Treatment Goals in Refractory mCRC

Andrea Cercek, MD: When patients reach third-line therapy, after they’ve progressed on standard cytotoxic therapies like FOLFOX and FOLFIRI, the conversation often entails anti-EGFR therapy—if they happen to be all—RAS wild-type. And if not, a large proportion of our patients are not, we discuss either enrollment in clinical trials or the standard therapies that are available for those patients—which are either Stivarga (regorafenib) or Lonsurf (trifluridine/tipiracil).

Choices are a bit personal, based on the patient’s preference. Some people are quite motivated to participate in clinical trials. In this case, that’s what we proceed with. Or, if patients prefer standard therapy or, perhaps, are unable to enroll in a clinical trial, then we consider either Stivarga or Lonsurf, at that time.

Tanios Bekaii-Saab, MD, FACP: The goals pretty much remain the same across multiple lines of therapy. Overall, this is palliative care. So, the primary goal of chemotherapy or any treatment is palliation. The secondary goal, and this is a very important goal, is prolonging survival. Frankly, they go hand in hand. The goals remain the same across multiple lines of therapy—how to balance quality of life with efficacy to improve outcomes with survival. We keep those goals on track across all of these lines of therapy. Unfortunately, as we go through lines of therapy, we start losing benefit. The disease becomes more aggressive and emerging clones become more resistant. So, we lose some benefit. We have to reassess the situation at every line of therapy. However, the balance is always the same—how to optimize efficacy while maintaining quality of life.

Zev A. Wainberg, MD: As patients approach later lines of therapy in colon cancer, helping them through quality of life issues becomes much more important. This includes supportive care aspects (which include introducing things that will help patients to support the fatigue and the anorexia and weakness that may be a consequence of their treatment), and management strategies—to deal with the ongoing treatment, if they’re getting treated at all. Some people increasingly utilize palliative care specialists, such as nurse practitioners or a palliative care service, which can help patients cope with the different aspects of the side effects as they approach later lines of therapy. Coinciding with that, there’s additional strategies that a lot of people use to help patients tolerate drugs better. This includes dose reductions and breaks from treatment, if indicated, to keep them going, if the treatment is working.

Transcript Edited for Clarity