To identify risk factors associated with poor prognosis in patients with advanced colorectal cancer using real-world data and to develop an optimal dynamic treatment strategy model for a population with traditional Chinese medicine (TCM) advantages, thereby providing evidence for individualized clinical decision-making.

A total of 426 patients with advanced colorectal cancer who were treated between January 2017 and January 2025 at Xiyuan Hospital of China Academy of Chinese Medical Sciences, Peking University Cancer Hospital, and Dongzhimen Hospital, Beijing University of Chinese Medicine were retrospectively enrolled. Baseline clinical characteristics were collected, and prognostic risk factors were screened using least absolute shrinkage and selection operator (LASSO) regression. A multivariate Cox proportional hazards regression model was constructed with the selected risk factors as argument and overall survival as the outcome. Patients receiving TCM were categorized into three therapeutic strategies according to the relative contribution of TCM and Western medical treatments: TCM alone, integrated TCM and Western medicine with equal emphasis, and TCM adjuvant to Western medicine. Continuous implementation of each strategy was defined as one treatment stage. Among these patients, 182 were included in the population with TCM advantages. With survival time as the primary outcome, prognostic risk factors and covariates derived from the research team′s previously established two-stage treatment strategy model were incorporated. A three-stage dynamic treatment strategy model for TCM was developed using a dynamic treatment regime approach for "multiple treatments + continuous outcomes." Survival outcomes were compared between patients managed according to the optimal dynamic treatment strategy and those who were not.

LASSO regression and multivariable Cox analysis demonstrated that age ≥60 years, right-sided colon cancer, BRAF mutation, body mass index (BMI) ≥ 24 kg/m², and Eastern Cooperative Oncology Group performance status score ≥ 2 were risk factors for poor prognosis in advanced colorectal cancer (HR > 1, P < 0.05). Palliative surgery and syndrome of internal obstruction by blood stasis and toxin were identified as protective factors (HR< 1, P < 0.05). At the initiation of TCM treatment, appropriate therapeutic strategies were selected based on variables such as prior targeted therapy, history of palliative surgery, BMI, and MD Anderson Symptom Inventory score. Survival analysis demonstrated that the median overall survival of patients receiving treatment per the optimal dynamic therapeutic strategy was 34.5 months, which was 9.9 months longer than that of patients who did not (24.6 months). The difference between the two groups was statistically significant (HR = 0.841, 95%CI: 0.793-0.897, P = 0.047).

The three-stage dynamic treatment strategy model for the population with TCM advantages, constructed by integrating prognostic risk factors of advanced colorectal cancer with covariates from a previously developed two-stage strategy model, supports individualized clinical decision-making and effectively improves clinical outcomes.