CAIRO and FOCUS

Current opinion on optimal systemic treatment for metastatic colorectal cancer: outcome of the ACTG/AGITG expert meeting ECCO 2013

The treatment of metastatic colorectal cancer has evolved greatly in the last 15 years, involving combined chemotherapy protocols and, in more recent times, new biologic agents. Clinical benefit from the use of targeted therapy with bevacizumab, aflibercept, cetuximab, panitumumab and regorafenib in the treatment of metastatic colorectal cancer is now well established with median overall survival accepted as over 24 months, and with super selection for extended RAS patients higher again. The optimal timing of treatment options requires careful consideration of predictive biomarkers, and importantly the potential for interactions, to derive the maximal benefit. A group of colorectal subspecialty medical oncologists from Australia, the USA, the Netherlands and Germany met during ECCO 2013 to discuss current practice. Subsequent new data from the American Society of Clinical Oncology were also reviewed. This article reviews the evidence discussed in support of modern treatments for colorectal cancer and the decision-making behind the treatment choices, with their benefits and risks.

Optimizing first-line chemotherapy for metastatic colorectal cancer

SUMMARY Up to half of all patients who develop colorectal cancer will be treated for metastatic disease; some can be cured but most are simply palliated. The optimum use of the available drugs tailored to the patient should be informed by evidence, where it is available, and are of much current debate. Treatment objectives must be clear in making these decisions. Improved response rate may be appropriate where disease may become resectable, with an aim for cure. Tolerability and quality of life balanced with long-term survival may be most relevant where this is not feasible. A good start appropriate to the individual in the first-line metastatic setting is of both physical and psychological importance and may affect subsequent therapeutic decisions. Where Phase III randomized controlled trial evidence is missing, clinical decisions must still be made. Here we explore the data available for optimized first-line therapy, the options created from this data and balance this against the benefits to the patient as a whole.

The role of targeted therapy in the treatment of advanced colorectal cancer

The introduction of targeted therapies in the treatment of metastatic colorectal cancer (MCRC) has resulted in significant improvements in efficacy outcomes. Both vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR) inhibitors have proven to be valid and valuable agents in the management of MCRC. This review will focus on the role of the anti-VEGF monoclonal antibody, bevacizumab, and the anti-EGFR monoclonal antibodies, cetuximab and panitumumab, in MCRC. Special focus will be placed on clinical evidence supporting the use of these agents in various lines of treatment, and on KRAS as a marker of response in relationship to anti-EGFR inhibitors.