Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses pursuing chemotherapy following tumor resection in advanced colorectal cancer (CRC).

Currently, no robust data have demonstrated the benefit of giving chemotherapy to patients with advanced-stage CRC after disease resection, says Choti. Conversely, in the early-stage setting, adjuvant chemotherapy is standard for patients with CRC as a means to prevent microscopic disease, Choti explains. 

In the advanced-stage setting, some clinical trials have attempted to demonstrate benefit with chemotherapy in chemotherapy-naïve patients; however, it has been difficult to confirm clinical benefit with this approach, Choti concludes. 

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Michael A. Choti, MD, discusses pursuing chemotherapy following tumor resection in advanced colorectal cancer. 



Dr. Choti on Pursuing Chemotherapy Following Tumor Resection in Advanced CRC 

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses challenging treatment decisions in patients with neuroendocrine tumors (NETs).

 virtual interactive conference, Choti moderated a Medical Crossfire

 on the multidisciplinary management of NETs. For patients with metastatic NETs, tumor grade and the degree of differentiation should inform the need for chemotherapy, hormonal therapy, or radiation therapy, says Choti. However, determining grade, tumor aggressiveness, and differentiation is variable and largely dependent on Ki-67 expression, says Choti. 

Additionally, questions remain regarding how aggressively metastatic NETs should be surgically resected, Choti explains. Some recommend that patients should undergo aggressive surgical resection irrespective of whether the entire burden of disease can be removed. In the early-stage setting, newly diagnosed patients with a small disease burden in the pancreas, for example, may benefit more from active surveillance vs surgery because they could have indolent disease, concludes Choti. 

Michael A. Choti, MD, discusses challenging treatment decisions in patients with neuroendocrine tumors.  



Dr. Choti on Challenging Treatment Decisions in NETs  

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses the role of upfront surgery in pancreatic adenocarcinoma.

There is some controversy regarding the optimal frontline treatment for patients with pancreatic cancer. There is no debate that patients with elevated CA 19-9, which indicates worse prognosis and increased risk of micrometastatic disease, should receive neoadjuvant chemotherapy. However, Choti, who prefers the use of neoadjuvant chemotherapy in all patients with pancreatic adenocarcinoma, says that upfront surgery can be considered in patients with low-risk disease or those with small, resectable tumors.

Some of the controversy stems from the idea that patients who receive neoadjuvant chemotherapy are at an increased risk of developing postoperative complications, says Choti. Moreover, it is thought that the toxicities associated with chemotherapy could decrease a patient’s fitness for surgery.

However, it is more often that frail patients become fit for surgery during their course of neoadjuvant chemotherapy. In turn, these patients could have better outcomes after surgery compared with patients who undergo upfront surgery, concludes Choti.

Michael A. Choti, MD, discusses the role of upfront surgery in pancreatic adenocarcinoma.

Dr. Choti on the Role of Upfront Surgery in Pancreatic Adenocarcinoma

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses the benefit of neoadjuvant chemotherapy in pancreatic cancer.

Although the guidelines for pancreatic cancer suggest up-front surgery, data from recent studies are making it clear that neoadjuvant chemotherapy is superior to up-front surgery, particularly with regard to a pancreaticoduodenectomy. Neoadjuvant chemotherapy provides patients with the opportunity to receive the therapy, explains Choti. If the pancreaticoduodenectomy is performed first, these frail patients tend to have a longer recovery and sometimes never receive chemotherapy after surgery, says Choti.

Furthermore, neoadjuvant chemotherapy treats the micrometastatic disease earlier compared with delaying until after surgery. Patients who receive surgery up front may not receive chemotherapy until months after surgery, if at all. For all those reasons, neoadjuvant chemotherapy appear to be the superior up-front approach, concludes Choti.

View more from the 2020 School of Gastrointestinal Oncology

Michael A. Choti, MD, discusses the benefit of neoadjuvant chemotherapy in pancreatic cancer.

Dr. Choti on the Benefits of Neoadjuvant Chemotherapy in Pancreatic Cancer

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses the future of treatment for patients with stage IV pancreatic cancer.

There are novel agents and new forms of chemotherapy in development for patients with inoperable, stage IV pancreatic cancer, says Choti. The strategy for these patients are to find effective therapies for which chemotherapy is applied in neoadjuvant or potentially curative situations.

The most common regimen is a combination of aggressive cytotoxic chemotherapy to offer in a neoadjuvant setting patients who are potentially operable. A common form of chemotherapy is a combination of fluorouracil, leucovorin, irinotecan, and oxaliplatincalled FOLFIRINOX. Another common regimen is the combination of gemcitabine and nab-paclitaxel (Abraxane), which is typically used in a neoadjuvant setting for patients with pancreatic cancer who are resectable or borderline resectable.

Michael A. Choti, MD, discusses the future of treatment for patients with stage IV pancreatic cancer.
 
 

Dr. Choti on Future Treatment of Patients With Stage IV Pancreatic Cancer

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses the role of immunotherapy in the treatment of patients with pancreatic cancer.

Immunotherapy has made virtually no impact in this space for the time being, but there are ongoing trials testing its role in patients with advanced disease. Choti says it seems as though pancreatic cancer is not an immunogenic disease and that these patients are not appropriate candidates for this class of agents. Therefore, it is not amenable for immunotherapy. However, there is a very small subset of patients with microsatellite instability-high tumors where this type of treatment has potential.

A phase IIa trial presented at the 2018 ESMO Congress indicated that pembrolizumab (Keytruda) may have an impact in combination with the CXCR4 antagonist BL-8040 for patients with metastatic pancreatic adenocarcinoma. Patients received 5 days of BL-8040 monotherapy followed by repeated 3-week cycles of pembrolizumab combined with BL-8040 every 3 weeks. The median overall survival with this treatment was 3.4 months in the 29 evaluable patients.

Dr. Choti Discusses Immunotherapy in Pancreatic Cancer

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses the role of surgery in the treatment of patients with pancreatic cancer.

Pancreatic adenocarcinoma remains a very aggressive and life-threatening disease. The only curative strategy for these patients is surgery, but Choti says that the vast majority of these patients do not have operable disease at the time of presentation. Most patients with pancreatic cancer have either metastatic or locally advanced disease, which precludes the ability to resect the tumor. As a result, early diagnosis through imaging is crucial.

If there is no evidence of metastatic disease and the tumor is located away from vital veins and arteries, surgery can be a potential treatment option. The surgical approach is chosen based on where the tumor is located in the pancreas—head, body, or tail, Choti notes. For example, if the tumor is in the head of the pancreas, a Whipple procedure referred to as a pancreaticoduodenectomy is often used, whereas if the tumor is located in the body or tail of the pancreas, then a distal pancreatectomy can be done.

In recent years, a multimodality approach has emerged in the treatment of patients with pancreatic cancer. There are now more effective forms of systemic chemotherapy available, says Choti, and these agents are being introduced not only in the advanced setting, but more aggressively in upfront treatment.

Dr. Choti Discusses Role of Surgery in Pancreatic Cancer

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses the role of surgery in the treatment of patients with rectal cancer.

Surgery is very important, says Choti, and to achieve the best outcome the procedure generally involves full removal of the rectal lymph node. Neoadjuvant therapy can sometimes make the surgery easier. Through chemotherapy or radiotherapy, shrinking the tumor preoperatively can lead to sphincter-preserving surgery so that a permanent colostomy will not be required. Patients who typically have the best outcomes are the ones with low tumors located near the anus.

Choti adds that new surgical techniques using robotics are changing the treatment landscape. Total mesorectal excision can now be performed more effectively, leading to a better reconstructive result in the adjuvant setting.

Dr. Choti on the Role of Surgery in Rectal Cancer

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses updates in neoadjuvant and adjuvant therapy for patients with colorectal cancer (CRC).

Choti says that the role of neoadjuvant and adjuvant therapy has been changing in CRC, particularly in rectal cancer. Most patients with rectal cancer receive neoadjuvant chemotherapy and radiation, and then adjuvant chemotherapy following surgery. Now, there is an increasing trend to move chemotherapy prior to neoadjuvant chemoradiation, Choti says.

In colon cancer, there have been changes regarding postoperative adjuvant therapy. Typically, patients receive surgery first, and then postoperative chemotherapy is offered to some patients, usually those with stage III disease, notes Choti. New studies have shown that the duration of chemotherapy can be reduced from the usual 6 months to 3 months in some cases. Choti says that the advantage of this shorter schedule, particularly with oxaliplatin-based regimens, is a reduction in adverse events such as neurotoxicity. It cannot be said that 3 months is appropriate for all patients.

Michael A. Choti, MD, chief of surgery, Banner MD Anderson Cancer Center, discusses updates in neoadjuvant and adjuvant therapy for patients with colorectal cancer.
 

Michael A. Choti, MD

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