Population-based Screening for BRAF V600E in Metastatic Colorectal Cancer Reveals Increased Prevalence and Poor Prognosis

Affiliations

PMID: 32571791
DOI: 10.1158/1078-0432.CCR-20-1024

Abstract

PURPOSE BRAFV600E mutations portend poor prognosis in metastatic colorectal cancer (mCRC); however, the true prevalence and prognosis are unknown, as unwell patients may not undergo BRAF sequencing. PATIENTS AND METHODS We reviewed a population-based cohort of 1898 patients with CRC that underwent reflexive immunohistochemistry (IHC) mismatch repair (MMR) & BRAFV600E testing. Outcomes among IHC detected BRAFV600E mCRC (BRAFIHC) were compared to patients with next generation sequencing identified BRAFV600E mutated mCRC from two institutions (BRAFNGS) with patients spanning from 2004-2018. RESULTS All-stage population prevalence of BRAFV600E was 12.5% (238/1898) and did not differ between early and metastatic stages (p=0.094). Prevalence among mCRC was 10.6% (61/575), of whom 51 (83.6%) were referred to oncology and 26 (42.6%) had NGS testing. BRAFIHC had worse median overall survival (mOS) than BRAFNGS (5.5 vs 20.4 months, hazard ratio (HR) 2.90, 95% confidence interval (CI) 1.89-4.45, p<0.0001) which persisted in multivariate analysis (p<0.0001). Across a combined NGS and IHC cohort, BRAFV600E tumors with deficient MMR showed worse mOS compared to MMR proficient tumors (8.9 vs 17.2 months, HR 1.46, 95% CI 0.96-2.27, p=0.043). In this combined cohort, first-line progression free survival was 5.9 months, with minimal differences between regimens. Within the population-based cohort, attrition between treatment lines was high with only 60.7% receiving first-line chemotherapy and 26.2% receiving second-line. CONCLUSION BRAFV600E mutated mCRC has a worse prognosis than previously suggested, potentially arising from referral bias for testing. High attrition between lines of therapy suggests efficacious therapies need to be prioritized early for patients to benefit.