Comparative survival outcomes of CAPOX, FOLFOX, and FOLFIRI among colorectal cancer patients in Amhara Region, Ethiopia: A multicenter retrospective cohort study

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BACKGROUND: Colorectal cancer (CRC) poses a growing public health concern in Ethiopia, where patients often present at advanced stages and treatment resources are limited. This study aimed to assess the comparative survival outcomes of CAPOX, FOLFOX, and FOLFIRI on mortality among CRC patients in the Amhara region. METHODS: A retrospective cohort study was conducted using medical records of colorectal cancer patients treated in oncology centers of the Amhara region. Multivariable Cox proportional hazards regression was employed to estimate adjusted hazard ratios (AHR) for mortality associated with chemotherapy regimens using FOLFOX as an explicit reference category and other clinical variables. The primary outcome was all cause mortality, and the mortality incidence rate was calculated per 100 person-months of follow-up. RESULTS: A total of 338 patients contributed 4824.9 person-months of follow-up, with an overall mortality incidence rate of 3.48 deaths per 100 person-months. Compared directly to patients receiving FOLFOX, those treated with CAPOX AHR = 2.15 (95% CI: 1.42-3.26) and FOLFIRI AHR = 2.48 (95% CI: 1.61-3.82). (AHR = 2.15, 95% CI: 1.42-3.26) exhibited a significantly higher risk of mortality. Poor performance status (ECOG 3-4) and undifferentiated tumor histology were also associated with significantly worse survival (AHR = 2.46 and 2.03, respectively). In contrast, FOLFOX did not show a significant association with increased mortality. CONCLUSION: This study found a high CRC mortality rate in the Amhara region, with CAPOX and FOLFIRI regimens associated with increased mortality risk. However, stage-stratified analyses revealed that these survival differences narrowed substantially among non-metastatic patients (Stage I-III), indicating that the observed hazard disparities are largely attributable to confounding by indication, baseline patient frailty, and toxicity management challenges rather than inherent regimen inefficacy.

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