What options are available to extend survival in this patient with metastatic disease?
Based on ECOG 3200, patients who did not receive bevacizumab in the first-line setting, and even progressed in the first-line setting, improvemed in response rate in progression-free survival and in overall survival with the addition of bevacizumab.
In this particular patient there is no progression on FOLFOX chemotherapy, so there is stable disease. The addition of bevacizumab is important in this setting in prolonging her progression-free survival, not only based on the fact that it is helpful in a second-line treatment if this is somehow to be not a great response to FOLFOX, but also based on first-line chemotherapy studies, mainly the IFL clinical trial, IFL Avastin versus IFL where we see improvement in response rate, progression-free survival and overall survival, and also based on the clinical trial and 016966 study, which showed that adding the bevacizumab, Avastin to oxaliplatin-based therapy improves progression-free survival.
In this particular patient where surgery is not possible, and one cannot downstage to resection would be to use a maintenance chemotherapy that delays the progression-free survival as long as possible, that is well tolerated with minimal side effect, one could add bevacizumab to 5FU.
In support of this strategy is also the Tyro 3 (?) Clinical trial, which has looked at maintenance chemotherapy with fluoropyrimidine plus bevacizumab after an induction chemotherapy with oxaliplatin-based chemotherapy plus bevacizumab. In that particular setting there was also a delay in progression-free survival and treatment failure. Dr. Fakih's number one choice in this patient would be maintenance with 5FU and bevacizumab.
CASE 2: Metastatic Colorectal Cancer (CRC)
Beverly C. is a 73-year-old retired nurse originally from Albany, New York. She and her husband enjoy golf and traveling.
In 2010, routine colonoscopy revealed a large adenomatous polyp that was subsequently removed endoscopically.
In January of 2014, she presented to her PCP with symptoms of irregular bowel movements, fatigue, and unexplained weight loss.
CT scan revealed a large mass in the sigmoid colon and multiple hepatic lesions
Patient was eventually diagnosed with stage IV colorectal cancer with metastasis to the liver
She underwent resection of the sigmoid mass followed by FOLFOX for metastatic disease
After 6 months she developed stage 3 sensory neuropathy and oxaliplatin was discontinued; at that time, hepatic lesions were stable
She is now continuing treatment with 5-FU and leucovorin until disease progression