Third- or Later-line Therapy for Metastatic Colorectal Cancer: Reviewing Best Practice

An increasing number of patients with metastatic colorectal cancer (mCRC) are able to receive 3 or more lines of therapy. Treatments in this setting can include regorafenib (an oral multikinase inhibitor), trifluridine/tipiracil hydrochloride (TAS-102), antibodies that target epidermal growth factor receptor for patients with RAS wild-type tumors (if no prior exposure), and, where approved, anti-programmed cell death protein 1 inhibitors for patients with microsatellite instability-high mCRC. Although guidelines describe the available treatment options, few insights are provided to guide selection and sequencing. In this article, we share expert opinion from diverse geographic regions, to offer guidance for best practice when selecting and managing third-line treatment for mCRC. Various factors, including performance status, age, and tumor sidedness, can be used to guide treatment selection. Biomarkers, such as RAS, BRAF, and microsatellite instability, can be useful for treatment stratification. Management of adverse events, to maintain quality of life, is a key consideration and is crucial to best practice in this setting. Common toxicities associated with third-line treatments are hand-foot skin reaction, fatigue, diarrhea, and cytopenias. Patients who receive third-line and later-line treatments should be monitored for these events, especially during the first 2 cycles. Dose modifications can also be used to manage toxicities and to minimize the effect on quality of life, while maximizing treatment benefit. Clinical trials of emerging agents, new treatment combinations, and novel therapies continue the efforts to improve outcomes for patients with mCRC. Sharing expert opinions on best practice for treatment selection and management can ultimately improve outcomes for patients with mCRC.

Regorafenib in the Real-Life Clinical Practice: Data from the Czech Registry

OBJECTIVE

To describe the use of regorafenib for the treatment of metastatic colorectal cancer (mCRC) in clinical practice in the Czech Republic, and to describe the clinical outcomes of patients in terms of safety and survival.

PATIENTS AND METHODS

The data of patients treated with regorafenib were extracted from the national CORECT registry. The CORECT registry is a non-interventional post-marketing database, gathering information about patients with CRC and treated with targeted agents. Twenty oncology centres in the Czech Republic contributed to this registry. Collected data included patients' characteristics, disease history, cancer treatments, response to treatments and safety.

RESULTS

A total of 148 patients treated with regorafenib in clinical practice were analysed. At regorafenib initiation, almost all patients were fully active or slightly restricted in physical activity. Regorafenib was not administered as first-line treatment in any patient. Median progression-free survival was 3.5 months and median overall survival was 9.3 months. One-year survival rate was 44.6 %. Four partial responses were observed and 51 stable diseases. Progression was observed in 66 patients (44.6 %). The main reported adverse events were skin toxicity (5.4 %) and fatigue (2.0 %).

CONCLUSIONS

Regorafenib is a well-established treatment for pretreated patients with mCRC, however real-life data are scarce. Our results demonstrated slightly better efficacy of regorafenib and better safety profile in patients with mCRC compared to the randomised trials.

Recent Developments in Regorafenib Treatment for Gastrointestinal Cancers: Presentations at the Meeting of the European Society for Medical Oncology (ESMO) Congress 2016

The European Society for Medical Oncology (ESMO) Congress was held in Copenhagen, Denmark from 7th–11th October 2016. The use of the promiscuous multikinase inhibitor regorafenib (Stivarga®, BAY 73-4506) in the treatment of cancers of the gastrointestinal (GI) tract was strongly featured at this meeting. Regorafenib targets multiple kinases involved in oncogenesis and angiogenesis, and is US Food and Drug Administration (FDA)-approved for the treatment of advanced metastatic colorectal cancer and GI stromal tumours, following progression on standard therapies. In this review, we summarise the results of completed clinical trials on the use of regorafenib alone or in combination with other therapies for the treatment of GI cancers. We highlight the results of the Phase III RESORCE study which demonstrated the efficacy of regorafenib as a second-line therapy in patients with advanced hepatocellular carcinoma who have progressed on sorafenib. We review some promising preliminary data on the use of regorafenib in other GI cancers, such as gastric cancer, oesophageal cancer, pancreatic cancer, and soft tissue carcinomas, and provide a brief overview of ongoing and planned trials. Finally, we discuss the incidence and management of regorafenib-related toxicities and summarise attempts to identify predictive biomarkers of regorafenib sensitivity.