Single agent fluorouracil for first-line treatment of advanced colorectal cancer as standard?

Strategies of sequential therapies in unresectable metastatic colorectal cancer: a meta-analysis

BACKGROUND

Before the emergence of first-line combination chemotherapy, the standard of care for unresectable metastatic colorectal cancer (mcrc) was first-line monotherapy with modulated 5-fluorouracil. Several large phase iii randomized controlled trials, now completed, have assessed whether a planned sequential chemotherapy strategy-beginning with fluoropyrimidine monotherapy until treatment failure, followed by another regimen (either monotherapy or combination chemotherapy) until treatment failure-could result in the same survival benefit produced with an upfront combination chemotherapy strategy, but with less toxicity for patients.

METHODS

The medline and embase databases, and abstracts from meetings of the American Society for Clinical Oncology and the European Society for Medical Oncology, were searched for reports comparing a sequential strategy of chemotherapy with an upfront combination chemotherapy in adult patients with mcrc. Publications that reported efficacy or toxicity data (or both) were included.

RESULTS

The five eligible trials that were identified included 4532 patients. A meta-analysis of those trials demonstrates a statistically significant survival advantage for combination chemotherapy (hazard ratio: 0.92; 95% confidence interval: 0.86 to 0.99). However, the median survival advantage (3-6 weeks in most trials) is small and of questionable clinical significance. Three trials reported first-line toxicities. Upfront combination chemotherapy results in significantly more neutropenia, febrile neutropenia, thrombocytopenia, diarrhea, nausea, vomiting, and sensory neuropathy. Sequential chemotherapy results in significantly more hand-foot syndrome.

CONCLUSIONS

Given the small survival advantage associated with upfront combination chemotherapy, planned sequential chemotherapy and upfront combination chemotherapy can both be considered treatment strategies. Treatment should be chosen on an individual basis considering patient and tumour characteristics, toxicity of each strategy, and patient preference.

Systemic treatment of liver metastases from colorectal cancer

Patients presenting with synchronous or metachronous colorectal cancer liver metastases (CLM) should be evaluated for multimodal management with curative intent. Preoperative systemic chemotherapy shows beneficial impact on adjuvant progression-free survival and also borderline on overall survival, without significantly increasing initially R0 resectable patients postoperative complication rates. Postoperative chemotherapy recommended based on the perioperative trial experience for those patients achieving at least stable disease during preoperative chemotherapy, or based on the adjuvant trials for patients receiving upfront resection. 'Borderline' resectable CLM, preoperative chemotherapy plays an important role in both in achievement of a resectable status and improvement of prognosis. Recent 4 drug combinations demonstrated response rates up to 80% even for advanced disease and are thus promising regimens for further evaluation in patients with resectable or unresectable liver-limited (+/- lung) disease.

ESMO Consensus Guidelines for management of patients with colon and rectal cancer. a personalized approach to clinical decision making

Colorectal cancer (CRC) is the most common tumour type in both sexes combined in Western countries. Although screening programmes including the implementation of faecal occult blood test and colonoscopy might be able to reduce mortality by removing precursor lesions and by making diagnosis at an earlier stage, the burden of disease and mortality is still high. Improvement of diagnostic and treatment options increased staging accuracy, functional outcome for early stages as well as survival. Although high quality surgery is still the mainstay of curative treatment, the management of CRC must be a multi-modal approach performed by an experienced multi-disciplinary expert team. Optimal choice of the individual treatment modality according to disease localization and extent, tumour biology and patient factors is able to maintain quality of life, enables long-term survival and even cure in selected patients by a combination of chemotherapy and surgery. Treatment decisions must be based on the available evidence, which has been the basis for this consensus conference-based guideline delivering a clear proposal for diagnostic and treatment measures in each stage of rectal and colon cancer and the individual clinical situations. This ESMO guideline is recommended to be used as the basis for treatment and management decisions.

Treatment with bevacizumab and FOLFOXIRI in patients with advanced colorectal cancer: presentation of two novel trials (CHARTA and PERIMAX) and review of the literature

BACKGROUND

More than half of patients with colorectal cancer will develop metastatic disease either evident at the time of initial diagnosis or during their course of disease. Besides multidisciplinary management further treatment intensification is warranted to improve the still limited prognosis.

METHODS/DESIGN

In these two multi-centre, randomized phase II trials, conducted in Germany, 380 patients with R0-resectable colorectal liver metastases (PERIMAX) and with unresectable, metastatic colorectal cancer (CHARTA) will be recruited. Patients previously untreated for metastatic disease with either synchronous or metachronous metastases are randomly assigned in a 1:1 ratio to resection of colorectal liver metastases followed by postoperative FOLFOX for 6 months or perioperative FOLFOXIRI and bevacizumab for 3 months pre- and postoperative and resection (PERIMAX), or to induction chemotherapy with FOLFOX and bevacizumab +/- irinotecan for a maximum of 6 months followed by maintenance treatment with fluoropyrimidine and bevacizumab. The primary objective of these trials is to evaluate the feasibility and efficacy of FOLFOXIRI and bevacizumab in metastatic colorectal cancer. Primary endpoint is failure free survival rate at 18 months in the PERIMAX trial and progression free survival rate at 9 months in CHARTA. Secondary objectives include efficacy, safety and tolerability.

DISCUSSION

The CHARTA and PERIMAX trials are designed to evaluate the benefits and limitations of a highly active four-drug regimen in distinct treatment situations of metastatic CRC. Eligible patients are classified into resectable liver metastases to be randomized to perioperative treatment with FOLFOXIRI and bevacizumab or postoperative FOLFOX in the PERIMAX, or unresectable metastatic CRC to be randomized between FOLFOX and bevacizumab with or without irinotecan, stratified for clinical groups according to disease and patients' characteristics in the CHARTA trial.

TRIAL REGISTRATION

Clinical trial identifier CHARTA: NCT01321957, PERIMAX: NCT01540435.

Overview of biomarkers in metastatic colorectal cancer: tumour, blood and patient-related factors

During the last 20 years there have been major therapeutic developments in colorectal cancer (CRC) with the introduction of multiple novel therapeutic agents into routine clinical practice. This has improved survival in both the adjuvant and advanced disease settings. However, improvements have come with substantial increases in expense to the community and potential toxicity to the patient. There has been substantial research to identify tumour factors in CRC that predict treatment response and survival outcomes. This research has identified clinically useful predictive biomarkers to aid clinical decision making, such as the presence or absence of KRAS gene mutations which can determine the benefit of using epidermal growth factor receptor (EGFR) inhibiting antibodies. However, less attention has been paid to the identification and impact of predictive patient-derived factors such as age, gender and the presence of comorbid conditions or evidence of a systemic inflammatory response. In this article, the current concepts of tumour and patient-related predictive factors in CRC management are reviewed.

Personalized treatment of colorectal cancer

In the last 15 years, significant progress in the management of colorectal cancer (CRC) has been achieved with several new agents licensed extending median overall survival for stage IV disease to about 2 years. Treatment of CRC is stage-specific, multidisciplinary, and based on patient and tumor characteristics. Although especially early stages (0-III, according to Union for International Cancer Control) are treated with curative intent, patients with limited stage IV disease (liver and/or lung or localized peritoneal metastases) might still be curable in a multimodality approach including surgery, perioperative chemotherapy and/or radiotherapy. Despite the broad variety of prognostic factors, treatment decisions and selection of drugs are mainly based on clinicopathologic variables for early stage CRC, extent of disease, potential resectability, patients' eligibility to receive aggressive treatments including chemotherapy, surgery, and very few molecular markers such as KRAS mutational status for advanced disease. However, a tailored approach for the treatment of CRC taking into account all mentioned factors is currently recommended by national and international guidelines and will be discussed in this review.

Liver metastases from colorectal cancer: how to best complement medical treatment with surgical approaches

Colorectal liver metastases (CLM) represent a major challenge for oncologists and surgeons. In fact, in this setting, the optimal treatment of patients can achieve a long-term survival and sometimes a definitive cure of disease. In recent years, improvements in both medical therapies and surgical approaches have led to an increased rate of patients considered amenable for surgery on CLM. New perspectives in the management of CLM underline the need for a comprehensive assessment of patient and tumor characteristics, to integrate technical and prognostic issues into an individualized therapeutic strategy in different patient subgroups. The multidisciplinary evaluation from the onset and during treatment remains the key element to maximizing the benefit of more intensive treatment modalities.

Optimal delivery of cytotoxic chemotherapy for colon cancer

Colon cancer is treated adjuvantly with 5-flourouracil (5-FU) and oxaliplatin, most commonly as part of the FOLFOX regimen, which has less toxicity than the older regimen FLOX (bolus 5-FU and oxaliplatin) that has fallen out of favor. For patients who cannot tolerate oxaliplatin, 5-FU can be given as a single agent. Patients with metastatic disease may be treated with a number of regimens, including FOLFOX and FOLFIRI; however, the environment is a not a monotonous vanilla and chocolate FOLFOX and FOLFIRI. Cytotoxic agents, sequentially or in combination, are frequently combined with biologic agents to improve response in metastatic disease. Clinical investigators have focused considerable attention on how best to apply all the agents active in metastatic colon cancer, a practice in evolution. In this article, we highlight important, informative research regarding cytotoxic chemotherapy for colon cancer. We also recognize the contribution made by skilled surgeons, interventional radiologists, and radiation oncologists who will push the envelope and as well, the pharmacogenomic and molecular markers that help us to understand mechanisms of disease, predict toxicity, and refine our therapy.

Palliative treatment of unresectable metastatic colorectal cancer

IMPORTANCE OF THE FIELD

Treatment options for metastatic colorectal cancer (mCRC) patients have rapidly increased in the past years, but 50 - 70% of mCRC patients are still unlikely to undergo radical resection of metastases and are candidates for palliative therapy only.

AREAS COVERED IN THIS REVIEW

Oxaliplatin and irinotecan have widened the chemotherapy alternatives available in this setting and effective targeted agents against vascular endothelial growth factor and epidermal growth factor receptor have further improved treatment efficacy. This review covers the main areas of debate in the optimal treatment of unresectable mCRC patients, focusing on the implications for everyday clinical practice and future research of the most relevant clinical trials and molecular investigations published from 1999 to 2009.

WHAT THE READER WILL GAIN

Insights into treatment individualization strategies are provided in the review.

TAKE HOME MESSAGE

'One size fits all' can not longer be considered an adequate approach to unresectable mCRC, and treatment with both chemotherapy and biologic agents should be guided by prognostic and predictive factors in order to maximize the benefit while reducing futile toxicities.

Survival, surgical management and perioperative mortality of colorectal cancer in the 21-year experience of a specialised registry

BACKGROUND AND AIMS

A general improvement of colorectal cancer prognosis has been observed. Reasons of this more favourable trend are diffusion of screening, advancements in molecular biology, new developments in chemotherapy and surgical techniques. Through the data of a colorectal cancer registry, we purposed to evaluate changes in surgical procedures for colorectal neoplasms and to analyse trends of perioperative mortality.

PATIENTS AND METHODS

Patients with colorectal cancer were registered from 1984 to 2004. The main surgical procedures were recorded and classified. Perioperative mortality was defined as death of patients within 1 month since the operation.

RESULTS

Regression analysis showed an increase over time of right and left hemicolectomy. Both colectomy and endoscopic polypectomy showed significant rise over time. In contrast, abdominoperineal operations dropped during the study period. A similar decrease was observed for palliative surgery. Perioperative mortality declined from 7-11% to 3-6% of all operations; main factors associated with perioperative mortality were presence of comorbidities, increasing age and advanced stage.

CONCLUSION

The better prognosis of patients with colorectal cancer was associated with changes of surgical techniques, with a tendency to prefer large operations over limited resections. Perioperative mortality showed a gradual decrease and is at present in the order of 3% to 6% of all operations.

Adding cetuximab to capecitabine plus oxaliplatin (XELOX) in first-line treatment of metastatic colorectal cancer: a randomized phase II trial of the Swiss Group for Clinical Cancer Research SAKK

BACKGROUND

To determine the activity and tolerability of adding cetuximab to the oxaliplatin and capecitabine (XELOX) combination in first-line treatment of metastatic colorectal cancer (MCC).

PATIENTS AND METHODS

In a multicenter two-arm phase II trial, patients were randomized to receive oxaliplatin 130 mg/m(2) on day 1 and capecitabine 1000 mg/m(2) twice daily on days 1-14 every 3 weeks alone or in combination with standard dose cetuximab. Treatment was limited to a maximum of six cycles.

RESULTS

Seventy-four patients with good performance status entered the trial. Objective partial response rates after external review and radiological confirmation were 14% and 41% in the XELOX and in the XELOX + Cetuximab arm, respectively. Stable disease has been observed in 62% and 35% of the patients, with 76% disease control in both arms. Cetuximab led to skin rash in 65% of the patients. The median overall survival was 16.5 months for arm A and 20.5 months for arm B. The median time to progression was 5.8 months for arm A and 7.2 months for arm B.

CONCLUSION

Differences in response rates between the treatment arms indicate that cetuximab may improve outcome with XELOX. The correct place of the cetuximab, oxaliplatin and fluoropyrimidine combinations in first-line treatment of MCC has to be assessed in phase III trials.