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Pinto C, Orlandi A, Normanno N, Maiello E, Calegari MA, Antonuzzo L, Bordonaro R, Zampino MG, Pini S, Bergamo F, Tonini G, Avallone A, Latiano TP, Rosati G, Cogoni AA, Ballestrero A, Zaniboni A, Roselli M, Tamberi S, Barone C. Fluorouracil, Leucovorin, and Irinotecan Plus Cetuximab Versus Cetuximab as Maintenance Therapy in First-Line Therapy for RAS and BRAF Wild-Type Metastatic Colorectal Cancer: Phase III ERMES Study. J Clin Oncol 2024; 42:1278-1287. [PMID: 38181312 PMCID: PMC11095858 DOI: 10.1200/jco.23.01021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/12/2023] [Accepted: 09/25/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE The intensity of anti-EGFR-based first-line therapy for RAS/BRAF wild-type (wt) metastatic colorectal cancer (mCRC), once disease control is achieved, is controversial. A de-escalation strategy with anti-EGFR monotherapy represents a potential option to maintain efficacy while reducing cytotoxicity. METHODS In this multicenter, open-label, phase III trial, patients with untreated RAS/BRAF wt mCRC were randomly assigned to receive either fluorouracil, leucovorin, and irinotecan/cetuximab (FOLFIRI/Cet) until disease progression (arm A) or FOLFIRI/Cet for eight cycles followed by Cet alone (arm B). The coprimary end points were a noninferior progression-free survival (PFS) in the modified per-protocol (mPP) population (>eight cycles) and a lower incidence of grade (G) 3-4 adverse events (AEs) for arm B compared with arm A. RESULTS Overall, 606 patients were randomly assigned, with 300 assigned to arm A and 306 to arm B. The median follow-up was 22.3 months. In the mPP population, 291 events occurred with a PFS of 10 versus 12.2 months for arms B and A, respectively (P of noninferiority = .43). In the intention-to-treatment (ITT, ≥one cycle) population, 503 events occurred with a PFS of 9 versus 10.7 months (P = .39). The overall survival was 35.7 versus 30.7 months (P = .119) and 31.0 versus 25.2 months (P = .32) in the mPP and ITT population, respectively. Arm B had lower G3-4 AEs during the maintenance period than arm A (20.2% v 35.1%). CONCLUSION The ERMES study did not demonstrate noninferiority of maintenance with Cet alone. Despite a more favorable safety profile, maintenance with single-agent Cet after induction with FOLFIRI/Cet cannot be recommended for all patients but could represent an option in selected cases.
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Affiliation(s)
- Carmine Pinto
- Medical Oncology, Comprehensive Cancer Centre Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Armando Orlandi
- Comprehensive Cancer Center, UOC Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Nicola Normanno
- Translational Research Departement, Istituto Nazionale Tumori IRCCS—Fondazione G. Pascale, Napoli, Italy
| | - Evaristo Maiello
- Oncology Unit, Foundation IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Maria A. Calegari
- Comprehensive Cancer Center, UOC Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Lorenzo Antonuzzo
- Department of Experimental and Clinical Medicine, University of Florence, Italy Clinical Oncology Unit, Careggi University Hospital, Firenze, Italy
| | - Roberto Bordonaro
- Medical Oncology, Azienda Ospedaliera ARNAS Garibaldi, Catania, Italy
| | - Maria G. Zampino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Sara Pini
- Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Francesca Bergamo
- Dipartimento Oncologia 1, IOV—Istituto Oncologico Veneto IRCCS, Padova, Italy
| | - Giuseppe Tonini
- Dipartimento di Oncologia, Fondazione Policlinico Campus Bio-Medico, Facoltà di Medicina Università Campus Bio-Medico, Rome, Italy
| | - Antonio Avallone
- Medical Oncology, Istituto Nazionale Tumori-IRCCS Fondazione G. Pascale, Naples, Italy
| | - Tiziana P. Latiano
- Oncology Unit, Foundation IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Gerardo Rosati
- Medical Oncology Unit, S. Carlo Hospital, Potenza, Italy
| | | | - Alberto Ballestrero
- DiMI Università degli Studi di Genova e Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | | | - Mario Roselli
- Medical Oncology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Stefano Tamberi
- UO Medical Oncology, Area Vasta Romagna Ausl di Ravenna, Presidio Ospedaliero di Faenza, Ospedale Civile degli Infermi, Faenza, Italy
| | - Carlo Barone
- Comprehensive Cancer Center, UOC Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
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Parisi A, Cortellini A, Venditti O, Filippi R, Salvatore L, Tortora G, Ghidini M, Nigro O, Gelsomino F, Zurlo IV, Fulgenzi C, Lombardi P, Roselló Keränen S, Depetris I, Giampieri R, Morelli C, Di Marino P, Di Pietro FR, Zanaletti N, Vitale P, Garajova I, Spinelli GP, Zoratto F, Roberto M, Petrillo A, Aimar G, Patruno L, D'Orazio C, Ficorella C, Ferri C, Porzio G. Post-Induction Management in Patients With Left-Sided RAS and BRAF Wild-Type Metastatic Colorectal Cancer Treated With First-Line Anti-EGFR-Based Doublet Regimens: A Multicentre Study. Front Oncol 2021; 11:712053. [PMID: 34778029 PMCID: PMC8579084 DOI: 10.3389/fonc.2021.712053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/28/2021] [Indexed: 01/09/2023] Open
Abstract
Background Few data regarding post-induction management following first-line anti-epidermal growth factor receptor (EGFR)-based doublet regimens in patients with left-sided RAS/BRAF wild-type metastatic colorectal cancer (mCRC) are available. Methods This multicenter, retrospective study aimed at evaluating clinicians’ attitude, and the safety and effectiveness of post-induction strategies in consecutive patients affected by left-sided RAS/BRAF wild-type mCRC treated with doublet chemotherapy plus anti-EGFR as first-line regimen, who did not experience disease progression within 6 months from induction initiation, at 21 Italian and 1 Spanish Institutions. The measured clinical outcomes were: progression-free survival (PFS), overall survival (OS), adverse events, and objective response rate (ORR). Results At the data cutoff, among 686 consecutive patients with left-sided RAS/BRAF wild-type mCRC treated with doublet plus anti-EGFR as first-line regimen from March 2012 to October 2020, 355 eligible patients have been included in the present analysis. Among these, 118 (33.2%), 66 (18.6%), and 11 (3.1%) received a maintenance with 5-fluorouracil/leucovorin (5FU/LV)+anti-EGFR, anti-EGFR, and 5FU/LV, respectively, while 160 (45.1%) patients continued induction treatment (non-maintenance) until disease progression, unacceptable toxicity, patient decision, or completion of planned treatment. The median period of follow-up for the overall population was 33.7 months (95%CI = 28.9–35.6). The median PFS values of the 5FU/LV+anti-EGFR, anti-EGFR, 5FU/LV, and non-maintenance cohorts were 16.0 (95%CI = 14.3–17.7, 86 events), 13.0 (95%CI = 11.4–14.5, 56 events), 14.0 (95%CI = 8.1–20.0, 8 events), and 10.1 months (95%CI = 9.0–11.2, 136 events), respectively (p < 0.001). The median OS values were 39.6 (95%CI = 31.5–47.7, 43 events), 36.1 (95%CI = 31.6–40.7, 36 events), 39.5 (95%CI = 28.2–50.8, 4 events), and 25.1 months (95%CI = 22.6–27.6, 99 events), respectively (p < 0.001). After adjusting for key covariates, a statistically significant improvement in PFS in favor of 5FU/LV+anti-EGFR (HR = 0.59, 95%CI = 0.44–0.77, p < 0.001) and anti-EGFR (HR = 0.71, 95%CI = 0.51–0.98, p = 0.039) compared to the non-maintenance cohort was found. Compared to the non-maintenance cohort, OS was improved by 5FU/LV+anti-EGFR (HR = 0.55, 95%CI = 0.38–0.81, p = 0.002) and, with marginal significance, by anti-EGFR (HR = 0.67, 95%CI = 0.51–0.98, p = 0.051). No difference was found in ORR. Any grade non-hematological and hematological events were generally higher in the non-maintenance compared to the maintenance cohorts. Conclusion Among the treatment strategies following an anti-EGFR-based doublet first-line induction regimen in patients affected by left-sided RAS/BRAF wild-type mCRC treated in a “real-life” setting, 5FU/LV+anti-EGFR resulted the most adopted, effective, and relatively safe regimen.
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Affiliation(s)
- Alessandro Parisi
- Medical Oncology, St. Salvatore Hospital, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alessio Cortellini
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.,Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Olga Venditti
- Medical Oncology, St. Salvatore Hospital, L'Aquila, Italy
| | - Roberto Filippi
- Department of Oncology, University of Turin, Turin, Italy.,Division of Medical Oncology, Candiolo Cancer Institute, Fondazione Del Piemonte Per L'oncologia-Istiruto di Ricerca e Cura a Carattere Scientifico (FPO-IRCCS), Candiolo, Italy.,Centro Oncologico Ematologico Subalpino, Azienda Universitaria Ospedaliera Città della Salute e della Scienza di Torino, Turin, Italy
| | - Lisa Salvatore
- Università Cattolica del Sacro Cuore, Rome, Italy.,Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Giampaolo Tortora
- Università Cattolica del Sacro Cuore, Rome, Italy.,Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Olga Nigro
- Medical Oncology, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Fabio Gelsomino
- Department of Oncology and Hematology, Division of Oncology, University Hospital of Modena, Modena, Italy
| | | | - Claudia Fulgenzi
- Medical Oncology, Campus Bio-Medico, University of Rome, Rome, Italy
| | - Pasquale Lombardi
- Division of Medical Oncology, Candiolo Cancer Institute, Fondazione Del Piemonte Per L'oncologia-Istiruto di Ricerca e Cura a Carattere Scientifico (FPO-IRCCS), Candiolo, Italy
| | - Susana Roselló Keränen
- Department of Medical Oncology, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain.,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - Ilaria Depetris
- Medical Oncology, ASL TO4, Ospedale Civile di Ivrea, Turin, Italy
| | - Riccardo Giampieri
- Clinica Oncologica e Centro Regionale di Genetica Oncologica, Università Politecnica delle Marche, AOU Ospedali Riuniti-Ancona, Ancona, Italy
| | - Cristina Morelli
- Medical Oncology Unit and PhD Program in Systems and Experimental Medicine (XXXV cycle), Tor Vergata University Hospital, Rome, Italy
| | - Pietro Di Marino
- Department of Medical, Oral and Biotechnological Sciences and Center for Advance Studies and Technology (CAST), G. D'Annunzio University, Chieti, Italy.,Clinical Oncology Unit, S.S. Annunziata Hospital, Chieti, Italy
| | | | - Nicoletta Zanaletti
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori-IRCCS-Fondazione G.Pascale, Naples, Italy
| | - Pasquale Vitale
- Department of Precision Medicine, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Ingrid Garajova
- Medical Oncology Unit, University Hospital of Parma, Parma, Italy
| | - Gian Paolo Spinelli
- UOC Territorial Oncology-AUSL Latina-CdS Aprilia-University of Rome "Sapienza", Rome, Italy
| | | | - Michela Roberto
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Oncology Unit, Sant'Andrea Hospital, Rome, Italy
| | | | - Giacomo Aimar
- Department of Oncology, University of Turin, Turin, Italy.,Division of Medical Oncology, Candiolo Cancer Institute, Fondazione Del Piemonte Per L'oncologia-Istiruto di Ricerca e Cura a Carattere Scientifico (FPO-IRCCS), Candiolo, Italy
| | - Leonardo Patruno
- Medical Oncology, St. Salvatore Hospital, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Carla D'Orazio
- Medical Oncology, St. Salvatore Hospital, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Corrado Ficorella
- Medical Oncology, St. Salvatore Hospital, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giampiero Porzio
- Medical Oncology, St. Salvatore Hospital, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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