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Up-front Treatment of Metastatic Gastroesophageal Cancer

Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Yelena Y. Janjigian, MD, Memorial Sloan Kettering Cancer Center; Manish Shah, MD, Weill Cornell Medical College; Ian Chau, MD, Royal Marsden Hospital
Published: Friday, Dec 09, 2016


Transcript:

Johanna Bendell, MD:
With all that said, I’m going to do a mini lightning round, okay? Here it is. It’s like a game show. First-line treatment of metastatic disease: our goals are palliation, making the patient feel better. Everybody agree? That was the first test. So, then the question is, we have a bunch of different chemotherapy options we can use. What is your go-to regimen, first-line, Manish?

Manish Shah, MD: I think a doublet. So, a platinum + 5-FU doublet, like FOLFOX, is commonly used. Just a minute on that though. With the other options, if you think of taxanes in the second-line setting, ramucirumab, irinotecan, or maybe a PD-1 inhibitor coming on board, I actually think that for some patients, it might be advantageous to use a modified 3-drug regimen in the first-line setting if it’s done safely, because you want to have every drug available to them. Similar to colon cancer, what we learned is that the more drugs patients get, the longer they’re going to survive. I think my go-to is FOLFOX, but I’m thinking about how we can incorporate more drugs overall.

Johanna Bendell, MD: Ian?

Ian Chau, MD: We have a lot of thoughts when second-line paclitaxel started to become routinely used, and we have been concerned about the neurotoxicity for oxaliplatin. There was a period where we were using the triple epirubicin/oxaliplatin/capecitabine (EOX) as a standard, and we have actually changed that and switched oxaliplatin back to cisplatin, mainly to try to preserve the nerve for as long as possible. Again, yes, we do give patients epirubicin/cisplatin/capecitabine, so the ECX regimen. Or sometimes, as I said, there are many occasions where we only give doublet, so cisplatin/capecitabine. We do use a lot of carboplatin, actually, for our older-age patients, and that’s probably quite a long tradition that we have been doing it. And a lot of older folks with comorbidities actually really tolerate that well. But it is probably a niche thing that we do a bit more often maybe than at other institutions. But for those who can’t swallow, I do use FOLFOX a lot for those for whom we really feel can’t get the oral intake. [For] capecitabine, we do dissolve it, but [if we’re] not certain they can get all the drugs in, then I do go to FOLFOX.

Johanna Bendell, MD: Here’s a quick question. So, in the classic 5-FU and cisplatin regimen, infusional 5-FU is a big old dose of 5-FU for just a few days, and a big old dose of cisplatin, and then you give the patient some time to chill out. In the setting of being palliative and looking at quality of life, have you ever modified some of these dosing regimens?

Ian Chau, MD: I certainly don’t use that regimen. But that’s because we have the ECF. So, the 5-FU was given as a low-dose continued infusion every single day. So, we don’t give the 5-day big dose of 5FU infusion. We certainly, when we do need to give continuous infusion 5-FU, we do the low dose together with cisplatin or carboplatin. Of course, we say all that in a HER2-negative patient. I know we haven’t actually touched on HER2-positive disease yet, but all the things that we talked about are, of course, for HER2-negative gastric cancer.

Johanna Bendell, MD: Gotcha. And we’ll come back to that. Yelena?

Yelena Janjigian, MD: Well, I’ll throw a curve ball. I would argue that gastric cancer in the United States is rare, so every single patient, if fit and if a trial is available, should be treated in one. And in my practice, I would say that the majority of the patients are fit, and so a clinical trial is where we start. But outside of that, I would go by the patient’s baseline comorbidities. So, in a patient without significant neuropathy, 5-FU platinum is what I would recommend. In the de Gramont infusion, 5-FU is modified FOLFOX-6. But now, in the patient who has neuropathy or is diabetic or a violinist and cannot even bear to get any neuropathy, there are data to support FOLFIRI. In the first-line setting, it was compared head-to-head against a triplet and has done just as well with less toxicity. So, although it’s very rare, it is supported to use FOLFIRI in the first-line setting.

Johanna Bendell, MD: Excellent.

Ian Chau, MD: Can I make one point about what Yelena just said. I think nowadays we shouldn’t just think of the violinist needing their fingers. You need that for your iPhone, your iPad. Actually, I find relatives who actually get chemotherapy. I’d say that their life is completely destroyed because they can’t use their Smartphones anymore. So, actually, nowadays, life has changed. We can’t just think of musicians. Now, in everyday life, they need their fingers.

Manish Shah, MD: And then you will have patients that say that their life is better because they can’t use their iPhone.

Transcript Edited for Clarity
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Transcript:

Johanna Bendell, MD:
With all that said, I’m going to do a mini lightning round, okay? Here it is. It’s like a game show. First-line treatment of metastatic disease: our goals are palliation, making the patient feel better. Everybody agree? That was the first test. So, then the question is, we have a bunch of different chemotherapy options we can use. What is your go-to regimen, first-line, Manish?

Manish Shah, MD: I think a doublet. So, a platinum + 5-FU doublet, like FOLFOX, is commonly used. Just a minute on that though. With the other options, if you think of taxanes in the second-line setting, ramucirumab, irinotecan, or maybe a PD-1 inhibitor coming on board, I actually think that for some patients, it might be advantageous to use a modified 3-drug regimen in the first-line setting if it’s done safely, because you want to have every drug available to them. Similar to colon cancer, what we learned is that the more drugs patients get, the longer they’re going to survive. I think my go-to is FOLFOX, but I’m thinking about how we can incorporate more drugs overall.

Johanna Bendell, MD: Ian?

Ian Chau, MD: We have a lot of thoughts when second-line paclitaxel started to become routinely used, and we have been concerned about the neurotoxicity for oxaliplatin. There was a period where we were using the triple epirubicin/oxaliplatin/capecitabine (EOX) as a standard, and we have actually changed that and switched oxaliplatin back to cisplatin, mainly to try to preserve the nerve for as long as possible. Again, yes, we do give patients epirubicin/cisplatin/capecitabine, so the ECX regimen. Or sometimes, as I said, there are many occasions where we only give doublet, so cisplatin/capecitabine. We do use a lot of carboplatin, actually, for our older-age patients, and that’s probably quite a long tradition that we have been doing it. And a lot of older folks with comorbidities actually really tolerate that well. But it is probably a niche thing that we do a bit more often maybe than at other institutions. But for those who can’t swallow, I do use FOLFOX a lot for those for whom we really feel can’t get the oral intake. [For] capecitabine, we do dissolve it, but [if we’re] not certain they can get all the drugs in, then I do go to FOLFOX.

Johanna Bendell, MD: Here’s a quick question. So, in the classic 5-FU and cisplatin regimen, infusional 5-FU is a big old dose of 5-FU for just a few days, and a big old dose of cisplatin, and then you give the patient some time to chill out. In the setting of being palliative and looking at quality of life, have you ever modified some of these dosing regimens?

Ian Chau, MD: I certainly don’t use that regimen. But that’s because we have the ECF. So, the 5-FU was given as a low-dose continued infusion every single day. So, we don’t give the 5-day big dose of 5FU infusion. We certainly, when we do need to give continuous infusion 5-FU, we do the low dose together with cisplatin or carboplatin. Of course, we say all that in a HER2-negative patient. I know we haven’t actually touched on HER2-positive disease yet, but all the things that we talked about are, of course, for HER2-negative gastric cancer.

Johanna Bendell, MD: Gotcha. And we’ll come back to that. Yelena?

Yelena Janjigian, MD: Well, I’ll throw a curve ball. I would argue that gastric cancer in the United States is rare, so every single patient, if fit and if a trial is available, should be treated in one. And in my practice, I would say that the majority of the patients are fit, and so a clinical trial is where we start. But outside of that, I would go by the patient’s baseline comorbidities. So, in a patient without significant neuropathy, 5-FU platinum is what I would recommend. In the de Gramont infusion, 5-FU is modified FOLFOX-6. But now, in the patient who has neuropathy or is diabetic or a violinist and cannot even bear to get any neuropathy, there are data to support FOLFIRI. In the first-line setting, it was compared head-to-head against a triplet and has done just as well with less toxicity. So, although it’s very rare, it is supported to use FOLFIRI in the first-line setting.

Johanna Bendell, MD: Excellent.

Ian Chau, MD: Can I make one point about what Yelena just said. I think nowadays we shouldn’t just think of the violinist needing their fingers. You need that for your iPhone, your iPad. Actually, I find relatives who actually get chemotherapy. I’d say that their life is completely destroyed because they can’t use their Smartphones anymore. So, actually, nowadays, life has changed. We can’t just think of musicians. Now, in everyday life, they need their fingers.

Manish Shah, MD: And then you will have patients that say that their life is better because they can’t use their iPhone.

Transcript Edited for Clarity
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