Continuum of care for colorectal cancer: Finding the optimal treatment course (2)

Discussion

The continuum-of-care approach in CRC emphasizes individualized therapy that exposes patient to different combinations of cytotoxic and targeted agents. Physicians can utilize, discontinue, or re-use agents across several lines of treatment, according to factors such as: treatment goals; patient preference; patient’s general condition; disease characteristics; and efficacy and tolerability profiles of the drugs. However, the choice of first-line treatment affects which subsequent treatment options can be used, and physicians often undergo an intensive discussion of benefits and risks with patients and their families before each treatment decision.

Patients with unresectable disease but without other tumour-related symptoms are generally offered a doublet cytotoxic regimen, such as oxaliplatin with a fluoropyrimidine, and a targeted agent, for disease control. Current clinical evidence favours bevacizumab in the first-line setting, but KRAS wild-type tumours may benefit from an anti-epidermal growth factor receptor antibody. Upon progression, oxaliplatin or irinotecan may be offered in a sequential manner, along with a targeted biological agent. As second-line treatment, the clinical benefit of the antiangiogenic agent aflibercept was demonstrated in VELUR, a phase III, randomized, placebo-controlled trial. Aflibercept with 5-fluorouracil, leucovorin and irinotecan (FOLFIRI) significantly improved overall survival (13.50 versus 12.06 months; hazard ratio [HR] 0.817; 95% confidence interval [CI] 0.713-0.937; p<0.0032) and progression-free survival (6.90 vs 4.67 months; HR 0.758; 95% CI 0.661-0.869; p<0.0001) in patients with mCRC previously treated with an oxaliplatin-based regimen, including those who had received bevacizumab. In the present case, the distinct mechanisms of action of irinotecan and aflibercept may have contributed to the patient’s good response. Her regimen appears effective and is also particularly suitable for patients who have a preference for convenient outpatient treatment.





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