Marwan G. Fakih, MD: Age and Performance Status Issue in Determining Therapy

Is age or performance status an issue for this patient in determining subsequent therapy?

There have been three randomized clinical trials that have evaluated each one of those antiangiogenic agents in the second-line treatment of patients who have progressed on first-line chemotherapy with oxaliplatin-based treatment. All three agents have shown improvements in disease-free, in progression-free survival and in overall survival in the second-line treatment of metastatic colorectal cancer.

Another option of treatment would be anti-EGFR therapy, plus irinotecan-based treatment, specifically FOLFIRI plus cetuximab or FOLFIRI plus Panitumumab. And another option would be just to use irinotecan plus cetuximab, or irinotecan plus Panitumumab. All these options that I have listed are considered within the guidelines of NCCN.

CASE 1: Metastatic Colorectal Cancer (CRC)

Neil H. is a 62-year-old construction manager from Houston, Texas.

• His prior medical history is notable for obesity, mild hypertension, hyperuricemia, and gout

The patient was diagnosed with colon cancer in February 2011, after reporting to his PCP with symptoms of intermittent nausea, vomiting, and blood in his stool

• Patient underwent resection of the sigmoid colon with lymph node evaluation (12 nodes examined), which showed adenocarcinoma stage T3N0M0; mutational status showed RAS WT; BRAF negative

In January of 2013, he presented to his oncologist for evaluation after his CEA had increased to 85 ng/mL.

The patient was asymptomatic at the time of recurrence

CT scan showed multiple unresectable metastatic lesions to the liver and lung; the patient’s ECOG performance status was 0

He received initial therapy with FOLFOX and bevacizumab for metastatic disease

After 6 cycles the patient experienced a good response but developed grade 3 neuropathy and oxaliplatin was discontinued

The patient was continued on 5FU with bevacizumab with eventual improvement of his neuropathy symptoms; his disease continued to be stable

In February of 2015, the patient presents with fatigue, nonexertional dyspnea, and cough, and his CEA had increased to 110 ng/mL.

• CT scan was consistent with progression of liver and pulmonary lesions