Comparing Late-line Treatment Sequence of Regorafenib and Reduced-intensity FOLFOXIRI for Refractory Metastatic Colorectal Cancer

Sequential Treatment of Metastatic Colorectal Cancer in Taiwan: Real-World Evidence From Regorafenib and Trifluridine/Tipiracil Use

OBJECTIVE

This study aims to evaluate the real-world effectiveness and safety of sequential treatment with regorafenib and trifluridine/tipiracil (FTD-TPI) in patients with metastatic colorectal cancer (mCRC) in Taiwan.

METHODS

Data were obtained from Taiwan's National Health Insurance Research Database (NHIRD) to assess clinical outcomes in mCRC patients who were treated with both drugs in either sequential order from 2016 to 2019. Overall survival (OS) was analyzed using Kaplan-Meier curves and Cox's proportional hazard models, with adjustments made for age, gender, Quan-CCI score, presence of liver metastases, number of metastatic sites, and the use of anti-epidermal growth factor receptor medications. Additionally, age-stratified subgroups and sensitivity analyses were conducted to examine the robustness of our findings.

RESULTS

Five hundred and twenty-eight patients receiving both study drugs were included. The regorafenib/FTD-TPI group demonstrated a longer median OS of 14.1 months compared with 10.2 months in the FTD-TPI/regorafenib group (p = 0.007). The survival benefit for the regorafenib/FTD-TPI sequence remained significant after adjustment (adjusted HR, 1.49; p = 0.002). The mean treatment duration was also longer for regorafenib/FTD-TPI than FTD-TPI/regorafenib (337 vs. 214 days; p < 0.01). No significant difference between the sequential treatment groups was observed in any adverse event of interest. Both subgroup and sensitivity analyses yielded outcomes consistent with the main analysis.

CONCLUSION

The findings indicated that initiating treatment with regorafenib followed by FTD-TPI had superior clinical outcomes compared with the reverse sequence among mCRC patients. This study offers real-world evidence for clinical decision-making and treatment optimization.

A Systematic Review and Meta-Analysis of the Efficacy and Safety of Regorafenib in the Treatment of Metastatic Colorectal Cancer

BACKGROUND AND OBJECTIVE

Colorectal cancer (CRC) is a leading cause of cancer-related mortality worldwide. Despite advances in treatment, metastatic colorectal cancer (mCRC) remains a significant challenge due to its heterogeneity and resistance to therapy. Regorafenib, a multikinase inhibitor, can inhibit tumor progression through multiple mechanisms, thereby improving patient prognosis. It has emerged as a potential treatment option for mCRC patients who have progressed on standard therapies. This systematic review and meta-analysis aims to evaluate the efficacy and safety of Regorafenib in this patient population, synthesizing data from clinical trials to provide a comprehensive understanding of its role in mCRC treatment.

METHODS

A systematic literature search was conducted via the PubMed, Web of Science (WOS), and Embase databases from January 2012 to December 2024. Studies were included if they were randomized controlled trials (RCTs) or clinical trials that reported outcomes of regorafenib treatment in mCRC patients, including overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR). Secondary outcomes included the incidence of serious adverse events (SAEs). OS refers to the length of time from the start of treatment until the death of the patient from any cause, while mortality specifically denotes the number of deaths occurring within the study period. Data were extracted by two independent reviewers using a standardized form. The meta-analysis was performed using RevMan 5.0 statistical software.

RESULTS

A total of 5,082 articles were retrieved, and ultimately, 9 eligible studies involving a total of 2,823 patients were included. All 9 included studies reported OS and PFS. In these mCRC patients, the dose of regorafenib was usually 160 mg daily. The meta results indicated that the OS of patients in the regorafenib group was significantly different [MD = 1.33, 95% CI (0.33, 2.33), P = 0.009]. Eight studies reported the ORR of the disease [OR = 1.13, 95% CI (0.73, 1.76), P = 0.57]. Five studies reported the DCR, and the DCR of patients in the regorafenib group was significantly different from that of patients in the control group [OR = 3.45, 95% CI (2.04, 5.84), P < 0.00001]. The incidence of SAEs (> grade 3) was reported in all 9 included studies [OR = 2.48, 95% CI (1.29, 4.73), P = 0.006].

CONCLUSION

In this systematic review of prospective trials, regorafenib resulted in improved OS with manageable adverse effects for patients with advanced mCRC. Still, considering the safety, future research should focus on investigating the dose optimization of regorafenib, as well as predictive biomarkers for therapeutic efficacy.

Polymorphism at codon 31 of CDKN1A (p21) as a predictive factor for bevacizumab therapy in glioblastoma multiforme

Glioblastoma (GBM), a prevalent and malignant brain tumor, poses a challenge in surgical resection due to its invasive nature within the brain parenchyma. CDKN1A (p21, Waf-1), a cyclin-dependent kinase inhibitor, plays a pivotal role in regulating cell growth arrest, terminal differentiation, and apoptosis. The existence of natural variants of CDKN1A has been associated with specific cancer types. In this retrospective study, our objective was to identify polymorphic variants of CDKN1A, specifically c.93C > A (codon 31 Ser31Arg), and investigate its potential impact within the scope of bevacizumab therapy for glioblastoma multiforme. This study involved a cohort of 139 unrelated adult Chinese GBM patients in Taiwan. Genomic DNA extracted from tumor samples was utilized for genotyping using the polymerase chain reaction (PCR) restriction fragment length polymorphism method (PCR-RFLP analysis). Through unconditional logistic regression analysis, odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. Our findings unveiled that among these GBM patients, the distribution of codon 31 polymorphisms was as follows: 23.02% were Serine homozygotes (Ser/Ser), 27.34% were Arginine homozygotes (Arg/Arg), and 49.64% were Serine/Arginine heterozygotes (Ser/Arg). While CDKN1A c.93C > A polymorphisms did not exhibit a direct association with overall survival in GBM patients, noteworthy survival benefits emerged among individuals with Arg/Arg and Arg/Ser genotypes who received combined concurrent chemoradiotherapy (CCRT) and bevacizumab treatment compared to those who underwent CCRT alone. Our findings indicate a significant involvement of the CDKN1A c.93C > A polymorphism in the development and onset of GBM, offering potential implications for the early prognostication of bevacizumab therapy outcomes.

Regorafenib induces NOX5-mediated endoplasmic reticulum stress and potentiates the anti-tumor activity of cisplatin in non-small cell lung cancer cells

Lung cancer is one of the most commonly diagnosed cancers worldwide. Although cisplatin-based chemotherapy regimens serve a pivotal role in non-small cell lung cancer (NSCLC) treatment, drug resistance and serious side effects limited its further clinical application. Regorafenib, a small-molecule multi-kinase inhibitor, was demonstrated to have promising anti-tumor activity in various solid tumors. In the present study, we found that regorafenib markedly enhanced cisplatin-induced cytotoxicity in lung cancer cells by activating reactive oxygen species (ROS)-mediated endoplasmic reticulum stress (ER Stress), c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase (MAPK) signaling pathways. Regorafenib increased ROS generation by promoting NADPH oxidase 5 (NOX5) expression, and knocking down NOX5 attenuated ROS-mediated cytotoxicity of regorafenib in lung cancer cells. Additionally, mice xenograft model validated that synergistic anti-tumor effects of combined treatment with regorafenib and cisplatin. Our results suggested that combination therapy with regorafenib and cisplatin may serve as a potential therapeutic strategy for some NSCLC patients.

Ramucirumab plus triplet chemotherapy as an alternative salvage treatment for patients with metastatic colorectal cancer

BACKGROUND

Ramucirumab is indicated for salvage treatment after failure of first-line treatment for metastatic colorectal cancer (mCRC). However, the application of ramucirumab at later-line treatment in real-world practice has not received much discussion.

METHODS

In this retrospective study, we enrolled 70 patients with mCRC who received ramucirumab plus chemotherapy at National Taiwan University Hospital between 2018 and 2019.

RESULTS

Compared with those who received third- or later-line ramucirumab treatment, patients who received second-line ramucirumab treatment had significantly longer median time to treatment discontinuation (mTTD; 6.7 vs 3.6 months, P = .004) and median overall survival (mOS; not reached vs 7.6 months, P = .009). Multivariate analyses revealed that second-line ramucirumab and triplet chemotherapy backbone were the only independent predictive factors for long mTTD and mOS. Patients who received ramucirumab with triplet chemotherapy had a significantly longer mOS than did patients who received ramucirumab with doublet chemotherapy (not reached vs 5.6 months, P = .002). Among those receiving second-line ramucirumab treatment, combination with triplet chemotherapy led to a longer mTTD than did combination with doublet chemotherapy, but the difference was non-significant (not reached vs 4.4 months, P = .108). By contrast, in patients receiving fourth- or later-line ramucirumab, combination with triplet chemotherapy led to significantly longer mTTD than did combination with doublet chemotherapy (8.0 vs 2.9 months, P = .032).

CONCLUSION

Ramucirumab plus triplet chemotherapy may be an alternative regimen in patients with mCRC, particularly as a later-line treatment modality.

Preference criteria for regorafenib in treating refractory metastatic colorectal cancer are the small tumor burden, slow growth and poor/scanty spread

Given the unclear preference criteria for regorafenib in treating refractory metastatic colorectal cancer (mCRC), this study aimed to construct an algorithm in selecting right patients for regorafenib. This was a multicenter retrospective cohort study. Patients with pathology confirmed mCRC and administered with regorafenib for > 3 weeks were enrolled. Patients with good response were defined to have progression-free survival (PFS) of ≥ 4 months. The Kaplan–Meier plot was used to analyze survival. A Cox proportional hazards model was used to analyze univariate and multivariate prognostic factors and was visualized using forest plot. A clustering heatmap was used to classify patients according to responses. The decision tree and nomogram were used to construct the approaching algorithm. A total of 613 patients was analyzed. The median PFS and overall survival (OS) were 2.7 and 10.6 months, respectively. The partial response and stable disease rate are 2.4% and 36.4%. The interval between metastasis (M1) and regorafenib, metastatic status (number, liver, and brain), and CEA level were independent prognostics factors of PFS that classifies patients into three groups: good, bad and modest-1/modest-2 group with PFS >  = 4 months rates of 51%, 20%, 39% and 30%, respectively. Results were used to develop the decision tree and nomogram for approaching patients indicated with regorafenib. The preference criteria for regorafenib in treating patients with refractory mCRC are small tumor burden (CEA), slow growth (interval between metastasis and regorafenib) and poor/scanty spread (metastatic status: number and sites of metastasis): The 3S rules.

TRIAL registration ClinicalTrials.gov Identifier: NCT03829852; Date of first registration (February 11, 2019).

Sequenced treatment after regorafenib and survival in metastatic colorectal cancer: a qualitative clinical review

There is limited evidence-based guidance regarding treatment sequencing and outcomes following regorafenib in patients with refractory metastatic colorectal cancer (mCRC). A targeted literature review was conducted to identify studies with clinical outcomes associated with regorafenib therapy and subsequent treatment following regorafenib therapy. The median overall survival range of the nine studies with sequenced-based survival data was 2.1–19.3 months for regorafenib prior to subsequent therapy in refractory mCRC. Safety outcomes in patients treated with regorafenib prior to other therapies in mCRC were generally comparable to reported adverse events in clinical trials for subsequent agents. Data from this review demonstrate a potential correlation between survival and the use of regorafenib prior to subsequent chemotherapy or targeted therapy in patients with refractory mCRC.