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The Prospective Observational Cohort and the Nested Randomized Controlled Trial in the Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC Study) Question the Reliance on Existing Evidence for the Magnitude of Benefit From Lung Metastasectomy.

The excellent study by Alabraba and Gomez caught our attention.(1) In a systematic review performed to a high standard they draw attention to the burden of treatments in elderly patients with metastatic colorectal cancer (CRC). They conclude that the “survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly” and they go further to suggest that under certain circumstances which they specify, clinicians “may consider surveillance cessation in patients aged 75 years and above.” We fully support the second suggestion and the preparedness of the Nottingham group to challenge orthodoxy. We refer to further evidence as readers consider how these finding might influence their own practice. On the question of the clinical effectiveness of surveillance, there have been 16 randomised controlled trials (RCTs) testing the plausible hypothesis that the earlier asymptomatic disease is detected, the more likely it will be amenable to surgical resection, and the better will be survival. The first trial of surveillance following resection of colorectal cancer tested effectiveness of the then novel use of the tumour marker carcinoma embryonic antigen (CEA). It recruited 1447 patients from 1982-1993.(2) As other means became available, surveillance became more intensive. The trials have been systematically reviewed and put through meta-analysis with the consistent finding that although more patients are found with operable metastases, surgery confers no survival benefit.(3, 4) It has been suggested