Adjuvant Therapy and Surveillance in Recurrent CRC

Tanios Bekaii-Saab, MD, FACP:When the patient initially presented, his tumor was on the right side, which certainly confers a worse prognosis. It was somewhat obstructing, not completely obstructing, that’s why he’s a T3 and not a T4, so there was still a passageway. His risks of recurrence without chemotherapy at the time would have been a little bit more than 50%. And for a patient, at least at his initial presentation—younger, healthier—overall, FOLFOX would make a lot of sense, which is essentially what he received. The question today is mostly 3- versus 6-month regimen. At the time, he was treated the standard for 6 months. Obviously, the patient was not able to complete the full 6 months, he completed 9 out of the 12 planned cycles, which is kind of expected with oxaliplatin, mostly because of the cumulative neuropathy. But I do believe that the patient was adequately treated at the time with surgery followed by adjuvant therapy to cut down on the risk of recurrence. Unfortunately, the patient ultimately recurred anyways, and that could partially be related to the location of his tumor.

Surveillance itself is a subject of great debate. A number of studies suggest, one way or the other, that perhaps just routine follow-up with no scanning with labs would be more than sufficient. We tend to argue that you probably need a scan, at least in the first 2 to 3 years, because the most common time for recurrence is in those first 2 to 3 years. Obviously, in this patient, it took a little longer than that, which we see in the rare patient or in the unusual situation. But most of the recurrences happened in the first 2 to 3 years.

The other debate is about the frequency. We tend to be a little bit more conservative and do it every 6 months for the first 2 years and then more at the third year. However, if you look at the guidelines, they are a little bit loose. They suggest 6 to 12 months in the first 2 years, and then maybe another 1 or 2 on a yearly basis after that. So, there is no specific guideline that’s supported by high-level evidence. It’s mostly a good level evidence. It’s also so you’ll feel comfortable with it. The reason why we’d like to do those scans, especially earlier on, is a lot of these patients may present with isolated liver lesions or isolated lung lesions, and we can certainly consider resecting them and provide the patient another shot at remission and maybe for some cure. Unfortunately, in this patient, it’s a different story, but that’s overall why we try to be a little bit more conservatively aggressive with the scans.

Transcript edited for clarity.

January 2017

A 62-year-old African-American man presented with recurrent CRC

• Diagnosed at age 55 with stage 3 CRC, treated with surgery and adjuvant FOLFOX
• He underwent colonoscopy with biopsy
  • 6-cm ulcerated non-obstructive mass noted in the right colon
  • Pathology confirmed poorly-differentiated adenocarcinoma
  • Staging; T3N1M0
• History
  • Former smoker, 1 pack a day; quit 20 years ago
  • Obese, BMI = 30.2 kg/m²
  • Mother had inflammatory bowel disease, died at age 70
  • Other medications: metoprolol for hypertension, omeprazole, regular NSAID use
• PET/CT scan showed recurrent disease with multiple metastases in liver
  • CEA, 28.4 ng/mL
  • Biopsy of liver lesions suggests poorly-differentiated with colon primary
  • Mutation analysis;KRASandNRAS,WT;BRAF-wild-type; microsatellite-stable
• He was started on FOLFIRI with bevacizumab and achieved partial response

January 2018

• The patient reports feeling short of breath.
• PET/CT showed progressive disease in the liver and multiple metastases in both lung fields
• Therapy options were discussed with the patient; he preferred an oral therapy
• He was started on regorafenib, 80 mg once daily
  • He experienced grade 2 dermatologic toxicity on his hands and feet (palmar-plantar erythrodysesthesia syndrome [PPES]), which was managed with dose escalation from 80 mg to 120 mg to 160 mg. With recovery, he resumed regorafenib at 120 mg/day
  • At present,he remains on regorafenib 120 mg/day with evidence of stable disease at 6-month follow-up