Optimal Sequencing in Later Lines of Therapy for mCRC - Episode 1

Continuum of Care Concept in mCRC

Axel Grothey, MD:The concept of continuum of care relates to the idea that we want to expose all patients with metastatic colorectal cancer in the palliative setting to all active agents sequentially. This relates back to the idea that we have not had 1 major breakthrough event in colorectal cancer for the majority of patients—1 agent that could, perhaps, double survival times. The improvements that we’ve seen in overall survival over the last decade—moving from just 5-FU [5-fluorouracil]-based therapy, 12 months survival, to now expecting patients to live 3 years or more—really relate to the idea that we add incremental benefits on top of each other. Every single drug that was approved for the management of colorectal cancer added a little bit, hazard ratios of 0.8, 0.7; 2 to 3 months in survival benefit in clinical trials. But over time, with the use of all of these agents in this continuum of care, which includes maintenance strategies, reintroduction of chemotherapies, introduction of novel agents, we’ve really moved the bar in terms of overall survival for our patients. This is really the strategy we employ in the palliative management of metastatic colorectal cancer.

The idea of lines of therapy is a little bit muddled nowadays. We’re not really talking about lines of treatments anymore—first-line, second-line, third-line—because we introduce maintenance therapies, reintroduction, rechallenges of drugs. The idea has really moved forward to this continuum of exposure of agents for patients. I don’t believe there’s a big difference between the academic setting and the community setting in terms of how many agents, how many lines of therapy patients are really exposed to, with the exception that academic centers might have more access to phase I studies, novel agents, clinical trials, etcetera. But I do believe that the tools we have to keep our patients alive are available in both academic and community settings, so patients’ outcomes should not be different.

An unmet need that patients have in the metastatic setting is duration of time in quality of life. When I talk to my patients in the palliative setting, I say, “I cannot cure you. My goal is to keep you around for as long as possible and maintain your quality of life for as long as possible.” I think these are basic parameters that we need to communicate to our patients—that it’s time, but it’s also quality of time that really matters. This does represent an unmet need. We need new drugs. We need better selection of patients for the treatment choices that we have available.

Transcript edited for clarity.