Tanios Bekaii-Saab, MD: Options Available to Extend Survival

What options are available to extend survival in this patient with metastatic disease?

Options are more limited than a KRAS wild-type or a RAS wild-type patient, but there are still at least three, perhaps now four, lines of therapy. For such a patient one should start with FOLFOX obviously, went to FOLFIRI/Bev in the second-line and then moving to regorafenib in the third-line. And the fourth-line would be a drug that’s going to be recently, that is going to be approved hopefully in the near future, TAS-102.

This situation may end up with four lines of therapy that would maximize the likelihood of survival. It is this continuum of giving sequencing these multiple lines of therapy has moved the needle of survival from in the old days, not so old but they seem like they’re old days, from one year to anywhere between two-to-three years at the medium.

So you go with the continuum of care since this patient started with FOLFOX, the second-line would be FOLFIRI/bevacizumab, and then third-line would be regorafenib. These are the approved agents and regimens at this point of time. And then TAS-102 which will likely be approved in the very near future will become an option after failure of regorafenib for this particular patient. So right there there are have four lines of therapy that would be lined up for this patient.

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