Upfront Treatment Strategies for Metastatic Colorectal Cancer

Resection is ideal for eligible patients with colorectal cancer (CRC), since it is easier to eradicate micrometastatic disease with systemic therapies, according to Richard L. Goldberg, MD. Upfront chemotherapy may be appropriate, if the disease is borderline resectable or if downstaging could potentially change the surgical outcome, adds Howard S. Hochster, MD.

In a patient who has a rectal tumor close to the anal verge and one isolated 2-cm liver lesion, upfront systemic therapy may be appropriate, says Fadi Braiteh, MD. After completing induction therapy, it is best to remove microscopic disease first, adds Braiteh. In this setting, chemoradiation and standard management of the rectal primary tumor could delay liver treatment and lead to further disease progression, notes Braiteh.

An individual with low levels of carcinoembryonic antigen (CEA), one positive node, a single small lesion, and synchronous disease post surgery would have one point on the Fong score, translating to a 50% probability of cure with no further therapy, says Goldberg. The benefit of adding adjuvant therapy in this setting is unclear, but it may improve the chances of cure, adds Goldberg, who prefers to use cytotoxic therapies as adjuvant treatment.

Discontinuing chemotherapy depends on the bulk of the disease, the pace of disease, and patient-specific goals, says Goldberg. Many patients will need a break before restarting treatment, adds Hochster.