Treatment of Metastatic Colorectal Cancer - Episode 6
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Moderator, John L. Marshall, MD, presents a case based discussion focused on the treatment of a 60 year-old man with colorectal cancer (CRC) that has metastasized to the liver. The patient has a good performance status with RAS wild-type CRC. After a consultation with the patient, the surgeon believes the central liver metastases are resectable, if tumor shrinkage can be accomplished.
In this situation, when an anatomical response is needed, it may be appropriate to utilize FOLFOXIRI, believes Axel Grothey, MD. Recent evidence from the EPOC trial discourages the addition of an EGFR inhibitor before surgery, at least in combination with FOLFOX. As a result, if a response is needed and a biologic is required, Grothey recommends utilizing bevacizumab.
In many cases, a response is not needed desperately enough to warrant FOLFOXIRI, Alan P. Venook, MD, believes. In this situation, FOLFIRI is appropriate alone, since bevacizumab may be difficult to administer in the preoperative setting, Venook believes. In the past, before the EPOC study, it would have been common to utilize FOLFIRI plus an EGFR inhibitor in this setting.
The cytotoxic combination may not be appropriate for a patient who plans undergo major liver resection, due to concerns over residual toxicity, Fadi Braiteh, MD, CPI, believes. As a result, a shorter duration of treatment in this setting is required. However, after surgery, looking at the FIRE-3 trial, patients may benefit from FOLFIRI plus cetuximab, Braiteh notes.
At this point in time, given data from recent clinical trials, EGFR inhibitors may not play a role in the preoperative setting, states Tanios Bekaii-Saab, MD. Additionally, looking at the TRIBE trial, bevacizumab with FOLFOXIRI or FOLFIRI demonstrated similar results. Outside of this, Bekaii-Saab believes, the most important predictor of how well patients will do is dependent on the R0 resection rate.
At this point, Marshall questions the utilization of irinotecan in this setting, noting that FOLFOX alone or in combination with bevacizumab seems to have the most supporting evidence in this space. To this point, Grothey notes that he uses preoperative data to help determine the postoperative therapy. In this setting, Grothey agrees that FOLFOX is preferential.