Treatment of Patients With Late-Stage Colorectal Cancer: ASCO Resource-Stratified Guideline

Abstract

PURPOSE To provide expert guidance to clinicians and policymakers in resource-constrained settings on the management of patients with late-stage colorectal cancer. METHODS ASCO convened a multidisciplinary, multinational Expert Panel that reviewed existing guidelines, conducted a modified ADAPTE process, and used a formal consensus process with additional experts for two rounds of formal ratings. RESULTS Existing sets of guidelines from four guideline developers were identified and reviewed; adapted recommendations from five guidelines form the evidence base and provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% on all recommendations. RECOMMENDATIONS Common elements of symptom management include addressing clinically acute situations. Diagnosis should involve the primary tumor and, in some cases, endoscopy, and staging should involve digital rectal exam and/or imaging, depending on resources available. Most patients receive treatment with chemotherapy, where chemotherapy is available. If, after a period of chemotherapy, patients become candidates for surgical resection with curative intent of both primary tumor and liver or lung metastatic lesions on the basis of evaluation in multidisciplinary tumor boards, the guidelines recommend patients undergo surgery in centers of expertise if possible. On-treatment surveillance includes a combination of taking medical history, performing physical examinations, blood work, and imaging; specifics, including frequency, depend on resource-based setting. Additional information is available at www.asco.org/resource-stratified-guidelines .

A phase II study of FOLFOXIRI plus bevacizumab as initial chemotherapy for patients with untreated metastatic colorectal cancer: TRICC1414 (BeTRI)

“…Oxaliplatin often causes cumulative neurotoxicity before clinical progression [ 20 ]. NCCN and ASCO guidelines recommend discontinuation of oxaliplatin from FOLFOX or CAPEOX three–four months after initiation of treatment or sooner for unacceptable neurotoxicity, with other drugs in the regimen maintained until time of tumor progression [ 6 , 7 ]. In contrast, continuation of FOLFIRI induction treatment is recommended for at least as long as tumor shrinkage continues, or disease stabilization is maintained with tolerable toxicities [ 5 ].…”

“…The major clinical practice guidelines, including the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guideline 2019, all recommend FOLFOXIRI plus bevacizumab as a first-line therapeutic option for selected patients with mCRC [5][6][7][8]. Only two prospective, single-arm phase II trials of FOLFOXIRI plus bevacizumab have been conducted to assess the safety and efficacy in Japan.…”

Evidence-based recommendations for gastrointestinal cancers during the COVID-19 pandemic by the Brazilian Gastrointestinal Tumours Group

“…When regorafenib is used, start with a dose-escalation schedule as studied in the ReDOS trial [47]. • In later lines, for patients whose cancers have either HER2 amplification, BRAF V600E mutations, or are RAS/RAF wild-type, need treatment and are refractory to 5-FU/capecitabine, consider switching to targeted therapies alone, without concurrent use of cytotoxic agents [70]. • Weekly cetuximab should be avoided.…”

“…• Weekly cetuximab should be avoided. Instead, use every-other-week anti-epidermal growth factor receptor (EGFR) dosing [70].…”

Systems analysis of protein signatures predicting cetuximab responses in KRAS, NRAS, BRAF and PIK3CA wild‐type patient‐derived xenograft models of metastatic colorectal cancer

“…Anti‐EGFR therapies have significantly improved survival in metastatic CRC patients 3 . Guidelines recommend to test for KRAS , NRAS and BRAF mutations as well as microsatellite instability status in CRC patients being considered for anti‐EGFR therapy 4,5 on the basis of the ineffectiveness of anti‐EGFR therapy in patients with activating KRAS , BRAF and NRAS mutations, 6 and favourable responses to immune check point inhibitors in patients with high microsatellite instability 4 . Although PI3KCA mutational analysis is not recommended yet, 4 PIK3CA exon 20 mutations were linked with a worse outcome compared to wild‐type status in patients with metastatic CRC 7 .…”