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Sequencing Decisions in Relapsed/Refractory Colorectal Cancer

Panelists:Tanios Bekaii-Saab, MD, Ohio State University – James Cancer Hospital; Johanna Bendell, MD, Sarah Cannon Research Institute; Charles S. Fuchs, MD, Dana-Farber Cancer Institute; Richard Kim, MD, Moffitt Cancer Center; John L. Marshall, MD, Georgetown University Hospital
Published: Monday, Apr 11, 2016


Transcript:

John L. Marshall, MD:
Is there one that’s a favorite? They both have the same kind of indication. As you said, TAS-102 was given after regorafenib in that study in some patients. Is there an ideal patient where you might just go one way or the other?

Tanios Bekaii-Saab, MD: When you look at the studies, there is obviously a timeline between the two studies. We don’t have any experience with TAS-102 followed by regorafenib, although that experience may come clinically in some patients. But on trial, with the RECOURSE study, I do have patients who went on regorafenib that seemed to have done well on TAS-102. And for most patients, that tends to be my choice, to continue the process for regorafenib and use TAS-102 following regorafenib.

John L. Marshall, MD: Particular patients, low volume, high volume?

Tanios Bekaii-Saab, MD: At this stage, I think volume is less relevant. I think that if a patient comes to you after multiple lines of therapy and their bone marrow is quite beaten up, you may want to think twice about TAS-0102. But, if you have a patient who comes to you with liver function abnormalities, or had some significant issues with hand and foot syndrome...

John L. Marshall, MD: May be PS on the decline already.

Tanios Bekaii-Saab, MD: Exactly. Then you may want to think about TAS-102 first. But, for the majority of the patients—frankly, in my clinic—we’re able to go through that sequence with no significant problems.

John L. Marshall, MD: As we talked about before, I want to kind of come back to this one more time. So, we might also have oxaliplatin still in our pocket at this point, too. Is there a preference? Anybody want to jump in on if you still had OX, is there a patient where you’d say no, I’m going to play that before these drugs, versus play these drugs and bring OX later? Anybody got a bias?

Johanna Bendell, MD: Just the neuropathy issue. So, the neuropathy and the platelet count—just like Tony was alluding to—if I can use it again, I’m going to probably squeeze it out before I go to one of the two others. And, then I tend to use TAS-102, first, just because of the side-effect profile. But, you can argue with me either way.

John L. Marshall, MD: Some people are saying with response, because neither of these drugs you’re going to count on for a response. Maybe somebody with more symptomatic metastatic disease, you might have a bias that OX would more likely get you a response versus not.

Charles S. Fuchs, MD, MPH: Perhaps. I think we’ve all reintroduced oxaliplatin. You definitely get some responses, but it’s infrequent. I wouldn’t necessarily count on getting disease shrinkage with that approach.

John L. Marshall, MD: Okay. I think we have covered the subject of metastatic colorectal cancer from diagnosis to multidisciplinary care, to the new drugs, to toxicity management. I really think this has just been a fabulous discussion. We’ve reviewed a lot of information regarding therapeutic strategies in metastatic colorectal cancer. To close, I’d really like to get final thoughts from each of our panelists. And Tony, you get the easy one because you get to go first. Where are we with colorectal? What are the important takeaways for our doctors to have? You get one. Don’t use them all up with one speech.

Tanios Bekaii-Saab, MD: I think it’s an exciting time. A lot of options, a lot of potential, and we’re talking about survival beyond 3 years now in most of our patients with metastatic colorectal cancer. It’s an exciting time.

John L. Marshall, MD: Johanna.

Johanna Bendell, MD: Here’s where the challenge is coming. We’re starting to break colon cancer down in multiple different types of diseases that are all going to need a little bit of a different treatment. So yeah, it’s going to get confusing like breast cancer got confusing. Bear with us as we figure it out, but I think in the end, it’s all going to be better for the patients.

John L. Marshall, MD: Richard.

Richard Kim, MD: I think we discussed this at the beginning, but I think in terms of the multi-disciplinary approach, and the definition of resection is different from surgery to surgery. So, my last thought is that if you’re uncomfortable with some surgeon’s decision of not going for a potential resection, I think it’s okay to get a second opinion from a different surgeon. I’ve done that because those are the patients that are potentially curable. I would definitely recommend if you’re uncomfortable with the decision to get a second opinion from another surgeon for potential resection of the liver.

John L. Marshall, MD: Charlie, you get to take us home.

Charles S. Fuchs, MD, MPH: I have to go last. Bear in mind, the Holy Grail is how do we target RAS? It’s 40% to 50% of patients. No one seems to figure it out. I actually think there’s hope on the horizon. There are a number of approaches, and so stay tuned, because maybe the next time we see a KRAS-mutant patient, we’ll actually have a drug for them.

John L. Marshall, MD: That’s great. We can hope for that and cross our fingers. On behalf of our fabulous panel, we really want to thank you for joining us, and we hope you found this peer-exchange discussion to be both useful and informative.

Transcript Edited for Clarity
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Transcript:

John L. Marshall, MD:
Is there one that’s a favorite? They both have the same kind of indication. As you said, TAS-102 was given after regorafenib in that study in some patients. Is there an ideal patient where you might just go one way or the other?

Tanios Bekaii-Saab, MD: When you look at the studies, there is obviously a timeline between the two studies. We don’t have any experience with TAS-102 followed by regorafenib, although that experience may come clinically in some patients. But on trial, with the RECOURSE study, I do have patients who went on regorafenib that seemed to have done well on TAS-102. And for most patients, that tends to be my choice, to continue the process for regorafenib and use TAS-102 following regorafenib.

John L. Marshall, MD: Particular patients, low volume, high volume?

Tanios Bekaii-Saab, MD: At this stage, I think volume is less relevant. I think that if a patient comes to you after multiple lines of therapy and their bone marrow is quite beaten up, you may want to think twice about TAS-0102. But, if you have a patient who comes to you with liver function abnormalities, or had some significant issues with hand and foot syndrome...

John L. Marshall, MD: May be PS on the decline already.

Tanios Bekaii-Saab, MD: Exactly. Then you may want to think about TAS-102 first. But, for the majority of the patients—frankly, in my clinic—we’re able to go through that sequence with no significant problems.

John L. Marshall, MD: As we talked about before, I want to kind of come back to this one more time. So, we might also have oxaliplatin still in our pocket at this point, too. Is there a preference? Anybody want to jump in on if you still had OX, is there a patient where you’d say no, I’m going to play that before these drugs, versus play these drugs and bring OX later? Anybody got a bias?

Johanna Bendell, MD: Just the neuropathy issue. So, the neuropathy and the platelet count—just like Tony was alluding to—if I can use it again, I’m going to probably squeeze it out before I go to one of the two others. And, then I tend to use TAS-102, first, just because of the side-effect profile. But, you can argue with me either way.

John L. Marshall, MD: Some people are saying with response, because neither of these drugs you’re going to count on for a response. Maybe somebody with more symptomatic metastatic disease, you might have a bias that OX would more likely get you a response versus not.

Charles S. Fuchs, MD, MPH: Perhaps. I think we’ve all reintroduced oxaliplatin. You definitely get some responses, but it’s infrequent. I wouldn’t necessarily count on getting disease shrinkage with that approach.

John L. Marshall, MD: Okay. I think we have covered the subject of metastatic colorectal cancer from diagnosis to multidisciplinary care, to the new drugs, to toxicity management. I really think this has just been a fabulous discussion. We’ve reviewed a lot of information regarding therapeutic strategies in metastatic colorectal cancer. To close, I’d really like to get final thoughts from each of our panelists. And Tony, you get the easy one because you get to go first. Where are we with colorectal? What are the important takeaways for our doctors to have? You get one. Don’t use them all up with one speech.

Tanios Bekaii-Saab, MD: I think it’s an exciting time. A lot of options, a lot of potential, and we’re talking about survival beyond 3 years now in most of our patients with metastatic colorectal cancer. It’s an exciting time.

John L. Marshall, MD: Johanna.

Johanna Bendell, MD: Here’s where the challenge is coming. We’re starting to break colon cancer down in multiple different types of diseases that are all going to need a little bit of a different treatment. So yeah, it’s going to get confusing like breast cancer got confusing. Bear with us as we figure it out, but I think in the end, it’s all going to be better for the patients.

John L. Marshall, MD: Richard.

Richard Kim, MD: I think we discussed this at the beginning, but I think in terms of the multi-disciplinary approach, and the definition of resection is different from surgery to surgery. So, my last thought is that if you’re uncomfortable with some surgeon’s decision of not going for a potential resection, I think it’s okay to get a second opinion from a different surgeon. I’ve done that because those are the patients that are potentially curable. I would definitely recommend if you’re uncomfortable with the decision to get a second opinion from another surgeon for potential resection of the liver.

John L. Marshall, MD: Charlie, you get to take us home.

Charles S. Fuchs, MD, MPH: I have to go last. Bear in mind, the Holy Grail is how do we target RAS? It’s 40% to 50% of patients. No one seems to figure it out. I actually think there’s hope on the horizon. There are a number of approaches, and so stay tuned, because maybe the next time we see a KRAS-mutant patient, we’ll actually have a drug for them.

John L. Marshall, MD: That’s great. We can hope for that and cross our fingers. On behalf of our fabulous panel, we really want to thank you for joining us, and we hope you found this peer-exchange discussion to be both useful and informative.

Transcript Edited for Clarity
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