Dr. Marshall on Challenges in CRC Treatment

John L. Marshall, MD, chief, Division of Hematology/Oncology, Medstar Georgetown University Hospital, professor of medicine and oncology, and director, Otto J. Ruesch Center for the Cure of Gastrointestinal Cancer, Georgetown-Lombardi Comprehensive Cancer Center, discusses the challenges in the colorectal cancer (CRC) field.

The treatment of patients with CRC is often considered in terms of lines of therapy, but that school of thought implies that once a therapy is used, it can never be used again, says Marshall, and the patient moves onto a different therapy. CRC treatment is more of a chess game in that the pieces on the board can be moved more than once, explains Marshall. The same is true in CRC, as therapies can be used multiple times, according to Marshall.

In the frontline, more aggressive initial treatment is being used, with FOLFIRINOX plus bevacizumab (Avastin) given to nearly all patients. In terms of maintenance therapy, some of the therapies are put on hold so they can be used later, says Marshall.

One of the biggest challenges faced in cancer medicine, according to Marshall, is the concept that certain medicines can only administered to patients with refractory disease and other agents can only be used for frontline treatment. For example, regorafenib (Stivarga) and TAS-102 (trifluridine/tipiracil; Lonsurf) are both valuable drugs that provide patients with 6 to 9 months of stable disease. If a physician waits too long to administer these agents, patients might miss the opportunity to gain benefit from their use.

As such, drugs that have survival advantages should not be saved for a later time when they will not be effective, advises Marshall. These drugs should be used in earlier maintenance windows, and regimens from the second-line and beyond should be moved earlier on in the treatment journey, when achieving stable disease matters most, concludes Marshall.

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