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Pfeiffer P, Köhne CH, Qvortrup C. The changing face of treatment for metastatic colorectal cancer. Expert Rev Anticancer Ther 2018; 19:61-70. [PMID: 30381969 DOI: 10.1080/14737140.2019.1543593] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Introduction: Since late 1990's therapy of metastatic colorectal cancer (mCRC) patients has changed considerable, and the combination of doublet or triplet chemotherapy and a targeted agent are now routinely used. With the introduction of more intensified regimens, it has become even more important to identify patients that will benefit from and can tolerate therapy. Furthermore, the increasing understanding of the biology of mCRC has led to the discovery of new potential targets. Therefore, therapy of patients with mCRC has undergone considerable change from 'one strategy fits all' towards a more personalized therapy. Areas covered: We present an overview of the recent literature on approved systemic treatment of mCRC however with focus on how the treatment strategy has changed based on clinical and molecular parameters that presently are used routinely in the clinical situation. Expert commentary: The face of treatment of mCRC has changed from 'one strategy fits all' to a personalized approach in which both clinical, molecular parameters and the aim of therapy have to be taking into account when planning the optimal treatment strategy for the individual mCRC patient.
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Affiliation(s)
- Per Pfeiffer
- a Department of Oncology , Odense University Hospital , Odense C , Denmark
| | - Claus-Henning Köhne
- b University Campus Klinikum Oldenburg, Carl von Ossietzky University, North-West-German Cancer Center , Oldenburg , NS , Germany
| | - Camilla Qvortrup
- c Department of Oncology, Rigshospitalet , Copenhagen University , Copenhagen , Denmark
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Winther SB, Österlund P, Berglund Å, Glimelius B, Qvortrup C, Sorbye H, Pfeiffer P. Randomized study comparing full dose monotherapy (S-1 followed by irinotecan) and reduced dose combination therapy (S-1/oxaliplatin followed by S-1/irinotecan) as initial therapy for older patients with metastatic colorectal cancer: NORDIC 9. BMC Cancer 2017; 17:548. [PMID: 28814275 PMCID: PMC5559862 DOI: 10.1186/s12885-017-3526-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 08/01/2017] [Indexed: 12/22/2022] Open
Abstract
Background Metastatic colorectal cancer (mCRC) is a disease of older age, but there is a relative lack of knowledge about effects of chemotherapy in older patients as they are under-represented in clinical trials. Little data can guide whether the strategy in older mCRC patients should be a sequential full-dose monotherapy chemotherapy approach or a dose-reduced combination chemotherapy approach. The oral 5FU prodrug S-1 seems to have less side effects than capecitabine and should be an optimal drug for older patients, but few data are available. Improved geriatric assessments are needed to select which older patients should receive therapy. Methods The NORDIC 9 trial is a Nordic multicenter randomized phase II study comparing full dose monotherapy (S-1 30 mg/m2 twice daily days 1–14 every 3 weeks, followed by second line irinotecan 250–350 mg/m2 iv day 1 every 3 weeks or 180–250 mg/m2 iv day 1 every 2 weeks) with reduced dose combination therapy (S-1 20 mg/m2 days 1–14 + oxaliplatin 100 mg/m2 iv day 1 every 3 weeks, followed by second line S-1 20 mg/m2 days 1–14 + irinotecan 180 mg/m2 day 1 every 3 week) for older patients (≥70 years) with mCRC who are not candidates for full-dose standard combination therapy. Additional bevacizumab (7.5 mg/kg) is optional in first-line. Blood samples and tumor tissue will be collected to investigate predictive markers. Geriatric screening tools (G-8, VES-13, Timed-Up-and-Go and Handgrip strength), Charlson Comorbidty Index and quality of life (EORTC QLQ-C30) will be evaluated as predictors of efficacy and toxicity. The target sample size is 150 patients. The primary endpoint is progression-free survival and secondary endpoints are time-to-failure of strategy, overall survival, response rate, toxicity, and correlations between biomarkers, pre-treatment characteristics and geriatric assessments. Discussion The study will add knowledge on how to treat older mCRC patients who are not candidates for standard combination therapy. Furthermore it may provide understanding of efficacy and tolerability of chemotherapy in older cancer patients and thus offer a better chance for tailored treatment strategies in these patients. Trial registration EU Clinical Trial Register, EudraCT no. 2014–000394-39. Registered 05 May 2014.
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Affiliation(s)
| | - Pia Österlund
- Department of Oncology, Helsinki University Central Hospital, Stenbäckinkatu 9, PO BOX 100, FI-00029, Helsinki, Finland.,Clinicum, Helsinki University, Haartmaninkatu 8, 3th floor, PO BOX 63, 00014, Helsinki, Finland
| | - Åke Berglund
- Department of Immunology, Genetics and Pathology, Uppsala University, Dag Hammarskjölds väg 20, 751 85, Uppsala, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Dag Hammarskjölds väg 20, 751 85, Uppsala, Sweden
| | - Camilla Qvortrup
- Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - Halfdan Sorbye
- Department of Oncology and Department of Clinical Science, Haukeland University Hospital, Postboks 1400, 5021, Bergen, Norway
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
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Cameron MG, Kersten C, Vistad I, van Helvoirt R, Weyde K, Undseth C, Mjaaland I, Skovlund E, Fosså SD, Guren MG. Palliative pelvic radiotherapy for symptomatic rectal cancer - a prospective multicenter study. Acta Oncol 2016; 55:1400-1407. [PMID: 27332723 DOI: 10.1080/0284186x.2016.1191666] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE Palliative pelvic radiotherapy (PPRT) is used to treat locally advanced rectal cancer (RC) although symptomatic effects and toxicities are poorly documented. Aims were to evaluate symptom severity, quality of life (QOL) and toxicity after PPRT. MATERIAL AND METHODS Fifty-one patients with symptomatic primary or recurrent RC prescribed PPRT with fractions of 3 Gy to 30-39 Gy were included. Primary outcome was severity of target symptoms (TS) 12 weeks after PPRT. Pelvic symptom burden, toxicity, and QOL were assessed. Response was defined as patient-reported TS improvement or resolution. RESULTS Pain (n = 24), rectal dysfunction (n = 16), and hematochezia (n = 9) were the most common TSs. Overall response rate among evaluable patients 12 weeks after PPRT was 28/33 (85%). Eighteen patients did not complete the study follow-up, 16 due to deteriorating health. TS responses were 10/13 (77%) for pain, 9/10 (90%) for rectal dysfunction, and 8/8 for hematochezia. Non-target pelvic symptom severity decreased and median QOL scores remained stable. There was no grade 4 toxicity. Median survival was nine months. CONCLUSIONS In the majority of patients with symptomatic primary or recurrent RC, PPRT with 30-39 Gy contributes to pelvic symptom relief, with little toxicity. Patients prescribed PPRT of RC have limited life expectancy. Future studies should investigate simplification of PPRT.
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Affiliation(s)
- Marte G. Cameron
- Center for Cancer Treatment, Sørlandet Hospital, Kristiansand, Norway
| | - Christian Kersten
- Center for Cancer Treatment, Sørlandet Hospital, Kristiansand, Norway
| | - Ingvild Vistad
- Department of Obstetrics and Gynecology, Sørlandet Hospital, Kristiansand, Norway
| | - Rene van Helvoirt
- Center for Cancer Treatment, Sørlandet Hospital, Kristiansand, Norway
| | - Kjetil Weyde
- Department of Oncology, Innlandet Hospital, Gjøvik, Norway
| | | | - Ingvil Mjaaland
- Department of Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Eva Skovlund
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim and the Norwegian Institute of Public Health, Oslo, Norway
| | - Sophie D. Fosså
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Marianne G. Guren
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- K. G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Oslo, Norway
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Winther SB, Zubcevic K, Qvortrup C, Vestermark LW, Jensen HA, Krogh M, Sorbye H, Pfeiffer P. Experience with S-1 in older Caucasian patients with metastatic colorectal cancer (mCRC): Findings from an observational chart review. Acta Oncol 2016; 55:881-5. [PMID: 27181284 DOI: 10.3109/0284186x.2016.1161825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND An aging population will increase the number of older patients with metastatic colorectal cancer (mCRC). However, there is limited knowledge about treatment in older patients as they are under-represented in clinical trials. The oral fluoropyrimidine S-1 is associated with a lower rate of adverse events than capecitabine and may therefore be a suitable drug for elderly. However, data on the use of S-1 in Caucasian mCRC patients are lacking/scarce. MATERIAL AND METHODS In the present study we evaluated safety and the efficacy of S-1 alone or in combination with oxaliplatin (SOx) or irinotecan (IRIS) in older mCRC patients. Patients who received at least one cycle of S-1 (first-line therapy), SOx (mainly first-line therapy) or IRIS (second-line therapy) were included. RESULTS From June 2012 to December 2014, 71 older patients received ≥1 cycle of either S-1 (n = 9), SOx (n = 44) or IRIS (n = 18) for mCRC. Median age was 76 years and most patients had a WHO performance status of 0 (32%) or 1 (56%). All patients were evaluable for response and safety. In the SOx group, 18 (41%) and 20 patients (45%) had partial response (PR) and stable disease (SD), respectively (disease control rate 86%). Median progression-free survival (PFS) was 8.5 months and median overall survival (OS) was 18.5 months. In the S-1 group (median age 82 years), PR was 22%, median PFS 6.4 months and median OS 15.8 months. In the IRIS group, PR was 28%, median PFS 7.8 months and the median OS 16.5 months. In general, therapy was well tolerated; main non-hematological toxicities were fatigue and diarrhea. CONCLUSION S-1 monotherapy, SOx and IRIS were well tolerated for older patients with mCRC and could become alternative regimens in older mCRC patients. These regimens are now further evaluated in the randomized ongoing NORDIC9 trial.
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Affiliation(s)
| | - Kanita Zubcevic
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Camilla Qvortrup
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | | | - Merete Krogh
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Halfdan Sorbye
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
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Winther SB, Jørgensen TL, Pfeiffer P, Qvortrup C. Can we predict toxicity and efficacy in older patients with cancer? Older patients with colorectal cancer as an example. ESMO Open 2016; 1:e000021. [PMID: 27843604 PMCID: PMC5070237 DOI: 10.1136/esmoopen-2015-000021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 12/29/2022] Open
Abstract
Colorectal cancer is a disease of the elderly. As older and frail patients are under-represented in clinical trials, most of the evidence available on treatment of older metastatic colorectal patients with cancer originates from pooled analyses of the older patients included in large prospective clinical trials and from community-based studies. The aging process is highly individual and cannot be based on the chronological age alone. It is characterised by a decline in organ function with an increased risk of comorbidity and polypharmacy. These issues can result in an increased susceptibility to the complications of both the disease and treatment. Therefore, evaluation of performance status and the chronological age alone is not sufficient, and additionally assessment must be included in the treatment decision process. In the present review, we will focus on clinical aspects of treating older and frail metastatic colorectal patients with cancer, but also on the present knowledge on how to select and tailor therapy for this particular group of patients. TRIAL REGISTRATION NUMBER EudraCT 2014-000394-39, pre-results.
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Affiliation(s)
- Stine Braendegaard Winther
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Camilla Qvortrup
- Department of Oncology, Odense University Hospital, Odense, Denmark
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Glimelius B, Johansen C, Muren LP, Nilbert M. Acta Oncologica and a new generation of scientists in oncology. Acta Oncol 2014; 53:849-51. [PMID: 24954366 DOI: 10.3109/0284186x.2014.913102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Bengt Glimelius
- Department of Radiology, Oncology and Radiation Science, Uppsala University , Uppsala , Sweden
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