ONCAlert | 2018 ASCO Annual Meeting
Colorectal Cancer Case Studies

Cathy Eng, MD, FACP: Fourth-line Treatment for Progressive Disease

Cathy Eng, MD, FACP
Published Online:Aug 12, 2015
Following Diane's first-line recurrence, she is switched to FOLFIRI, and bevacizumab is continued.

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What are your choices for fourth-line treatment in this patient with progressive disease?

Cathy Eng, MD, FACP, The University of Texas MD Anderson Cancer Center, says that for any patient who has refractory colorectal cancer, the most important thing to consider is not only looking at their laboratory tests, but also looking at their performance status. That is very critical in making a decision about whether or not to pursue additional therapy for palliation, as well as participation in a clinical trial, which has very significant eligibility criteria. It is important to consider best supportive care, and sometimes that may be the best option. The degree of performance status is critical in learning about this patient when making the decision about fourth-line treatment. In this patient, a performance status of at least 0 to 1 would be ideal before considering fourth-line therapy. Periodically, physicians do consider looking at patients with an ECOG performance status of 2, and that is reasonable, as long as it is due to tumor burden. If the benefit of therapy could potentially alleviate and reduce the tumor burden and help improve the performance status, then ECOG performance status of 2 is reasonable. However, 0 to 1 is ideal for participation in any clinical trial, as well as for consideration of continuing therapy. In this case, for a patient that’s already gone through anti-angiogenic therapy first-line, second-line, as well as anti-EGFR therapy, the next line of therapy outside of a clinical trial would be the consideration of regorafenib. Regorafenib could be started in this patient. However, it is not recommended to start at full dose. A dose reduction of at least 120 mg daily for the first two months is the best option. Some even utilize 80 mg daily to start, in order to make sure the patient tolerates it well. A dose increase should not be considered until after two months of therapy has been completed, and it is known that the patient has stable disease or improvement of clinical benefit or response to therapy. There’s significant hand-foot skin reaction for patients that start off at full dose, and if that occurs immediately when the patient starts therapy, it dissuades them from staying on therapy.

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