76
(P = 0.002, 6 months). Weight concerns also improved
significantly when compared with baseline (3 months,
+20, P < 0.001; 6 months, +14, P = 0.012). Symptoms
of diarrhoea (3 months, ‒17, P = 0.007; 6 months,‒
16, P = 0.008) and nausea ( ‒8, P = 0.032)
improved.
Conclusion In patients with incurable metastatic CRC,
surgery improved QOL.
Keywords Palliative surgery, QOL, metastatic colorec-
tal carcinoma
What does this paper add to the literature?
This is the first study to evaluate the impact of palliative
surgery on quality of life in patients with incurable
metastatic colorectal cancer. It adds to the limited liter-
ature on quality of life in patients with metastatic col-
orectal cancer.
In these patients with limited life expectancy, health-
related quality of life (QOL) becomes important.
Objective evidence of improvement in QOL must jus-
tify surgery in this group of patients as postoperative
morbidity can range from 18 to 47% [4,5]. Despite the
importance of this consideration, there is a dearth of
information on the QOL after palliative surgery for
incurable metastatic CRC. This study assessed QOL of
a group of patients with incurable metastatic CRC after
palliative surgery.
Method
The study was carried out under the approval of the
Centralized Institutional Review Board of the Singapore
Health Services. Newly diagnosed patients presenting
between June 2013 and June 2014 with incurable
357
Palliative surgery in metastatic CRC
metastatic CRC who were offered elective palliative sur-
gery were invited to participate in the study. Those who
presented acutely with intestinal obstruction, bleeding
or perforation requiring emergency intervention were
excluded. Demographic and clinicopathological data,
QOL score and survival were prospectively recorded in
a database using the Research Electronic Data Capture
(REDCap) platform. REDCap is a secure, web-based
application designed to support data capture for
research studies [6].
Incurable metastatic disease was defined as metastases
at sites other than the liver or lung or at more than one
site. In patients with an isolated liver or lung metastasis,
any disease burden which precluded resection with ade-
quate predicted organ function was defined as incurable.
Palliative surgery included resection of the primary
tumour (PTR), surgical bypass or a diverting stoma.
The choice of type of palliative surgical intervention (re-
section vs diversion) or the surgical approach (laparo-
scopic or open) was left to the discretion of the
attending surgeon.
Postoperative care and course
In patients who underwent a surgical bypass or PTR,
feeding was resumed after the resolution of ileus as evi-
denced by the passage of flatus and recovery of bowel
sounds. Prophylactic antibiotics were discontinued after
24 h. The removal of any postoperative drain was left
to the discretion of the individual surgeon. In patients
having a diversion, alimentation was generally com-
menced on the first postoperative day. No prophylactic
antibiotics were given other than the dose before induc-
tion. Venous thromboprophylaxis in the form of stock-
ings or pneumatic calf pumps was prescribed for all
patients. Pharmacological venous thromboprophylaxis
was prescribed only for high-risk patients without a
contraindication to anticoagulation. All intra-operative
and 30-day postoperative complications were recorded
prospectively. Complications were graded using the
Clavien–Dindo classification [7].
Assessment of health-related QOL
The European Organization for Research and Treatment
of Cancer (EORTC) QLQ-C30 and the QLQ-CR29
questionnaire were administered to all patients [8]; these
had been previously validated in our local population
[9]. The EORTC QLQ-C30 questionnaire contains
scales and items addressing functional aspects of health-
related QOL and symptoms pertinent to cancer patients.
It consists of five functional scales (physical, role,
emotional, cognitive and social), three symptom scales
358 Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 357–363
W. J. Tan et al.
(fatigue, nausea, and vomiting and pain), six single
symptom items (sleeping disorders, appetite loss, dysp-
noea, diarrhoea, constipation and financial problems)
and a global health-related QOL score. A high score for
the functional scale and global health-related QOL score
translates into a higher level of functioning and QOL.
Conversely, a higher score for the symptom scales
reflects a higher degree of symptomatology and thus
poorer QOL. The QLQ-C30 questionnaire is supple-
mented by the QLQ-CR29, the CRC-specific module of
the EORTC questionnaire [10].
Questionnaires were administered before surgical
intervention to obtain the baseline QOL value. They
were re-administered at 3 and 6 months after surgery.
All questionnaires were delivered by two healthcare pro-
viders who were not actively involved in the manage-
ment of the patients to minimize interviewer bias.
Statistical analysis
Statistical analysis was performed using SPSS for Win-
dows version 17 (SPSS, Chicago, Illinois, USA) and R
3.1.1 (R Core Team 2014, Vienna, Austria). All ques-
tionnaire responses were transformed linearly into scores
on a 0–100 scale according to the EORTC scoring
manual [11]. The distribution of baseline demographic
and clinical characteristics was examined using counts
with percentages for categorical data and mean with
standard deviation for continuous data. The indepen-
dent sample t-test for unequal sample size and unequal
variance was used to compare the mean baseline QOL
scores with the reference QOL scores for metastatic
CRC (n = 653) obtained from the EORTC reference
manual [12].
The mean difference in QOL scores and their 95%
confidence intervals (CI), between subsequent visits and
baseline were estimated using the generalized estimating
equation (GEE) by specifying an unstructured correla-
tion to account for repeated observations. The mean
QOL scores were compared between baseline and sub-
sequent visits using the Wald test. Statistical significance
was set at the 0.05 level and all tests were two-sided.
Results
Thirty patients were eligible for inclusion in the study.
Six declined participation and as such, 24 patients con-
stituted the study cohort. The median age was 64 years
with approximately 60% being men (Table 1). Twenty-
one patients were Chinese. Common presenting symp-
toms included obstructive symptoms, bleeding, change
in bowel habit and abdominal pain (Table 1). Twelve of
the 24 patients had a right-sided tumour, eight had a
W. J. Tan et al. Palliative surgery in metastatic CRC

Table 1 Characteristics of 24 patients with unresectable col- more site of metastasis. Following surgery, 21 out of 24
orectal metastases followed prospectively. patients proceeded with palliative chemotherapy. The
three patients who did not receive palliative chemother-
Variable No. of patients (n = 24)
apy were offered it but declined owing to concern
about the side effects.
Gender (%)
Male 14 (58)
Three (12.5%) patients developed perioperative com-
Female 10 (42) plications of which two were Grade I and one was
Median age (years) (range) 65 (45–76) Grade II. The Grade I complications included ileus
Ethnic group (%) requiring nasogastric tube decompression for 7 days
Chinese 21 (88) and the other was a superficial wound infection that was
Malay 2 (8) treated by wound dressings and oral antibiotics. The
Indian 1 (4) Grade II complication was bleeding from the anastomo-
Symptoms (%) sis after an anterior resection. This was managed conser-
Obstructive 7 (29) vatively by blood transfusion and spontaneously
Bleeding 9 (38)
resolved.
Abdominal pain 11 (46)
The median duration of follow-up was 11 (6–22)
Change in bowel habit 13 (54)
ASA grade (%)
months. Three patients died during the duration of the
1 15 (62.5) study at 2, 7 and 10 months after surgery. The baseline
2 6 (25) QOL scores of the study group compared with the
3 3 (12.5) score for metastatic CRC obtained from the EORTC
Location of tumour (%) reference manual are shown in Table 2. The study
Right colon 12 (50) group had significantly superior function scores in the
Left colon/sigmoid 8 (33) domain of physical functioning, role functioning, emo-
Rectum 4 (17) tional functioning and cognitive functioning
Type of surgery (%) (P = 0.001, P < 0.001, P = 0.006 and P = 0.016,
Right hemicolectomy 9 (38)
respectively). The study group also appeared to be less
Left hemicolectomy 2 (8)
symptomatic in the domains of fatigue, dyspnoea,
Anterior resection 5 (21)
Diverting stoma/by-pass 8 (33)
insomnia and financial difficulties (P = 0.008,
Site of metastases (%) P = 0.031, P = 0.009 and P = 0.028, respectively).
Liver 18 (75) The change in the QLQ-C30 QOL scores at 3 and
Lung 11 (46) 6 months after surgery compared with baseline is shown
Peritoneal 7 (29) in Table 3 and Fig. 1a,b. There was a statistically signif-
Total no. of metastatic sites (%) icant improvement in Global Health (GH) score and
1 12 (50) Social Functioning (SF) scores at 3 and 6 months after
2 9 (37.5) surgery (GH +11, P = 0.021; SF +15, P = 0.005).
3 3 (12.5) There was a marked improvement in diarrhoea symp-
Palliative chemotherapy status (%) 21 (91.7)
toms at 3 and 6 months after surgery (3 months, 17,
ASA, American Society of Anesthesiologists. P = 0.007; 6 months, 16, P = 0.008) and nausea was
also improved at 3 months ( 8, P = 0.032).
Analysis of the QLQ-CR29 (CRC Specific Module)
tumour in the left colon or sigmoid and four had a rec- QOL scores, (Table 4, Fig. 1c) showed markedly
tal tumour. Sixteen patients underwent resection of the improved anxiety scores from a baseline of 51 to 71
primary tumour, of which four were performed laparo- (P = 0.004) and 76 (P = 0.002) at 3 and 6 months
scopically. Among the remaining eight patients, seven after surgery. Weight loss was significantly less com-
underwent proximal diversion with a stoma. One pared with baseline (3 months, +20, P < 0.001;
patient with a hepatic flexure tumour was initially 6 months, +14, P = 0.012). Sexual interest appeared to
planned for primary resection but extensive peritoneal be diminished in men while it remained relatively pre-
disease was discovered intra-operatively and an ileocolic served in women.
bypass was performed instead.
The frequency of the various sites of metastases and
Discussion
their number is shown in Table 1. The majority of the
patients had liver metastases while approximately a third The prognosis for metastatic CRC is grim, with an esti-
had peritoneal disease. Half of the patients had two or mated 5-year survival of less than 10% [3]. An estimated

Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 357–363 359
Palliative surgery in metastatic CRC W. J. Tan et al.

Table 2 Comparison of baseline quality

Study cohort Reference sample
of life (QOL) of the study group with
QOL parameter (n = 24) (n = 653) P-value
reference values from the European
Organization for Research and Treatment
Global health 58 (27.1) 61 (22.9) 0.631 of Cancer (EORTC).
Physical functioning 85 (15.8) 73 (23.3) 0.001*
Role functioning 86 (24.7) 65 (33.4) < 0.001*
Emotional functioning 83 (19.2) 71 (23.7) 0.006*
Cognitive functioning 91 (13.9) 83 (20.9) 0.016*
Social functioning 75 (24.1) 74 (28.6) 0.891
Fatigue 26 (21.4) 39 (28) 0.008*
Nausea and vomiting 12 (17.4) 10 (19.2) 0.586
Pain 17 (20.6) 25 (28.9) 0.082
Dyspnoea 10 (18.3) 19 (27.3) 0.031*
Insomnia 15 (26.0) 31 (31.8) 0.009*
Appetite loss 22 (25.4) 23 (31.6) 0.944
Constipation 21 (33.8) 16 (27.1) 0.522
Diarrhoea 28 (36.3) 15 (25.6) 0.111
Financial difficulties 28 (28.9) 14 (26.4) 0.028*

P-values are from two independent sample t-tests with unequal sample size and
unequal variance.
*Statistically significant result.
Values are given as mean (SD).

Table 3 The estimated mean (95% CI) difference in quality of life (QOL) scores at 3 and 6 months after surgery compared with
baseline values.

3 month Change 6 month

Baseline mean mean score from baseline mean score Change from
QOL parameter score (95% CI) (95% CI) (95% CI) P-value (95% CI) baseline (95% CI) P-value

Function scores
Global health 58 (47–69) 69 (60–79) +11 ( 0.71 to 19) 0.021* 68 (57–79) +10 (5 to 25) 0.106
Physical functioning 85 (75–92) 92 (86–97) +7 ( 3 to 13) 0.250 88 (83–93) +3 ( 2 to 10) 0.160
Role functioning 86 (75–96) 87 (77–98) +1 ( 14 to 15) 0.950 78 (67–89) 8 ( 19 to 5) 0.240
Emotional functioning 83 (75–91) 90 (84–96) +7 (1 to 13) 0.075 87 (77–96) +4 ( 11 to 16.2) 0.697
Cognitive functioning 91 (85–97) 94 (90–98) +3 ( 1 to 9) 0.150 96 (92–99) +5 ( 1 to 10) 0.100
Social functioning 75 (65–85) 84 (73–95) +9 ( 6 to 17) 0.320 90 (82–99) +15 (11 to 25) 0.005*
Symptom scores
Fatigue 26 (17–35) 26 (17–35) 0 – 28 (18–38) +2 ( 9 to 11) 0.780
Nausea and vomiting 12 (5–19) 4 (0–8) 8 ( 15 to 1) 0.032* 8 (0–16) 4 ( 13 to 4) 0.345
Pain 17 (9–26) 8 (1–16) 9 ( 19 to 1) 0.082 14 (4–24) 3 ( 16 to 9) 0.596
Dyspnoea 10 (2–17) 11 (1–20) +1 ( 9 to 12) 0.807 7 (0–14) 3 ( 7 to 7) 0.984
Insomnia 15 (4–26) 18 (4–32) +3 ( 11 to 15) 0.743 10 (3–18) 5 ( 16 to 5) 0.336
Appetite loss 22 (11–33) 17 (6–28) 5 ( 19 to 8) 0.410 21 (7–35) 1 ( 17 to 16) 0.930
Constipation 21 (7–35) 8 (0–15) 13 ( 30 to 2) 0.101 18 (5–30) 3 ( 21 to 15) 0.728
Diarrhoea 28 (12–43) 11 (4–17) 17 ( 31 to 5) 0.007* 12 (3–22) 16 ( 30 to 4) 0.008*
Financial difficulties 28 (15–40) 21 (10–33) 7 ( 19 to 8) 0.405 26 (11–42) 2 ( 18 to 14) 0.820

*Statistically significant result.

40–70% of patients with metastatic CRC are symp- remain apprehensive regarding surgery in this group of
tomatic from the primary tumour at the time of diagno- patients due to the fear of morbidity. This is evident
sis [5,13]. These patients may potentially experience from a recent analysis of the database of the National
symptomatic relief from palliative surgery but clinicians Cancer Institute Surveillance, Epidemiology and End

360 Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 357–363
W. J. Tan et al. Palliative surgery in metastatic CRC

(a) Baseline QOL 3 months after surgery 6 months after surgery

100 P = 0.005
90

80
P = 0.021
70
Mean QOL score

60

50

40

30

20

10

0
Global Physical Role Emotional Cognitive Social
health functioning functioning functioning functioning functioning

(b) Baseline QOL 3 months after surgery 6 months after surgery

30 P = 0.008

25
Mean QOL score

20

15 P = 0.032

10

0
Fatigue Nausea & Pain Dyspnoea Insomnia Appetite Constipation Diarrhoea Financial
vomiting loss difficulties

(c) Baseline QOL 3 months after surgery 6 months after surgery

100 P = 0.012
P = 0.002 P = 0.008
90
Mean CR29 QOL score

80
70
60
50
40
30
20
10
0
Body image Anxiety Weight Sexual interest Sexual interest
male female
Figure 1 (a) Changes in the QLQ-C30 quality of life (QOL) function score after surgery. (b) Changes in the QLQ-C30 QOL
symptom scores after surgery. (c) Changes in the CR-29 QOL function scores after surgery.

Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 357–363 361
Palliative surgery in metastatic CRC
Table 4 The estimated mean (95% CI) difference in CR-29 quality of life (QOL) scores at 3 and 6 months after surgery compared
with baseline values.
Baseline mean 3 month mean Change from
QOL parameter score (95% CI) score (95% CI) baseline (95% CI)
Function score
Body image 84 (77–91) 91 (84–98) +7 ( 2 to 16)
Anxiety 51 (40–62) 71 (57–85) +20 (6 to 33)
Weight 70 (57–82) 90 (83–97) +20 (9 to 30)
Sexual interest
Male 84 (71–96) 75 (59–91) 9 ( 19 to
Female 93 (78–100) 93 (83–100) 0 –
*Statistically significant result.
Results which showed a reduction in primary tumour
resection rate from 74.5% in 1998 to 57.4% in 2010
[14]. Quality of life is particularly pertinent for patients
with incurable metastatic CRC, as resection of the pri-
mary tumour is unlikely significantly to prolong survival
[15]. Despite its importance, there is to our knowledge
no available study that assesses QOL after palliative sur-
gical intervention in patients with metastatic CRC.
The study group had significantly superior function
scores and symptom scores in several domains compared
with the EORTC reference population with metastatic
disease. While selection bias is one potential explana-
tion, this discrepancy may also be explained by cultural
effects as self-perceived QOL is inherently influenced by
expectations of what is considered the norm within a
community [12,16]. When the QOL scores of the pre-
sent study group were compared with another local
cohort of patients with peritoneal carcinomatosis, the
scores of the two groups were more similar than to that
of the EORTC reference population. This reiterates the
fact that cultural differences may potentially affect QOL
[17]. Thus, in the assessment of QOL after surgery,
baseline QOL should form the basis of comparison
rather than available reference values from other popula-
tions, as these may be influenced by various external
factors.
The patients in this group had significant improve-
ment in GH scores and SF scores at 3 and 6 months
after surgery. Anxiety scores and concern regarding
body weight were also markedly improved. The
improvement of function scores could be explained by
the significant improvement in nausea and diarrhoea
after surgery. These were clinically and statistically sig-
nificant, as previous studies have shown that score
changes of more than 5–10 points are clinically signifi-
cant [18]. The improvement in diarrhoea was particu-
larly marked, with a score reduction from 28
preoperatively to 11 postoperatively. It is plausible to
362 Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 357–363
W. J. Tan et al.
6 month mean Change from
P-value score (95% CI) baseline (95% CI) P-value
0.110 86 (78–94) +2 ( 6 to 9) 0.660
0.004* 76 (60–91) +25 (8 to 37) 0.002*
< 0.001* 84 (75–94) +14 (3 to 22) 0.012*
1) 0.026* 64 (43–85) 20 ( 35 to 5) 0.008*
96 (86–100) +3 ( 12 to 24) 0.550
deduce that this contributed significantly to the
patients’ perception of well-being and diminished anxi-
ety over body weight.
Concern about surgical morbidity is a valid consider-
ation in patients with metastatic CRC, but in the pre-
sent study surgical morbidity affected 12.5% of the 24
patients. The three important complications occurred in
the 16 patients who had undergone a primary tumour
resection, and thus the morbidity rate for primary
tumour resection was 19% (3/16). However, all the
complications were mild, being Grade I or II. Taking
this into account, the clinical significance of the mor-
bidity in the present study was less than the 4% rate of
major morbidity among 452 palliative primary tumour
resections reported retrospectively by Chew et al. [19]
from the Department of Colorectal Surgery, Singapore
General Hospital. The figures illustrate that acceptable
morbidity can be achieved in high-volume institutions
dedicated to colorectal surgical oncology.
The main limitation of this study lies in its small sam-
ple size. Thus, Type II errors which may potentially
understate the purported improvement in QOL after pal-
liative surgical intervention are inevitable. Despite the
limitations of sample size, statistically significant improve-
ments in the domains of GH, SF, anxiety, concern over
body weight, and symptoms of nausea and diarrhoea
were demonstrated. To our knowledge, this is the first
study to have evaluated the impact of palliative surgical
intervention on QOL in patients with incurable meta-
static CRC. Its prospective nature ensured reliable data
collection and provided baseline QOL scores, which form
the most reliable basis of comparison when assessing the
postoperative outcome. There are currently no com-
pleted randomized studies assessing QOL after treatment
of metastatic CRC. Although the SYNCHRONOUS trial
aims to evaluate the efficacy of primary tumour resection
before systemic chemotherapy and has QOL as a sec-
ondary outcome, it is still at the stage of recruitment
W. J. Tan et al. Palliative surgery in metastatic CRC

[20]. The present study will contribute to the currently Cancer Quality of Life Questionnaire (EORTC QLQ-c30):
scant literature available on QOL in metastatic CRC. Pal- validation of English version in Singapore. Qual Life Res
liative surgery in patients with incurable metastatic CRC 2005; 14: 1181–6.
can lead to an improved QOL with reduction in nausea 10 Sprangers MA, te Velde A, Aaronson NK. The construction
and testing of the EORTC colorectal cancer-specific quality
and diarrhoea with low morbidity.
of life questionnaire module (QLQ-CR38). European Orga-
nization for Research and Treatment of Cancer Study Group
on Quality of Life. Eur J Cancer 1999; 35: 238–47.
Conflicts of interest
11 Fayers PM, Aaronson NK, Bjordal K et al. The EORTC
There are no conflicts of interest. QLQ-C30 Scoring Manual. 3nd Edition. Brussels: European
Organisation for Research and Treatment of Cancer, 2001.
12 Fayers PM. Interpreting quality of life data: population-
References based reference data for the EORTC QLQ-C30. Eur J
Cancer 2001; 37: 1331–4.
1 Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman
13 Ruo L, Gougoutas C, Paty PB, Guillem JG, Cohen AM,
D. Global cancer statistics. CA Cancer J Clin 2011; 61:
Wong WD. Elective bowel resection for incurable stage IV
69–90.
colorectal cancer: prognostic variables for asymptomatic
2 Howlader N, Noone AM, Krapcho M et al. Survelliance,
patients. J Am Coll Surg 2003; 196: 722–8.
Epidemiology, and End Results Cancer Statistics Review,
14 Hu CY, Bailey CE, You YN et al. Time trend analysis of
1975–2010, Vol. 2013. Bethesda, MD: National Cancer
primary tumor resection for stage IV colorectal cancer: less
Institute, 2013.
surgery, improved survival. JAMA Surg 2015; 150: 245–
3 O’Connell JB, Maggard MA, Ko CY. Colon cancer survival
51.
rates with the new American Joint Committee on Cancer
15 Cirocchi R, Trastulli S, Abraha I et al. Non-resection ver-
sixth edition staging. J Natl Cancer Inst 2004; 96: 1420–5.
sus resection for an asymptomatic primary tumour in
4 Scheer MG, Sloots CE, van der Wilt GJ, Ruers TJ. Man-
patients with unresectable stage IV colorectal cancer.
agement of patients with asymptomatic colorectal cancer
Cochrane Database Syst Rev 2012; 8: CD008997.
and synchronous irresectable metastases. Ann Oncol 2008;
16 Farkkila N, Sintonen H, Saarto T et al. Health-related
19: 1829–35.
quality of life in colorectal cancer. Colorectal Dis 2013; 15:
5 Scoggins CR, Meszoely IM, Blanke CD, Beauchamp RD,
e215–22.
Leach SD. Nonoperative management of primary colorectal
17 Tan WJ, Wong JF, Chia CS, Tan GH, Soo KC, Teo MC.
cancer in patients with stage IV disease. Ann Surg Oncol
Quality of life after cytoreductive surgery and hyperthermic
1999; 6: 651–7.
intraperitoneal chemotherapy: an Asian perspective. Ann
6 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N,
Surg Oncol 2013; 20: 4219–23.
Conde JG. Research electronic data capture (REDCap) – a
18 Osoba D, Rodrigues G, Myles J, Zee B, Pater J. Interpret-
metadata-driven methodology and workflow process for
ing the significance of changes in health-related quality-of-
providing translational research informatics support. J
life scores. J Clin Oncol 1998; 16: 139–44.
Biomed Inform 2009; 42: 377–81.
19 Chew MH, Teo JY, Kabir T, Koh PK, Eu KW, Tang CL.
7 Clavien PA, Barkun J, de Oliveira ML et al. The Clavien-
Stage IV colorectal cancers: an analysis of factors predicting
Dindo classification of surgical complications: five-year
outcome and survival in 728 cases. J Gastrointest Surg
experience. Ann Surg 2009; 250: 187–96.
2012; 16: 603–12.
8 Aaronson NK, Ahmedzai S, Bergman B et al. The Euro-
20 Rahbari NN, Lordick F, Fink C et al. Resection of the pri-
pean Organization for Research and Treatment of Cancer
mary tumour versus no resection prior to systemic therapy
QLQ-C30: a quality-of-life instrument for use in interna-
in patients with colon cancer and synchronous unresectable
tional clinical trials in oncology. J Natl Cancer Inst 1993;
metastases (UICC stage IV): SYNCHRONOUS – a ran-
85: 365–76.
domised controlled multicentre trial (ISRCTN30964555).
9 Luo N, Fones CS, Lim SE, Xie F, Thumboo J, Li SC. The
BMC Cancer 2012; 12: 142.
European Organization for Research and Treatment of

Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 18, 357–363 363