Real-world treatment patterns and outcomes in refractory metastatic colorectal cancer

Third-line treatment and beyond in metastatic colorectal cancer: What do we have and what can we expect?

Colorectal cancer remains the third most common cancer worldwide and the second cause of cancer-related death. Treatment advances and precision oncological medicine for these tumours have been stalled in comparison to those for other common tumours such as lung and breast cancer. However, the recent publication of the SUNLIGHT trial results with the trifluridine/tipiracil (TAS-102)-bevacizumab combination and the irruption of new molecular targets with guided treatments have opened new possibilities in third-line metastatic colorectal cancer management. Anti-EGFR rechallenge, anti-HER2 targeted therapies or the promising results of Pressurised Intraperitoneal Aerosol Chemotherapy (PIPAC), are some of the available options that may modify what is presumably third-line colorectal treatment. Hereby, we present the evidence of the different treatment options in third-line colorectal cancer and beyond, as well as the possibilities of sequencing them.

Treatment Settings and Outcomes with Regorafenib and Trifluridine/Tipiracil at Third-Line Treatment and beyond in Metastatic Colorectal Cancer: A Real-World Multicenter Retrospective Study

BACKGROUND

Patients with refractory mCRC rarely undergo third-line or subsequent treatment. This strategy could negatively impact their survival. In this setting, regorafenib (R) and trifluridine/tipiracil (T) are two key new treatment options with statistically significant improvements in overall survival (OS), progression-free survival (PFS), and disease control with different tolerance profiles. This study aimed to retrospectively evaluate the efficacy and safety profiles of these agents in real-world practice.

MATERIALS AND METHODS

In 2012-2022, 866 patients diagnosed with mCRC who received sequential R and T (T/R, n = 146; R/T, n = 116]) or T (n = 325]) or R (n = 279) only were retrospectively recruited from 13 Italian cancer institutes.

RESULTS

The median OS is significantly longer in the R/T group (15.9 months) than in the T/R group (13.9 months) (p = 0.0194). The R/T sequence had a statistically significant advantage in the mPFS, which was 8.8 months with T/R vs. 11.2 months with R/T (p = 0.0005). We did not find significant differences in outcomes between groups receiving T or R only. A total of 582 grade 3/4 toxicities were recorded. The frequency of grade 3/4 hand-foot skin reactions was higher in the R/T sequence compared to the reverse sequence (37.3% vs. 7.4%) (p = 0.01), while grade 3/4 neutropenia was slightly lower in the R/T group than in the T/R group (66.2% vs. 78.2%) (p = 0.13). Toxicities in the non-sequential groups were similar and in line with previous studies.

CONCLUSIONS

The R/T sequence resulted in a significantly longer OS and PFS and improved disease control compared with the reverse sequence. R and T given not sequentially have similar impacts on survival. More data are needed to define the best sequence and to explore the efficacy of sequential (T/R or R/T) treatment combined with molecular-targeted drugs.

Outcomes of Patients with Metastatic Colorectal Cancer Treated with Trifluridine/Tipiracil beyond the Second Line: A Multicenter Retrospective Study from Saudi Arabia

Background

The outcome of patients with refractory metastatic colorectal cancer (mCRC) treated with trifluridine/tipiracil (FTD/TPI) beyond the second-line has not been studied in Saudi Arabia. Therefore, this multicenter retrospective analysis was conducted to evaluate the efficacy of FTD/TPI.

Methods

This multicenter retrospective analysis included five centers in Saudi Arabia. FTD/TPI was administered to all the patients beyond the oxaliplatin- and irinotecan-based chemotherapy regimens. The electronic medical records were reviewed, and progression-free survival (PFS) and overall survival (OS) were determined.

Results

The study included 100 patients with a mean age of 55.4 ± 11.8 years. The overall response to FTD/TPI was 4%. The median PFS was 4 months (95% confidence interval (CI) 3.487–4.513), and the median OS was 11 months (95% CI, 9.226–12.771). In a Cox regression analysis of the independent predictors for PFS, advanced stage of the disease (P = 0.037; HR, 2.614; and CI, 1.102–7.524), presence of lymph node metastasis (P = 0.018; HR, 3.664; and 95% CI, 1.187–8.650), and >2 metastatic sites (P = 0.020; HR, 1.723; and 95% CI, 1.089–2.727) were independent factors predicting disease progression. The Cox regression analysis confirmed that age ≥ 55 years (P = 0.046; HR, 1.667; and 95%, 1.097–3.100), advanced disease stage (P = 0.044; HR, 1.283; and 95% CI, 1.035–2.940), prior use of adjuvant chemotherapy (P = 0.037; HR, 0.892; and 95% CI, 0.481–0.994), liver metastasis (P = 0.025; HR, 2.015; and 95% CI, 1.091–3.720), >2 metastatic sites (P = 0.038; HR, 1.248; and 95% CI, 1.036–1.846), development of neutropenia after receiving first cycle of FTD/TPI (P = 0.042; HR, 1.505; and 95% CI, 1.064–2.167), and increased number of FTD/TPI cycles (P = 0.002; HR, 0.769; and 95% CI, 0.664–0.891) were independent variables for OS.

Conclusion

Treatment with FTD/TPI is feasible and effective in daily clinical practice in Saudi Arabian patients. The risk of progression increased with advanced disease stage, lymph node metastasis, bone metastasis, and metastasis to >2 sites. Age ≥ 55 years, advanced disease stage, liver metastasis, metastasis to >2 sites, neutropenia after the first cycle of FTD/TPI, and increased number of FTD/TPI cycles were independent factors predicting mortality.

Palliative Care in Colorectal Cancer

Approximately 25% of patients present with liver metastases at the time of the first diagnosis and up to 50% will further develop recurrence in the liver during their disease course. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV colorectal cancer patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy. Most patients with stage IV colorectal cancer have a poor prognosis, but numerous palliative modalities are available today. When a cure is no longer possible, treatment is directed toward providing symptomatic relief. Good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages.

TAS-102: A resurrected novel Fluoropyrimidine with expanding role in the treatment of gastrointestinal malignancies

TAS-102 is an orally administered fixed-dose formulation consisting of trifluorothymidine (TFT), a fluoropyrimidine antimetabolite, and tipiracil (TPI), an inhibitor of thymidine phosphorylase (TP) that prevents rapid degradation of TFT and ensures its bioavailability. The novelty of TAS-102 lies in its antitumor activity against 5-fluorouracil (5-FU) resistant tumors, demonstrated both in the in vitro models and xenografts. The cytotoxic activity of TFT relies primarily on extensive incorporation of the TFT metabolite into the cellular DNA inducing DNA dysfunction and cell death. In contrast, 5-fluorouracil (5-FU) interferes with DNA biosynthesis by inhibiting thymidylate synthase(TS), which partly explains the absence of cross-resistance between TAS-102 and 5-FU. TAS-102 is currently approved in the third-line setting for patients with metastatic colorectal and gastric cancer based on phase III randomized clinical trial data confirming an overall survival benefit with TAS-102. The preliminary data from recently reported studies suggest a potential expanding role of TAS-102 in a variety of gastrointestinal (GI) cancers. The current article presents an overview of the pharmacology, clinical development of TAS-102, and its emerging role in the treatment of GI cancers. In addition, we discussed the rationale underlying the ongoing clinical trials investigating various combinations of TAS-102 with other anticancer agents, including targeted therapies, in a wide range of GI tumors.

Metastatic Colorectal Carcinoma after Second Progression and the Role of Trifluridine-Tipiracil (TAS-102) in Switzerland

BACKGROUND

Metastatic colorectal carcinoma (mCRC) is one of the most prevalent types of cancer worldwide. After tumor progression with first- and second-line treatment, trifluridine (FTD) and tipiracil (TPI) has been shown to be a treatment option.

SUMMARY

Data from a pivotal phase 3 trial (RECOURSE) and an ongoing phase 3b trial (PRECONNECT) have shown that, in mCRC patients who experienced disease progression after 2 lines of standard therapy, treatment with FTD/TPI is safe and efficacious. Other third-line options include regorafenib, rechallenge with previous treatment lines or personalized approaches based on comprehensive molecular profiling. Randomized trials or sequential studies aiming for the right treatment sequence or predefined subtypes for FTD/TPI or regorafenib as well for rechallenge are missing. However, FTD/TPI as well as regorafenib are recommended by the current ESMO, German S3, and National Comprehensive Cancer Network (NCCN) guidelines in the same situation, thus offering physicians a number of alternatives for the treatment of mCRC patients after the second progression. Key Message: This narrative review summarizes published data and their impact for FTD/TPI as well for regorafenib and rechallenge chemotherapy in clinical practice settings of refractory situations of colorectal cancer.