Tanios Bekaii-Saab, MD: Principal Second-Line Options for Patient

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

Unfortunately for this patient (Beverly), in the presence of this mutation and KRAS, the options are more limited because one cannot use the EGFR inhibitors in this setting, so you lose a line of therapy there. But, there is chemotherapy, a different backbone. The patient had FOLFOX so we switched to FOLFIRI. And I think at this time we would introduce bevacizumab to take advantage of the added value of anti-angiogenesis.

This patient didn’t receive bevacizumab in the first-line. And the data suggests, although you can continue bevacizumab from first-line to second-line, the patients who are bevacizumab-naïve so they didn’t receive the bevacizumab in the first-line, you’re more likely to get even further benefit from adding it in the second-line. It was a little unusual for this patient not to receive bevacizumab in the first line, but it could still be used in the second-line.

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