75 yo with slow progression 1 y after FOLFOX/bev -> 5-FU/bev?
What systemic treatment would you most likely recommend for the following patients:
A 75-year-old patient with asymptomatic mCRC responds to FOLFOX/bevacizumab but develops peripheral neuropathy. Oxaliplatin is stopped and the patient continues on 5-FU/bevacizumab with good treatment tolerance but after 1 year develops slow, minimally symptomatic disease progression on imaging and the peripheral neuropathy has still not resolved. The tumor is KRAS wild type.
Same patient as above, but the tumor is KRAS mutant?
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Steven R Alberts, MD, MPH |
| Chair, Division of Medical Oncology Professor of Oncology Mayo Clinic Rochester, Minnesota |
For a 75-year-old asymptomatic patient with KRAS wild-type or mutant mCRC and unresolved peripheral neuropathy, I would probably administer FOLFIRI alone.
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Al B Benson III, MD |
| Professor of Medicine Associate Director for Clinical Investigations Robert H Lurie Comprehensive Cancer Center of Northwestern University Chicago, Illinois |
For a 75-year-old patient with asymptomatic KRAS wild-type disease, I would consider treatment with either FOLFIRI/bevacizumab or irinotecan/bevacizumab.
I would consider administering FOLFIRI and bevacizumab to this 75-year-old patient with asymptomatic KRAS-mutant mCRC.
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Charles S Fuchs, MD, MPH |
| Director Center for Gastrointestinal Cancer Dana-Farber/Harvard Cancer Center Professor of Medicine Harvard Medical School Boston, Massachusetts |
For a 75-year-old patient with KRAS wild-type or mutant mCRC, I would stop treatment with oxaliplatin if the peripheral neuropathy has not resolved. I would treat with FOLFIRI/bevacizumab. I have treated other diseases with aflibercept on clinical trials but I’ve not used it for colon cancer yet.
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Richard M Goldberg, MD |
| Professor of Medicine Physician-in-Chief, OSUCCC - James Cancer Hospital and Richard J Solove Research Institute Klotz Family Chair in Cancer Research The Ohio State University Columbus, Ohio |
I would administer FOLFIRI in combination with bevacizumab to a 75-year-old asymptomatic patient with KRAS wild-type mCRC.
For a 75-year-old asymptomatic patient with KRAS-mutant disease, I would likely administer FOLFIRI in combination with bevacizumab. However, I might start with a reduced dose of irinotecan for the first cycle.
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Axel Grothey, MD |
| Professor of Oncology Department of Medical Oncology Mayo Clinic Rochester, Minnesota |
For a 75-year-old asymptomatic patient with KRAS wild-type or mutant mCRC, I would administer FOLFIRI/bevacizumab because this patient survived after receiving FOLFOX/bevacizumab as initial therapy.
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Howard S Hochster, MD |
| Associate Director (Clinical Research) Yale Cancer Center Professor of Medicine Yale School of Medicine New Haven, Connecticut |
For a 75-year-old asymptomatic patient with KRAS wild-type mCRC, I would opt for irinotecan in combination with an EGFR antibody. I would choose cetuximab over panitumumab because I have used it for a longer period.
For a 75-year-old patient with KRAS-mutant mCRC, I would switch to irinotecan/bevacizumab. I would consider treatment with aflibercept. However, because we have no data on cross resistance and I am not sure whether it’s more efficacious than bevacizumab beyond progression, I don’t tend to use aflibercept.
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Herbert I Hurwitz, MD |
| Associate Professor of Medicine Division of Hematology/Oncology Clinical Director, Phase I Program Co-leader, GI Oncology Program Duke University Medical Center Durham, North Carolina |
For a 75-year-old patient with wild-type disease, I would opt for FOLFIRI and the EGFR antibody panitumumab. My second treatment choice would be FOLFIRI/bevacizumab because this patient was well enough to have received FOLFOX-based therapy in the first place. However, I might adjust the dosage.
If the 75-year-old asymptomatic patient with KRAS-mutant disease were well enough to have initially received FOLFOX/bevacizumab, I would administer FOLFIRI/bevacizumab as my first treatment choice. My next choice would be FOLFIRI/aflibercept.
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Wells A Messersmith, MD |
| Professor and Director GI Medical Oncology Program Co-Leader Developmental Therapeutics Program University of Colorado Cancer Center Aurora, Colorado |
For a 75-year-old patient with asymptomatic, KRAS wild-type mCRC, I would administer FOLFIRI/cetuximab. I believe in switching over to an EGFR monoclonal antibody for a patient with KRAS wild-type disease instead of continuing bevacizumab beyond disease progression.
If this patient had KRAS-mutant mCRC, I would administer FOLFIRI/bevacizumab.