Prospective Cohort Study Of Traditional Chinese Medicine In Treating Metastatic Colorectal Cancer After Chemotherapy Failure And Its Correlation With CtDNA

Part 1 Prospective cohort study and prognostic factors analysis of Traditio nal Chinese Medicine treating metastatic colorectal cancer after chemothera py failureObjective1.To evaluate the survival efficacy in patients of metastatic colorectal cancer after chemotherapy failure with Traditional Chinese medicine(TCM),and to elaborate the position of TCM in treating metastatic colorectal cancer.2.Further study on Prognostic factors of metastatic Colorectal Cancer after c hemotherapy failure with traditional Chinese Medicine.MethodsWe conducted an seven-center prospective cohort study in China among patie nts who had undergone chemotherapy failure for metastatic colorectal cancer.A ll patients came from Xi yuan Hospital of China Academy of Chinese Medical Sciences,Guang'nmen Hospital of China Academy of Chinese Medical Scien ces,Beijing Hospital of TCM Affiliated to Capital Medical University,Beijing cancer Hospital,Cancer Hospital of Chinese Academy of Medical Sciences,C hinese PLA general hospital,Longhua Hospital Affiliated to Shanghai Universit y of Traditional Chinese Medicine.According to the wishes of patients,all pat ients were divided into Integrated Chinese and Western Medicine group(ICM),western medicine treatment group(WM)and Traditional Chinese medicine treat ment group(TCM).If cohort migration occurs in three groups for a variety of reasons,clinical experts and statisticians will determine the actual treatment stat us of the patients to divide the cohort,and carry out a variety of subgroups o r sensitivity analysis.The patients were followed up for a long time until the end of the study or the death of the patients.The overall survival and progres sion-free survival of the three groups were observed.This study is based on th e research and development project of Beijing Science and Technology Commi ssion,"Evaluation of the efficacy and Safety of traditional Chinese Medicine in ttreating Advanced Colorectal Cancer(D161100005116002)",starting and endin g from January 2016 to March 2020.The project was approved by the Ethics Committee of Xiyuan Hospital of China Academy of Chinese Medical Sciences on August 30,2016(batch number:2016XLA121-3)and registered on the cli nical trials.gov website(Identifier:NCT02923622).During the implementation o f the project,the Beijing Qihuang Drug Clinical Research Center is responsible for the quality control and supervision of the project.Results1.PatientsAs of November 30,2018,a total of 254 patients were enrolled in this inte rim analysis.After statistical analysis of cohort migration,there were 77 cases in WM,95 cases in ICM and 82 cases in TCM.The median follow-up time was 10.63 months in the WM,13.33 months in the ICM,and 9.10 months in the TCM.The median exposure time of traditional Chinese medicine in the T CM was 2.67 months,and the longest exposure time was 24.63 months.The median exposure time of traditional Chinese medicine in the ICM was 3.67 m onths,and the longest exposure time was 19.47 months.There was no signific ant difference in BMI,primary location,time of diagnosis of stage IV,patholo gical type and degree of differentiation among the three groups.2.Survival analysis2.1 Overall progression-free survival analysisThe progression-free survival(PFS)was 5.4 months in the WM,6.13 month s in the ICM and 5.13 months in TCM(p>0.05).Furthermore,there was no si gnificant difference in the risk of death between the two groups(p>0.05).2.2 Overall median overall survival(OS)analysisThe median overall survival(mOS)was 8.5 months in WM,13.1 months in ICM and 6.87 months in TCM(p=0.002).The one-year survival rates were 4898%,57.98%and 33.98%,independently.There was no significant difference i n HR between the ICM and the WM(HR=0.865,95%CI 0.694-1.078,p>0.05).Compared with TCM group,HR in WM group was declined by 59%(HR=1.593,95%CI 1.033-2.456,p=0.035).Compared with the TCM group,HR in the ICM group was declined by 50%(HR=0.496,95%CI 0.33-0.746,p<0.001).2.3 Survival Analysis of subgroups in ICM Group and WM GroupAmong the patients with KPS score<80,OS in the ICM group was prolonge d by 3.77 months(9 months vs 5.23 months,p=0.030),and the risk of death was reduced by about 49%(HR=0.516,95%CI 0.272-0.979,p=0.043).2.4 Survival Analysis of subgroups in WM Group and TCM GroupCompared with the TCM group,in the colon cancer subgroup,the WM gro up prolong the OS by 1.27 months(7 months vs 5.73 months,p=0.048),but th ere was no statistic difference in HR.In the subgroup with the time of diagno sis of stage IV<18 months,the risk of death in the WM group was 1.49 ti mes lower than that in the TCM group(HR=2.49,95%CI 1.438-4.31,p=0.001),while the OS was not reached in the WM group and 5.5 months in the TCM group(p<0.001).2.5 Survival Analysis of subgroups in ICM group and TCM groupThe ICM could reduce the risk of death in male,? 65 years old,left and r ight colon,metastatic organ ? 2,no liver metastasis,KPS score<80 and diagno sis of stage IV<18 months subgroup(p<0.05),and prolonged OS(p<0.05).3.COX multivariate analysis3.1 Univariate analysis resultsThe primary location,the number of metastatic organs,KPS score,liver m etastasis,exposure time of TCM and western medicine anti-tumor treatment we re the prognostic factors of chemotherapy-failed mCRC patients.The risk of de ath in the right colon was 1.67 times higher than in the left colon(HR=1.670,95%CI 1.144-2.437,p=0.008).The risk of death from rectal cancer was 0.634 times higher than that from colon cancer(HR=0.634,95%CI 0.440-0.914,p=0.017).The risk of death in patients with metastatic organs>2 was 1.552 times higher than that with one metastatic organ(HR=1.552,95%CI 1.061-2.270,p=0.023).The risk of death in patients with a KPS score below 80 was 1.718 time s higher than that with a score?80(HR=2.718,95%CI 1.895-3.899,p<0.001).The risk of death increased by 52.9%in patients with liver metastasis(HR=1.529,95%CI 1.079-2.167,p=0.017).Prolonged exposure to TCM for every 3 mon ths reduced the risk of death by 56%(HR=0.444,95%CI 0.340-0.581,p<0.001).Western medicine anti-tumor therapy reduced the risk of death by 45%(HR=0.549,95%CI 0.384-0.785,p=0.001).3.2 Results of COX multivariate analysis3.2.1 Overall multivariate analysisExposure time of traditional Chinese medicine and anti-tumor treatment of w estern medicine were independent protective factors(HR=0.368,95%CI 0.271-0.5,p<0.001;HR=0.492,95%CI 0.324-0.747,p<0.001),while KPS score<80 was an independent risk factor for survival(HR=2.384,95%CI 1.579-3.599,p<0.001).3.2.2Multivariate analysis of population in ICM group and TCM groupKPS<80 is still an independent risk factor for survival(HR=1.914,95%CI 1.199-3.058,p=0.007).Exposure time of traditional Chinese medicine and an ti-tumor treatment of western medicine were independent protective factors(p<0.01).Compared with liver and kidney deficiency syndrome,phlegm-dampness internal accumulation syndrome,stasis toxin internal obstruction syndrome,qi and blood deficiency syndrome and other syndrome types,spleen and kidney d eficiency type was an independent protective factor(HR=0.478,95%CI 0.298-0.767,p=0.002).Conclusions1.The effect of western medicine,integrated Chinese and western medicine and traditional Chinese medicine in improving the progression-free survival has no statistic differences.2.Compared with WM group,ICM has a tendency to prolong the survival ti me of patients in metastatic colorectal cancer after chemotherapy failure,especia lly in patients with poor performance status.3.WM can prolong 1.63 months compared with TCM.In subgroups,WM can prolong OS of patients with primary site in colon and stage ? time of diagno sis?18 months.OS in subgroups such as sex,age,physical condition,tumor 1 oad and liver metastasis treated by traditional Chinese medicine has no statistic difference with western medicine.4.Compared with traditional Chinese medicine,the overall median survival of integrated Chinese and western medicine treatment has been significantly im proved.5.KPS score below 80 was an independent risk factor,and exposure time o f traditional Chinese medicine,anti-tumor therapy of western medicine and syn drome type of deficiency of spleen and kidney were all independent protective factors.Part2 Next-Generation Sequencing of ctDNA for prognosis of metastatic col orectal cancer after chemotherapy failureObjectiveBased on the first part of the study,ctDNA was detected in patients with m etastatic colorectal cancer after chemotherapy failure who treated with traditionaChinese medicine,so as to explore the relationship between ctDNA and clini cal factors with survival prognosis.MethodsBlood samples were collected from patients who volunteered for ctDNA testi ng,and the next generation of high-throughput gene sequencing liquid biopsy t echnique was used to detect ctDNA using a custom Geneseeq One NGS panel covering 416 tumor-related gene probes.Results1.PatientsAmong them,15(39.5%)were over 65 years old,23(60.5%)were under 65 years old,19(50%)were male and 19(50%)were female.TCM syndrome s include deficiency of spleen and kidney,accumulation of phlegm and dampne ss,deficiency of liver and kidney,deficiency of qi and blood,internal obstructio n of stasis and toxin.2.Detection of tumor gene mutation in blood cellTumor-related genes were detected in plasma of 24 cases(63.16%)of 38 ca ses of chemotherapy-failed advanced colorectal cancer.The most common gene s associated with colorectal cancer were TP53,APC,KRAS,PIK3CA,TOP1,SRC,FBXW7,SMAD4,FLT1,BRAF,ERBB2,MTOR,SMAD3,POLE,CTN NB1,FAT1,ABCB1,SMAD2,FLT4,GNAS.3.Analysis of ctDNA mutation and prognosisThere was significant difference in mOS between ctDNA high mutation grou p and low mutation group(11.0 months vs 18.5 months,p=0.015).The progno sis of KRAS mutant patients was worse than that of KRAS wild type patients(11.0 months vs 18.5 months,p=0.015).No significant correlation between the gene status of TP53 or APC with survival was found in this study.4.Relationship between gene mutation and clinical factorsTP53 gene mutation:it was statistically significant in the left and right hemi colons(56.67%vs 12.50%,p=0.045)and in liver metastasis(66.67%vs 29.41%,p=0.022),there were more mutations in patients with the number of metastati c organs ? 2(65.00%vs 33.33%,p=0.049),and the mutation of TP53 in TC M patients with deficiency of spleen and kidney was significantly higher than that in patients with non-deficiency of both spleen and kidney(78.57%vs 33.33%,p=0.017).There was difference in APC gene mutation between patients wi th liver metastasis(61.90%vs 23.53%,p=0.025).The mutation of KRAS in pa tients with liver metastasis was higher than that in patients without liver metas tasis(47.62%vs 17.65%,p=0.048),and the proportion of patients with multipl e organ metastasis was higher than that in patients with single organ metastasis(55.00%vs 11.11%,p=0.006).Conclusions1.The frequency of ctDNA mutation is significantly correlated with the surv ival efficacy of traditional Chinese medicine in treating metastatic colorectal ca ncer after chemotherapy failure.2.Patients with KRAS mutant have poor prognosis,and KRAS mutations in patients with liver metastasis and multiple organ metastasis are more significant3.The proportion of TP53 mutations in patients with left colon,liver metast asis,multiple organ metastasis,and spleen-kidney deficiency syndrome was hig her,but the correlation between TP53 and prognosis was not found in this stu dy.4.Although the relationship between APC gene and prognosis was not obser ved,patients with liver metastases had higher APC mutations than those witho ut liver metastases.