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Slide 1 of 50
Case Study
• 62-year-old woman presents
with intermittent bright red blood
per rectum for the past 3 weeks.
Sought attention from PCP
• Medical history
– Type 2 diabetes mellitus for 20
years
– Obesity (BMI: 32)
• Lifestyle issues
– Exercises <30 minutes per week
– Diet with 4–5 servings of red meat
per week
Slide 2 of 50
Risk Factors for Developing
Colorectal Cancer
Decreases Risk
Increases Risk
Uncertain Impact
Screening
Family history
Statins
Exercise
Calcium/
vitamin D
Aspirin
IBD
Diabetes
Fiber
Glycemic index
Obesity
Red meat
Western diet
Alcohol
Smoking
Fruits/vegetables
Postmenopausal
estrogen
Folic acid
IBD = irritable bowel disease.
Courtesy of Jeffrey A. Meyerhardt, MD, MPH.
Slide 3 of 50
Case Continues
• CT of chest, abdomen, and pelvis shows no
metastases
• Colonoscopy reveals a sigmoid colon cancer
• Patient undergoes a laparoscopic-assisted
sigmoid colectomy. Pathology report:
– 4.5-cm poorly differentiated adenocarcinoma
– Penetrates to subserosa
– 2 of 16 lymph nodes positive
– T3 N1 M0 (stage IIIB)
Slide 5 of 50
Question 1
What would you recommend for adjuvant
therapy in this patient?
a)
5-FU/leucovorin/oxaliplatin (FOLFOX)
b)
Capecitabine
c)
Intravenous 5-FU/leucovorin
d)
FOLFOX + bevacizumab
e)
FOLFOX + cetuximab
Slide 6 of 50
Rationale for Adjuvant Treatment
of Stage III Colon Cancer
Surgery Alone
Surgery + Adjuvant Chemotherapy
Reprinted from Greene FL, et al. Ann Surg. 2002;236:416, with permission from
Lippincott Williams & Wilkins.
Slide 7 of 50
Adjuvant Capecitabine
X-ACT Trial
Stage III colon cancer
N = 1987
Primary endpoint:
equivalence in diseasefree survival (DFS)
R
A
N
D
O
M
I
Z
E
Capecitabine
1250 mg/m BID
days 1–14, q3wk
24 weeks
Mayo Clinic regimen
IV 5-FU/LV
6 cycles
5-FU/LV
Capecitabine
Overall DFS (5 y)
57%
61%
.07
Overall survival (5 y)
68%
71%
.06
Courtesy of Christopher Twelves, MD.
P Value
Slide 8 of 50
MOSAIC
Adjuvant Oxaliplatin
Stage II (40%) and III (60%)
colon cancer
N = 2246
Primary endpoint:
R
A
N
D
O
M
I
Z
E
FOLFOX4
LV5FU2
Disease-free survival (DFS)
FOLFOX4
Overall DFS (5 y)
LV5FU2
P Value
73%
67%
.003
Stage III
66%
59%
.005
Stage II
84%
80%
.26
79%
76%
.06
Stage III
73%
69%
.03
Stage II
87%
87%
.99
Overall survival (6 y)
Courtesy of Aimery de Gramont, MD.
Slide 9 of 50
Targeted Biologic Treatments as
Adjuvant Therapy
• Currently no data regarding efficacy of
bevacizumab, cetuximab, or panitumumab in
adjuvant therapy
• Bevacizumab trials
– NSABP C-08 (stage II and III)—pending results
– AVANT (stage II and III)—pending results
– ECOG (stage II colon)—accruing
• Cetuximab trials
– NCCTG (stage III colon)—accruing
– PETACC-8 (stage III colon)—accruing
Slide 10 of 50
Clinical Challenges Associated with
Treating this Patient
• Diabetes mellitus
– Predisposition for developing chemotherapy-induced
neuropathy has been observed in patients whose nerves
have been damaged by diabetes mellitus1
– 1 study showed higher risk of recurrence with diabetes
mellitus2
• Obesity
– Increased central adiposity prior to diagnosis of colorectal
cancer associated with poorer overall and disease-specific
survival3
– Do not dose cap
1.Quasthoff S, et al. J Neurol. 2002;249:9. 2. Meyerhardt JA, et al. J Clin Oncol. 2003;21:433.
3. Haydon AM, et al. Gut. 2006;55:62.
Slide 11 of 50
Case Continues
• The patient receives FOLFOX adjuvant
therapy for 9 cycles but develops grade 2
persistent neuropathy
• She continues adjuvant therapy with
capecitabine for 2 additional months
• Neuropathy diminishes to grade 1 after 6
months and is nearly resolved at 12 months
after last dose of oxaliplatin
Slide 12 of 50
Incidence of Neurosensory Symptoms
During FOLFOX and Follow-up
Incidence of Neurosensory
Symptoms (%)
Evaluable Patients
n = 811 at 4 Years
60
Grade 1
Grade 2
Grade 3
50
40
Grade 0
84.3%
Grade 1
12.0%
Grade 2
2.8%
Grade 3
0.7%
30
20
10
0
During
Treatment
6 Months
Courtesy of Aimery de Garamont, MD.
1 Year
2 Years
3 Years
4 Years
Slide 13 of 50
Question 2
What other recommendations would you
make after completion of
adjuvant therapy?
a) Surveillance with intermittent clinic visits,
colonoscopies, and CT scans
b) Increasing physical activity
c) Avoidance of diet high in red meat, sugary
desserts, and refined grains
d) All of the above
Slide 14 of 50
Recurrence, Hazard Ratio
Exercise and Colon Cancer Recurrences
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
1
0.87
0.9
0.51
<3
3-8.9
9-17.9
18-26.9
0.55
>27
Meyerhardt et al
Metabolic Equivalent Task [MET]-H/Wk of Physical Activity
JAMA 2007
Meyerhardt JA, et al. J Clin Oncol. 2006;24:3535.
Slide 15 of 50
Diet and Colon Cancer Recurrences
Quintile of Western Pattern Diet
1
2
3
4
5
P Trend
0.95
1.51
1.75
3.28
<.0001
(0.66–1.36)
(1.06–2.15)
(1.19–2.58)
(2.15–2.07)
0.98
1.51
1.64
3.25
(0.68–1.43)
(1.05–2.17)
(1.09–2.46)
(2.04–5.19)
Disease-free survival
Energy-adjusted
only
Ref
Multivariate
adjusted
Ref
<.0001
Western pattern: high intakes of red meat, processed meat,
refined grains, sweets and dessert, french fries, and
high-fat dairy products
Adapted from Meyerhardt JA, et al. JAMA. 2007;298:754-764, with permission from
the American Medical Association.
Slide 16 of 50
Case Continues
• Patient increased her exercise level to
walking 6 days per week for approximately 1
hour daily
• A CT scan 3 months after therapy is read
NED
• The patient is followed every 3 months with
clinic visits and carcinoembryonic antigen
(CEA) testing
• At 14 months, CEA rose from 2.0 to 7.4
Slide 17 of 50
Case Continues
• CT of chest, abdomen, and pelvis shows 5
total lesions in her liver (bilobar); no lesions
identified elsewhere
• Patient’s neuropathy has fully resolved
• She is evaluated by a liver surgeon who does
not believe she is resectable at this point
Slide 18 of 50
Question 3
What treatment would you offer the patient
now?
a)
FOLFOX or FOLFIRI alone
b)
FOLFOX + bevacizumab
c)
FOLFIRI + bevacizumab
d)
FOLFIRI + cetuximab
e)
FOLFOX + bevacizumab + panitumumab
f)
Clinical trial
Slide 19 of 50
FOLFOX 1st-Line Standard for Metastatic
Colorectal Cancer
NCCTG 9741
R
A
N
D
O
M
I
Z
E
IFL (irinotecan/5-FU/LV)
n = 264
FOLFOX (5-FU/LV/oxali)
n = 267
IROX
(irinotecan/oxaliplatin)
n = 264
Response
Rate (%)
Time to
Progress
(Mo)
Median
Overall
Survival
(Mo)
IFL
31
6.9
15.0
FOLFOX
45
8.7
IROX
35
6.5
Goldberg RM, et al. J Clin Oncol. 2004;22:23.
Grade 3/4
Neutropenia
(%)
Grade 3/4
Diarrhea
(%)
Grade 3/4
Paresthesias
(%)
40
28
3
19.5
50
12
18
17.4
36
24
7
Slide 20 of 50
Goldberg JCO 2004.
Irinotecan vs Oxaliplatin–Phase II/III Data
Reference
Regimen
N
RR (%)
TTP (Mo)
OS (Mo)
Tournigand1
FOLFIRI
109
56
8.5
21.5
FOLFOX
111
54
8.1
20.6
FOLFIRI
164
31
7
14
FOLFOX
172
34
7
15
IFL
147
33
8.9
17.6
FLOX
148
32
7.6
17.4
FOLFIRI
58
36
8.4
18.5
FOLFOX
58
40
9.8
20.8
Gruppo Oncologico
Dell’Italia2
Hellenic Oncology
Group3
CALGB 802034
1. Tournigand C, et al. J Clin Oncol. 2004;22:229. 2. Colucci G, et al. J Clin Oncol. 2005;23:4866.
3. Kalofonos HP, et al. Ann Oncol. 2005;16:869. 4. Venook A, et al. 42nd ASCO; June 2-6, 2006. Abstract 3509.
Slide 21 of 50
Targeted Biologic Therapies in
Metastatic Colorectal Cancer
Targeted monoclonal antibodies represent
some of the newest developments in
colorectal cancer treatment
• Bevacizumab: anti-VEGF
• Cetuximab: EGFR inhibitor
• Panitumumab: EGFR inhibitor
Slide 22 of 50
Normal and Tumor Vasculature
Normal Blood Vessels
Maturation factors present
Less dependent on cell
survival factors
...
....
.
.......
Tumor Blood Vessels
.
............ ...
... .........
...
...
....
.
............
..
Growth and survival
factors (eg, VEGF)
present
..
............
...
.
............
...
Less permeable
Supporting pericytes
present
Leaky
Fewer pericytes
.
............
...
Reduced integrin
expression
Slide courtesy of A. Venook, MD. Illustration courtesy of Genentech BioOncology.
Preferential
expression of
v3 v5 &
51 integrins
Slide 23 of 50
Bevacizumab
3 Proposed Mechanisms of Action
Early effect
1 Regression
Later effect
3
Inhibition
2 Normalization
Slide courtesy of A. Venook, MD. Illustration courtesy of Genentech BioOncology.
Slide 24 of 50
Bevacizumab in Metastatic Colorectal Cancer
Pivotal 1st-Line Trial
R
A
N
D
O
M
I
Z
E
IFL
IFL + bevacizumab
Bevacizumab
+ IFL (n = 402)
IFL
(n = 411)
Hazard
Ratio
P Value
Median OS (mo)
20.3
15.6
0.66
<.001
Median PFS (mo)
10.6
6.2
0.54
<.001
Response rate (%)
44.8
34.8
Median duration
response (mo)
10.4
7.1
.004
0.62
Hurwitz H, et al. N Engl J Med. 2005;350:2335-2342. Copyright © 2005 Massachusetts
Medical Society. All rights reserved.
.001
Slide 25 of 50
Phase III Study of XELOX or FOLFOX4 ±
Bevacizumab in 1st-Line MCRC
Progression-Free Survival Estimate
XELOX-1/NO16966
XELOX/FOLFOX4 + bevacizumab n = 699 (513 events)
XELOX/FOLFOX4 + placebo
1.0
n = 701 (547 events)
0.8
HR = .83 [97.5% CI .72–.95]
P = .0023
0.6
0.4
0.2
8.0
9.4
0
0
5
10
15
20
25
Months
Courtesy of Leonard Saltz, MD.
Slide 26 of 50
1st-Line Bevacizumab in Metastatic
Colorectal Cancer
Progression-Free Survival
PFS or TTP (Months)
Hurwitz1
12
Saltz2
(NO16966)
10.6
Fuchs3 (BICC-C)
11.2
9.4
10
8.0
8
8.3
7.6
6.2
5.9
6
4
2
0
L
IF
L
IF
m
m
LF
FO
+
IR
B
B
ev
X
O
LF
X
O
LF
ev
I+
I
FO
X/
IR
LO
ev
FO
X/
B
LO
+
LF
FO
XE
XE
L
IF
L
IF
/B
ev
1. Hurwitz H, et al. N Engl J Med. 2004;350:2335. 2. Saltz L, et al. 43rd ASCO; June 1-5, 2007. Abstract 4028.
3. Fuchs C, et al. 43rd ASCO; June 1-5, 2007. Abstract 4027.
Slide 27 of 50
Bevacizumab Safety and Usage Guidelines
• Cardiovascular events
– Hypertension (60%–67%; severe, 7%–10%)1
 ACE inhibitors, beta blockers, diuretics, calcium channel
blockers
 Discontinue permanently for severe crisis
 Discontinue temporarily if severe hypertension uncontrolled
with medications
– Thromboembolic (TE) events (3.8%)2
 Do not use if arterial TE <6 mo, or if active cardiovascular
disease
 Give to >65 years of age (a relative risk)
1. Avastin (bevacizumab). Package insert. Genentech BioOncology; 2004.
2. Skillings J, et al. ASCO; May 13-17, 2005. Abstract 3019.
Slide 28 of 50
Bevacizumab Safety and
Usage Guidelines
• Bleeding (grade 3/4 in 4% of patients with
resected primary)1
– Avoid in patients with central nervous system
metastases, lung metastases with central cavitation
or hemoptysis, bleeding diathesis/coagulopathy
– Safe in patients with primary colorectal cancer in
place without active bleeding
1. Kopetz J, et al. GI ASCO; January 26-28, 2006. Abstract 243.
Slide 29 of 50
Bevacizumab Safety and Usage Guidelines
• Gastrointestinal (GI) perforations (1% with resected
primary; 6% with unresected primary)1
– Careful use in patients with abdominal carcinomatosis, GI
perforation/abdominal fistula/intra-abdominal abscess <6 mo
– Use with caution in patients with acute diverticulitis, obstruction,
history of abdominal/pelvic XRT
– Wait >6–8 weeks after major surgery/invasive GI procedure
before using
• Surgical wound healing complications
– Careful use in patients <28–56 days after surgery, nonhealing
wound/ulcer/fracture, anticipated major surgery
– Delay elective surgical procedures (hold bevacizumab >6 weeks
preoperatively)
1. Kopetz J, et al. GI ASCO;January 26-28, 2006. Abstract 243.
Slide 30 of 50
EGFR Activation Mediates Several
Processes
Available at http://commons.wikimedia.org/wiki/Image:EGFR_signaling_pathway.png
Slide 31 of 50
1st-Line Cetuximab in Metastatic
Colorectal Cancer
CRYSTAL
R
A
N
D
O
M
I
Z
E
FOLFIRI
n = 599
FOLFIRI + Cetuximab
n = 599
FOLFIRI
FOLFIRI +
Cetuximab
Hazard/
Odds
Ratio
Median PFS (mo)
8.0
8.9
0.85
1-year PFS (%)
23
34
Response rate (%)
39
47
% underwent surgery
with curative intent
2.5
6
P Value
.048
.004
3.0
.003
Van Cutsem E, et al. 43rd ASCO; June 1-5, 2007. Abstract 4000.
Slide 32 of 50
Randomized, Open-Label, Controlled Phase
IIIb Trial of Panitumumab in MCRC–PACCE
Ox-CT
(eg, FOLFOX)
Investigator’s
choice of
oxaliplatinor
irinotecanbased
chemotherapy
Iri-CT
(eg, FOLFIRI)
1:1
R
A
N
D
O
M
I
Z
E
1:1
Panitumumab
6 mg/kg q2wk +
ox-CT +
bevacizumab
n = 413
Ox-CT +
bevacizumab
n = 410
Panitumumab
6 mg/kg q2wk +
iri-CT +
bevacizumab
n = 115
Iri-CT +
bevacizumab
n = 115
Stratification factors: ECOG score, prior adjuvant therapy, disease site, oxaliplatin
doses/irinotecan regimen, number of metastatic organs
Tumor assessments: q12wk until disease progression or intolerability
Courtesy of Randy Hecht, MD.
Slide 33 of 50
PACCE Trial of Panitumumab
Efficacy by Central Review
Bev +
Ox-CT
(n = 410)
%
Pmab+
Bev +
Iri-CT
(n = 115)
%
Bev +
Iri-CT
(n = 115)
%
45
46
40
37
Complete response
0
<1
0
0
Partial response
45
45
40
37
29
34
26
36
9.5 m
11 m
10.6 m
10.7 m
Best ORR
Stable disease
Median PFS
Pmab+
Bev +
Ox-CT
(n = 413)
%
Pmab = panitumumab; Bev = bevacizumab; Ox-CT = oxaliplatin-based chemotherapy (eg, FOLFOX); IriCT = irinotecan-based chemotherapy (eg, FOLFIRI); ORR = overall response rate; PFS = progression-free
survival.
Courtesy of Randy Hecht, MD.
Slide 34 of 50
Phase III Trial of Cetuximab,
Bevacizumab, and FOLFOX/FOLFIRI
CALGB/SWOG 80405
• 1st-line
metastatic
colorectal
cancer
• Planned
accrual:
2289
R
A
N
D
O
M
I
Z
E
FOLFOX or FOLFIRIa +
bevacizumab
FOLFOX or FOLFIRIa + cetuximab
FOLFOX or FOLFIRIa +
cetuximab + bevacizumab
aPhysician-selected
chemotherapy.
Stratification based on chemotherapy, prior adjuvant chemotherapy, prior pelvic RT.
US NIH Clinical Trials Database. http://www.clinicaltrials.gov/ct2/show/NCT00265850?term=80405&rank=1.
Slide 35 of 50
EGFR Inhibitor–Induced Skin Reactions
Acne-like rash
Postinflammatory effects
Dry skin
Fissures
Paronychia
Pruritus
1
2
3
4
5
6
7
8
9
Description
of severe cases
THERAPY SUGGESTIONS
Topical anti-acne
creams (drying effect)
+/- tetracyclines
+/- antihistamines
Slide courtesy of Eric Van Cutsem, MD, PhD.
Pulse dye
laser
Emollients
Hydrocolloid
dressing
Antiseptic
soaks
or
Silver nitrate
(pyogenic
granuloma)
Propylene
glycol+/acetylsalicylate
Case Continues
• The patient enrolls in CALGB/SWOG 80405
• Her physician chooses FOLFOX, and she is
randomized to bevacizumab-only arm
– She tolerates it fairly well
• Her initial scans show stable disease
• After 7 months, her disease shows progression
with increased liver metastases and several
<1-cm lung nodules
Slide 37 of 50
Question 4
What treatment would you offer the
patient now?
a)
FOLFIRI + bevacizumab
b)
Irinotecan + cetuximab
c)
Irinotecan + cetuximab + bevacizumab
d)
Clinical trial
Slide 38 of 50
BRiTE Registry—Patients with Bevacizumab
Beyond Progression (BBP)
No
postPD Rx
(n =
253)
No
BBP
(n =
531)
BBP
(n =
642)
Number of
deaths (%)
168
(66%)
306
(58%)
260
(41%)
Median OS
(mo)
12.6
19.9
31.8
1-year (%)
survival
rate
52.5
77.3
87.7
Median
survival
beyond
1st PD
(mo)
3.6
9.5
19.2
Evaluable patients
on 1st-line bevacizumab
(n = 1953)
1st Progression
(n = 1445)
Physician decision—no randomization
No post-PD
Rx
(n = 253)
No BBP
(n = 531)
BBP
(n = 642)
PD = progressive disease; BBP = bevacizumab beyond 1st
progression.
Courtesy of Axel Grothey, MD.
Slide 39 of 50
2nd-Line Cetuximab
BOND Trial
Patients
progressed
on or within
3 months of
irinotecan
R
A
N
D
O
M
I
Z
E
Cetuximab
n = 111
Irinotecan + cetuximab
n = 218
Response
(%)
TTP
Median
OS
Cetuximab
11
1.5 m
6.9 m
9
2
Irinotecan +
cetuximab
23
4.1 m
8.6 m
5
22
Cunningham D, et al. N Engl J Med. 2004;351:337.
Grade 3/4
Rash (%)
Grade 3/4
Diarrhea
(%)
Slide 40 of 50
Panitumumab Registration Trial
Patients
progressed on
fluoropyrimidine,
oxaliplatin, and
irinotecan
R
A
N
D
O
M
I
Z
E
Panitumumab + best
supportive care (BSC)
n = 231
BSC
n = 232
Reprinted from Van Cutsem E, et al. J Clin Oncol. 2007;25:1658-1664, with permission
from the American Society of Clinical Oncology.
Panitumumab
n = 176
Slide 41 of 50
Antibody Combination
BOND-2
Patients
progressed on
or within 3
months of
irinotecan
No prior
bevacizumab
R
A
N
D
O
M
I
Z
E
Cetuximab +
bevacizumab
n = 40
Irinotecan + cetuximab +
bevacizumab
n = 43
Response
Rate (%)
Time to
Progress
Grade 3/4
Rash (%)
Grade 3/4
Diarrhea
(%)
Cetuximab +
bevacizumab
20
4.9 m
20
0
Cetuximab +
bevacizumab +
irinotecan
37
7.3 m
21
28
Saltz LB, et al. J Clin Oncol. 2007;25:4557.
Slide 42 of 50
Phase III Trial of Irinotecan/FOLFIRI +
Cetuximab ± Bevacizumab
in Patients with Relapsed MCRC
S0600/iBET
Previously
treated patients
with metastatic
colorectal
cancera
(N = 1260)
R
A
N
D
O
M
I
Z
E
Irinotecan or FOLFIRI + cetuximab
+
placebo
(q2–3wk)
Irinotecan or FOLFIRI + cetuximab
+
bevacizumab
(5 mg/kg q2–3wk)
Irinotecan or FOLFIRI + cetuximab
+
bevacizumab
(10 mg/kg q2–3wk)
Primary endpoint: OS
Secondary endpoint: PFS
iBET = Intergroup Bevacizumab Continuation Trial.
aPatients progressed on FOLFOX, OPTIMOX, or XELOX + bevacizumab in 1st-line.
http://clinicaltrials.gov/ct/show/NCT00499369?order=1. Accessed May 2008.
Slide 43 of 50
Question 5
The patient was favoring irinotecan and
cetuximab but read in the newspaper that
her tumor should be tested first to see if it
will respond to cetuximab.
Which of the following markers may predict a
response to EGFR monoclonal antibody therapy?
a) EGFR staining by immunohistochemistry
b) K-ras mutational analysis
c) VEGF levels in the blood
d) EGFR mutational analysis
Slide 44 of 50
Predictors of Response to Monoclonal
EGFR Inhibitors
• Patients with tumors that have K-ras mutations
may not benefit from cetuximab or panitumumab
• Other potential predictors
– Skin toxicity
– Amphiregulin and epiregulin
• Not predictors
– EGFR staining on immunohistochemistry
– EGFR mutations (rare in colorectal cancer)
Slide 45 of 50
K-ras and Cetuximab
Progression-free survival with
single-agent cetuximab in laterline metastatic colorectal cancer1
Cetuximab + irinotecan after
irinotecan progression2
1. Reprinted from Khambata-Ford S, et al. J Clin Oncol. 2007;25:3230-3237, with permission from the
American Society of Clinical Oncology.
2. Reprinted from Lievre A, et al. J Clin Oncol. 2008;26:374-379, with permission from the
American Society of Clinical Oncology.
Slide 46 of 50
K-ras and Panitumumab
K-ras Mutation
Wild-Type K-ras
Courtesy of Eric Van Custem, MD, Segaert and Van Cutsem. Ann Oncol. 2005.
Slide 47 of 50
1st-Line Cetuximab and K-ras Status
CRYSTAL Trial
R
A
N
D
O
M
I
Z
E
Median Progression-Free Survival
n = 599
FOLFIRI
FOLFIRI + Cetuximab
n = 599
All
patients
K-ras
wildtype
K-ras
mutant
FOLFIRI
8.0 m
8.7 m
8.1 m
FOLFIRI + Cetuximab
8.9 m
9.9 m
7.6 m
P value
.046
.02
.47
Van Cutsem E, et al. ASCO 2008. J Clin Oncol. 2008;26(suppl):abstract 2.
Slide 48 of 50
Phase III Trial of Cetuximab,
Bevacizumab, and FOLFOX/FOLFIRI
CALGB/SWOG 80405
• 1st-line
metastatic
colorectal
cancer
• Wt K-ras
• Planned
accrual: 2600
aPhysician-selected
R
A
N
D
O
M
I
Z
E
FOLFOX or FOLFIRIa +
bevacizumab
FOLFOX or FOLFIRIa + cetuximab
FOLFOX or FOLFIRIa +
cetuximab + bevacizumab
chemotherapy.
Stratification based on chemotherapy, prior adjuvant chemotherapy, prior pelvic RT.
US NIH Clinical Trials Database. http://www.clinicaltrials.gov/ct2/show/NCT00265850?term=80405&rank=1.
Slide 49 of 50
Conclusions
• Lifestyle adjustments may impact
outcome from colorectal cancer
• Biologic agents have a role in advanced
disease but their place in the adjuvant
setting remains to be determined
• The era for individualized colorectal cancer
treatments is approaching
Slide 50 of 50