Cancer Treatment Today » Metastatic

Gemzar for colon and rectal cancer

M Levin, MD — Fri, 09 Nov 2012 19:17:56 +0000

Gemzar( gemcitabine) has been tested for colon and recatl cancer. A 1992 study found that Gemcitabine did not demonstrate activity against advanced colorectal adenocarcinoma. ON teh other hand,a much later study found that Gemcitabine has a modest activity in heavily pre-treated colorectal cancer patients and may be an option in good performance status patients. There are a number of reports and ongoing studies of gemcitabine in combination for colorectal cancer. A recent study, Gemcitabine in Treating Patients With Advanced Colorectal Cancer, NCT00007943, was completed in 2009 but not published as of 2012.

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PET for possibly recurring colon cancer

M Levin, MD — Sun, 23 Sep 2012 18:38:25 +0000

After definitive treatmetn of colon cancer, patients are followed with CEA levels. When they begin to rise, a recurrence is suspected. PET is being more frequenlty used to detect and identify recurrence in this situation. More recently NCCN has been more supportive of PET in this setting. It used to support PET only in the situation of rising CEA and no identified recurrence for localization of disease recurrence in patients with rising CEA level and non-diagnostic CT scans. However, PET scan can potentially identify occult disease in this setting that CT may miss. Therefore, PET scans can led to more potentially curative resection in patients with elevated CEA and patients who are candidates for resection of isolated colorectal cancer liver metastases. PET scan prior to attempted resection also reduces the number of unnecessary surgeries.

On p. Col-9, 2012 NCCN recommends the use of CT scans of chest and abdomen in the situation of serial CEA elevations but also says “Consider PET/CT scan”.

CMS guidelines state that PET would rarely be used in the diagnosis of colorectal cancer. However, starting July 1, 2001, HCFA, now called the Centers for Medicare and Medicaid Services (CMS), is covering FDG-PET imaging for diagnosis, staging, and restaging of colorectal cancer.

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Xeloda and irinotecan for second or later lines in colorectal cancer

M Levin, MD — Sun, 23 Sep 2012 17:53:29 +0000

The issue that we will discuss is Xeliri (Xeloda and irinotecan) in second or later line of therapy. It is a tempting regimen because Xeldoa is an generally effective drug for colorectal cancer and it is oral. We start by pointing out that there are now six different classes of drugs with significant antitumor activity in colon cancer:

Fluoropyrimidine (5-fluorouracil [5-FU] which is usually given with leucovorin [LV], capecitabine, tegafur plus uracil [UFT]). Irinotecan, Oxaliplatin, Cetuximab and panitumumab. The latter two are monoclonal antibodies (MoAbs) directed against the epidermal growth factor receptor (EGFR), and bevacizumab, is a monoclonal antibody targeting vascular endothelial growth factor (VEGF). Zaltrap was recenlty(2012) also approved.

The best way to combine and sequence all of these drugs to optimize treatment is not yet established, although for intial treatment of metasatic colorectal cancer NCCN recommends combinations of 5FU and Lekovorin with oxaliplatin or irinotecan with or without Avastin, CAPEOX, 5FU/Leukovorin, Xeloda and Avastin or Folfoxiri.

For second or third line therapy, single agents are acceptable and NCCN lists irinotecan as a single agent. It also lists combinations, see p. COL-C of the NCCN guideline for colon cancer. NCCN has a complex schema when to give what for second line and also lists irinnotecan or Folfiri with Erbitux, Zaltrap or Vectbix. However, it does not list irinotecan with Xeloda.

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Chemo Options for Later Lines of Therapy for Metastatic Colon Cancer

M Levin, MD — Thu, 19 Jul 2012 02:55:29 +0000

There are now five different classes of drugs with significant antitumor activity in colon cancer:

Fluoropyrimidine(5-fluorouracil [5-FU] which is usually given with leucovorin [LV], capecitabine, tegafur plus uracil [UFT]), Irinotecan, Oxaliplatin, Cetuximab and panitumumab (Vectbix). The latter two are monoclonal antibodies (MoAbs) directed against the epidermal growth factor receptor (EGFR), and bevacizumab, is a monoclonal antibody targeting vascular endothelial growth factor (VEGF).

The best way to combine and sequence all of these drugs to optimize treatment is not yet established, although for initial treatment of metastatic colorectal cancer NCCN recommends combinations of 5FU and Lekovorin with oxaliplatin or irinotecan with or without Avastin, CAPEOX, 5FU/Leukovorin, Xeloda and Avastin or Folfoxiri.

For second or third line therapy, single agents are acceptable but NCCN lists only irinotecan as a single agent. It also lists combinations of these drugs, Erbitux and Vectbix(for wild type KRA patients), see p. COL-C of the NCCN guideline for colon cancer. NCCN has a complex schema when to give what for second line and also lists Erbitux and Vectbix. However, capecitabine is also FDA approved as a single agent. NCCN does not list 5FU/Leikovorin but it can also be considered appropriate given the long history of its use for colorectal metastatic cancer and support form many older papers.

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