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Role adjuvant chemotherapy in this setting will change significantly with incorporation of MRD evaluation post-surgery with prospective validation.
ASCO convened an Expert Panel to conduct a systematic review of relevant studies and develop recommendations for clinical practice.
Twenty-one observational studies and six randomized controlled trials met the systematic review inclusion criteria.
Adjuvant chemotherapy (ACT) is not routinely recommended for patients with stage II colon cancer who are not in a high-risk subgroup. Patients with T4 tumors are at higher risk of recurrence and should be offered ACT, whereas patients with other high-risk factors, including sampling of fewer than 12 lymph nodes in the surgical specimen, perineural or lymphatic invasion, poorly or undifferentiated tumor grade, intestinal obstruction, tumor perforation, or grade BD3 tumor budding, may be offered ACT. The addition of oxaliplatin to fluoropyrimidine-based ACT is not routinely recommended, but may be offered as a result of shared decision making. Patients with mismatch repair deficiency/microsatellite instability tumors should not be routinely offered ACT; if the combination of mismatch repair deficiency/microsatellite instability and high-risk factors results in a decision to offer ACT, oxaliplatin-containing chemotherapy is recommended. Duration of oxaliplatin-containing chemotherapy is also addressed, with recommendations for 3 or 6 months of treatment with capecitabine and oxaliplatin or fluorouracil, leucovorin, and oxaliplatin, with decision making informed by key evidence of 5-year disease-free survival in each treatment subgroup and the rate of adverse events, including peripheral neuropathy
No oxaliplatinum in stage 2 colon cancer, even high-risk patients, by the way, De Gramont is one of the authors (father of FOLOFX reigmens).
There is more movement towards using time to relapse as an endpoint for adjuvant studies. This report highlights that there is still a role for oxaliplatin in older patients with Stage III CRC. The time to relapse was not significantly different in patients who are younger vs older. TTR is suggested as a more informative endpoint as older patients uniformly have a lower DFS and OS in most trials.
Epi and nivo for mismatch repair-deficient (dMMR) colon cancer had 98% response rate with 68% complete response, non-recurred with a median of follow up of 26 months. Does this mean bye-bye surgery??? Probably. We will need to assess those who have complete response and have a close follow up. CtDNA may play big role here, along with a need for randomized trials.
COLOXIS is an interesting computer-based learning model that seems to be able to predict which patients are likely to benefit from adjuvant chemotherapy in colorectal cancer. This, along with ctDNA tests, may change whom we choose to offer adjuvant chemotherapy.
Negative study for the use of HIPEC in the adjuvant setting of high-risk or locally advanced colorectal cancers, including those with perforation and peritoneal invasion. HIPEC doesn’t seem to reduce the risk of peritoneal recurrence after potentially curative resection.
FCS Hematology Oncology Review creates a platform for our physician network to observe the most recent articles and studies available in the oncology and hematology world. By sharing these articles we are building our wealth of knowledge of new observations and treatments as they come available.
