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Goldberg RM, Montagut C, Wainberg ZA, Ronga P, Audhuy F, Taieb J, Stintzing S, Siena S, Santini D. Optimising the use of cetuximab in the continuum of care for patients with metastatic colorectal cancer. ESMO Open 2018; 3:e000353. [PMID: 29765773 PMCID: PMC5950648 DOI: 10.1136/esmoopen-2018-000353] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 12/17/2022] Open
Abstract
The anti-epidermal growth factor receptor (EGFR) monoclonal antibody cetuximab in combination with chemotherapy is a standard of care in the first-line treatment of RAS wild-type (wt) metastatic colorectal cancer (mCRC) and has demonstrated efficacy in later lines. Progressive disease (PD) occurs when tumours develop resistance to a therapy, although controversy remains about whether PD on a combination of chemotherapy and targeted agents implies resistance to both components. Here, we propose that some patients may gain additional clinical benefit from the reuse of cetuximab after having PD on regimens including cetuximab in an earlier treatment line. We conducted a non-systematic literature search in PubMed and reviewed published and ongoing clinical trials, focusing on later-line cetuximab reuse in patients with mCRC. Evidence from multiple studies suggests that cetuximab can be an efficacious and tolerable treatment when continued or when fit patients with mCRC are retreated with it after a break from anti-EGFR therapy. Furthermore, on the basis of available preclinical and clinical evidence, we propose that longitudinal monitoring of RAS status may identify patients suitable for such a strategy. Patients who experience progression on cetuximab plus chemotherapy but have maintained RAS wt tumour status may benefit from continuation of cetuximab with a chemotherapy backbone switch because they have probably developed resistance to the chemotherapeutic agents rather than the biologic component of the regimen. Conversely, patients whose disease progresses on cetuximab-based therapy due to drug-selected clonal expansion of RAS-mutant tumour cells may regain sensitivity to cetuximab following a defined break from anti-EGFR therapy. Looking to the future, we propose that RAS status determination at disease progression by liquid, needle or excisional biopsy may identify patients eligible for cetuximab continuation and rechallenge. With this approach, treatment benefit can be extended, adding to established continuum-of-care strategies in patients with mCRC.
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Affiliation(s)
- Richard M Goldberg
- Cancer Signature Program, West Virginia University Cancer Institute, Morgantown, West Virginia, USA
| | - Clara Montagut
- Gastrointestinal Cancer, Department of Medical Oncology, Hospital del Mar-IMIM, Barcelona, Spain
| | - Zev A Wainberg
- University of California Los Angeles David Geffen School of Medicine, Division of Hematology/Oncology, Department of Medicine, Los Angeles, California, USA
| | | | | | - Julien Taieb
- Hôpital Européen Georges-Pompidou, APHP, Paris Descartes University, Sorbonne Paris Cité, Department of GI Oncology, Paris, France
| | - Sebastian Stintzing
- University Hospital, Ludwig-Maximilians-University Munich, Department of Medicine III, Munich, Germany
| | - Salvatore Siena
- Università degli Studi di Milano, Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Department of Hematology and Oncology, Milan, Italy
| | - Daniele Santini
- Unit of Medical Oncology, Università Campus Bio-Medico, Rome, Italy
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