Advances in Colorectal Cancer - Episode 10

Case Study: Treating Metastatic Colorectal Cancer

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In this segment, moderator John L. Marshall, MD, presents a case study of a 62 year-old patient with KRAS wild-type metastatic colorectal cancer. He notes that the patient presented with significant tumor burden in the liver, some lung disease, and was symptomatic. Initially, the patient responded to FOLFOX plus bevacizumab but only remained on maintenance capecitabine and bevacizumab for 4 months before progression with the return of symptoms, including neuropathy.

Due to tumor burden, Heinz-Josef Lenz, MD, recommends the administration of an EGFR inhibitor. Data indicate that treatment with EGFR inhibitors may result in significant tumor shrinkage when administered as a monotherapy or in combination. However, Lenz notes, when administering EGFR inhibitors in this situation, he would not add 5-FU to the treatment regimen.

Marshall presents the same case study to Axel Grothey, MD; however, in this situation, the patient is not symptomatic. In a non-symptomatic patient, Grothey would administer a sequence of FOLFIRI and bevacizumab, followed by irinotecan plus cetuximab, and finally regorafenib in the salvage setting.

Moving across the panel, Marshall presents the case study to Johanna Bendell, MD, with the caveat that the patient is KRAS mutated, rather than wild type. For this patient, Bendell would combine FOLFIRI with either bevacizumab or aflibercept, since an anti-EGFR agent is not an option.

Finally, Marshall presents the case study to Claus-Henning Köhne, MD, PhD, with a note suggesting the patient has now progressed a year after treatment and has grown tired of chemotherapy. If the patient no longer benefits from treatment with FOLFIRI or FOLFOX, Köhne states that he would select treatment with an EGFR inhibitor rather than regorafenib.

A number of trials are currently comparing treatment with EGFR and VEGF inhibitors, to provide data on the optimal treatment decision, Lenz explains. These trials are exploring a comparison between cetuximab and bevacizumab with either FOLFOX or FOLFIRI. Additionally, he notes, trials are exploring potential biomarkers for bevacizumab.