Systemic chemotheRapy and the liVEr-fiRSt approach compared to index colorectal resection for colorectal cancer presenting with synchronous liver metastases (the RVERS trial)

Background and study aims
Bowel cancer is the third most common cancer in the United Kingdom and the liver is the most common site to which bowel cancer spreads. About a third of patients with bowel cancer will already have secondary tumours in the liver (called metastases) at the time that the bowel cancer is diagnosed. In this situation, the standard treatment is to remove the bowel cancer first by surgery, give chemotherapy and then about three to four months later, remove the liver tumours. This is known as the classic approach. The limitation with this is that the liver tumours are untreated during the period of bowel cancer surgery and the patient may have to wait several months for chemotherapy. An alternative approach, known as the “reverse” strategy, is to give chemotherapy as the first treatment for patients with bowel cancer with tumours in the liver, then remove the liver tumours and finally the bowel cancer. The reasoning behind this approach is that chemotherapy treats the whole body and tumours in both the liver and the bowel. The liver tumours are thought to be responsible for spread of bowel cancer to other sites so the reason for operating on these first is to reduce the chance of spread. Finally, it is the bowel surgery which is associated with unpleasant side effects such as the possibility of requiring a colostomy (stoma bag) and for men the possibility of impaired sexual function, and in some patients treated with the reverse approach the chemotherapy means that if the bowel tumour responds completely, surgical removal may not be necessary. This “watch and wait” policy if there has been a complete response, cannot be used if the bowel tumour has been the target of surgery before any other treatment.
Who can participate?
Patients over the age of 18 presenting with bowel cancer that has spread to the liver.
What does the study involve?
Participants will be randomly allocated to receive either the standard treatment or the newer reverse approach. In both options, both the bowel cancer and the liver tumour are treated; the difference lies in the sequence of treatment.