60 yo with obvious progression within a few months of FOLFOX/bev?
What systemic treatment would you most likely recommend for the following patients:
A 60-year-old patient with asymptomatic mCRC receives FOLFOX/bevacizumab but within a few months experiences obvious disease progression. The tumor is KRAS wild type.
Same 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 |
I would administer FOLFIRI and bevacizumab to this 60-year-old patient with asymptomatic, KRAS wild-type metastatic disease. I would reserve the use of an EGFR inhibitor for a later line of therapy.
For a 60-year-old patient with KRAS-mutant mCRC, I would administer FOLFIRI/bevacizumab.
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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 |
I would discuss bevacizumab continuation with either irinotecan or FOLFIRI with the 60-year-old patient with asymptomatic, KRAS wild-type mCRC. I would also discuss cetuximab as a treatment option for the patient, but it is possible that the disease will be responsive to chemotherapy alone. If the disease fails to respond to chemotherapy with or without bevacizumab, we still have the available option to administer cetuximab with FOLFIRI or irinotecan.
If this patient had KRAS-mutant disease, I would recommend treatment with irinotecan or FOLFIRI with bevacizumab.
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Charles S Fuchs, MD, MPH |
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Director Center for Gastrointestinal Cancer Dana-Farber/Harvard Cancer Center Professor of Medicine Harvard Medical School Boston, Massachusetts |
I would favor the administration of FOLFIRI/bevacizumab to this 60-year-old patient with asymptomatic, KRAS wild-type mCRC. If the disease is progressing rapidly with new symptoms or the patient experiences a deterioration in performance status, then I would use FOLFIRI with an EGFR antibody.
If this patient had KRAS-mutant mCRC, I would administer FOLFIRI/bevacizumab.
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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 |
For a 60-year-old patient with asymptomatic, KRAS wild-type mCRC, I would recommend treatment with FOLFIRI/bevacizumab. An alternative treatment is FOLFIRI with an EGFR antibody, but I may delay this until later. Panitumumab, not cetuximab, would be my preferred choice of EGFR antibody for 3 reasons. First, I practiced in North Carolina for a long time, and we saw a lot of anaphylactic reactions to cetuximab. Second, the standard for cetuximab therapy is weekly administration when used in combination with FOLFIRI, and panitumumab is received biweekly. Third, in my experience panitumumab is less costly than cetuximab.
If the patient had KRAS-mutant disease, I would administer FOLFIRI in combination with bevacizumab.
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Axel Grothey, MD |
| Professor of Oncology Department of Medical Oncology Mayo Clinic Rochester, Minnesota |
I would administer irinotecan in combination with an EGFR antibody to the 60-year-old patient with asymptomatic, KRAS wild-type mCRC. I normally use cetuximab.
EFGR antibodies have a track record with irinotecan. This is especially so if the patient is experiencing disease progression on FOLFOX. At this stage, the disease is probably also resistant to 5-FU, which is required by oxaliplatin to work. Irinotecan does not need oxaliplatin or 5-FU to be effective.
If the 60-year-old patient had KRAS-mutant mCRC, I would administer FOLFIRI/aflibercept.
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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 60-year-old patient with asymptomatic, KRAS wild-type mCRC, I would recommend treatment with irinotecan in combination with the EGFR antibody cetuximab. Due to the rapid disease progression on FOLFOX, I would switch to an irinotecan-based therapy.
If the 60-year-old patient had KRAS-mutant mCRC, I would probably switch to FOLFIRI/bevacizumab.
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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 |
In 80% to 90% of cases involving a 60-year-old patient with asymptomatic, KRAS wild-type mCRC, I would recommend treatment with FOLFIRI in combination with the EGFR antibody panitumumab. In the remaining 10% to 20% of cases, I would consider treatment with FOLFIRI/bevacizumab.
If this 60-year-old patient had KRAS-mutant mCRC, I would administer FOLFIRI/bevacizumab.
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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 60-year-old patient with asymptomatic, KRAS wild-type mCRC, I would recommend combination therapy with FOLFIRI and cetuximab.
For a 60-year-old patient who experiences quick disease progression on FOLFOX/bevacizumab, I would consider treatment with FOLFIRI/aflibercept. However, I have not been in a situation in which I have needed to administer aflibercept. I have never had a patient like this. Disease progression on first scan is not a common scenario, but this is certainly the type of case in which I would theoretically administer aflibercept.