Case Presentation in Advanced Colon Cancer Case: 2 - Episode 1
Michael A. Morse, MD:Unfortunately, this patient has presented with a T3N2b stage 3C colon cancer. They’ve recovered from surgery. They had a complete resection, and now they have come to see us to consider what the next step should be.
Whenever possible, we try to treat patients in a multidisciplinary setting. Now in the case of a person who has had a primary resection, the surgeon was primarily managing them, and now they’re referred to us. Typically, the surgeons will continue to follow those patients. And, of course, we also will need a gastroenterologist to be involved periodically to perform a colonoscopy. Some patients present with obstructive symptoms, and they never have a complete colonoscopy. They will need one shortly after they’ve recovered.
For patients who did have a complete colonoscopy, they would have another one performed in the year afterward. Of course, we need to consult with a pathologist and make sure that they provided us all the critical information to be able to prognosticate for the patient. So, for example, we need to know the usual, such as the T-stage and the end-stage. But we also want to know that an adequate number of lymph nodes were analyzed, and we also have asked them frequently to perform microsatellite instability testing on the tumor, as is recommended by NCCN guidelines now.
We have good fortune in our center that, right in the clinic, we have the surgeons and we have ready access to speaking with a pathologist if need be. We can consult with our radiologist when people have reimaging studies. Of course, we also have multidisciplinary conferences if we need to discuss them. I would say that multidisciplinary care is probably more critical in the initial evaluation of a metastatic patient, but certainly, we involve all our colleagues as appropriate even in the adjuvant setting.
This is a curable scenario. However, their risk of recurrence is quite high. So, what we’re trying to do is increase the chances of survival but also, of course, do it with as little effect on quality of life and long-term toxicity as possible. Although many individuals with colorectal cancer are olderindeed, the median age is somewhere between 68 and 70—there is a substantial fraction of patients who are younger and want to continue to work. They may have families they need to care for, and, of course, everybody has outside interests, and so we try to understand the important features of that person’s life outside their visit, to see us and help us tailor the therapies for those individuals.
Unfortunately, with stage 3C disease, the risk of recurrence without therapy is quite high. Some studies would put it at more than 70%. In fact, if one were to use online nomograms, the risk of recurrence exceeds 80%.
The features that I would be looking at in this patient are, of course, their T and N stages, and this person has many positive lymph nodes. On the other hand, there is some consideration about the number of negative nodes. Unfortunately, in this case, there were only 13 nodes removed and only 4 of them were negative. Other considerations are lymphovascular invasion and perineural spread, and the degree of differentiation of the tumor is also important in determining the risk of recurrence.
The NCCN guidelines list several options for patients with stage 3 disease. It could be FOLFOX or, in patients who are unwilling to take an infusional regimen, a modification called FLOX. There’s also capecitabine/oxaliplatin, the so-called XELOX or CAPOX regimen. But for patients who are unwilling to take the oxaliplatin component, there are data for capecitabine alone.
In this young, otherwise healthy patient who wants to take the most aggressive approach, I would typically use an oxaliplatin-containing regimen such as FOLFOX or CAPOX. And the reason for doing so is that there are randomized clinical trials that support that. For example, in the MOSAIC trial, patients were randomized to FOLFOX, versus infusional fluorouracil, and there was a better progression-free survival for patients receiving the oxaliplatin-containing regimen. There were similar data for CAPOX versus fluorouracil and leucovorin.
Transcript edited for clarity.