Marwan G. Fakih, MD: Principal Second-Line Options for Patient

What are the principal second-line options for this patient upon disease progression?

The patient is currently on 5FU and leucovorin. Dr. Fakih asks to consider any better strategies in the management of this patient? Dr. Fakih would consider the addition of antiangiogenic therapy in this setting. Despite the fact that this patient has type 2 diabetes, this patient has no history of myocardial infarction, has no history of CDA, and there is no clear contraindication for antiangiogenic therapy in this patient.

The patient receives 5FU and bevacizumab as a maintenance therapy and now her disease has progressed in the liver. There’s no extrahepatic disease. What are the treatment options for this patient in this particular setting? This patient has failed first-line chemotherapy, oxaliplatin-based in combination with bevacizumab. Based on multiple phase 3 clinical trials, we know that a switch to a second backbone chemotherapy, specifically with FOLFIRI, plus another antiangiogenic agent, will result in improvement in progression-free survival and overall survival. This patient has a RAS mutant colorectal cancer. Anti-EGFR therapy is not an option.

Dr. Fakih's second recommendation, as far as treatment of this patient, particularly in the setting of progressive disease, would be to move to a second-line chemotherapy with FOLFIRI plus an antiangiogenic agent. And all these three antiangiogenic agents would be an optional therapy. However, Dr. Fakih would pause here and discuss with the patient the comorbidities associated with treatment.

CASE 2: Metastatic Colorectal Cancer (CRC)

Beverly C. is a 73-year-old retired nurse originally from Albany, New York. She and her husband enjoy golf and traveling.

• Her prior medical history is notable for type 2 diabetes mellitus and basal cell carcinoma of the neck, successfully excised in 2009

In 2010, routine colonoscopy revealed a large adenomatous polyp that was subsequently removed endoscopically.

• Patient was advised to return for regular evaluation but subsequently relocated to Florida and was lost to follow-up

In January of 2014, she presented to her PCP with symptoms of irregular bowel movements, fatigue, and unexplained weight loss.

CT scan revealed a large mass in the sigmoid colon and multiple hepatic lesions

Patient was eventually diagnosed with stage IV colorectal cancer with metastasis to the liver

She underwent resection of the sigmoid mass followed by FOLFOX for metastatic disease

After 6 months she developed stage 3 sensory neuropathy and oxaliplatin was discontinued; at that time, hepatic lesions were stable

She is now continuing treatment with 5-FU and leucovorin until disease progression