First- and Second-Line Treatment of mCRC in Specific Populations

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John Marshall, MD, asks the panelists about the first-line use of cetuximab in patients with wild-type metastatic colorectal cancer. Johanna Bendell, MD, notes that toxicity is the biggest issue with cetuximab; in appropriate patients, she would use cetuximab with FOLFIRI as first-line therapy.

For wild-type KRAS or pan RAS wild-type, Marwan Fakih, MD, individualizes treatment based on patient characteristics. Fakih employs an aggressive approach in patients with potentially resectable mCRC, using an anti-EGFR therapy plus chemotherapy. He favors FOLFOXIRI in patients with good performance status; for patients whose performance status is not good, he favors FOLFIRI plus cetuximab.

Next, Marshall asks the panelists to comment on second-line treatment selection for patients with wild-type RAS mCRC who have received FOLFOX or capecitabine/oxaliplatin/bevacizumab as first-line therapy. Heinz-Josef Lenz, MD, prefers an EGFR agent in symptomatic patients with a heavy tumor burden. Lenz considers bevacizumab a good option for asymptomatic patients with indolent disease.

Alan Venook, MD, comments that treatment selection is an art. His first steps are to take into account the goal of therapy and the toxicity profile that the patient is willing to live with. Venook states that multidisciplinary assessment of the patient is very important to establish the goal of therapy. Another issue—deciding when to change therapy—may be as important as or more important than which agents are used, according to Venook.