A 68 year old..former teacher.... ESMO Preceptorship Programme - - PowerPoint PPT Presentation

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a 68 year old former teacher
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A 68 year old..former teacher.... ESMO Preceptorship Programme - - PowerPoint PPT Presentation

Apr 04, 2024 209 likes •512 views

ESMO Preceptorship Programme Colorectal Cancer Valencia 12-13 May 2017 Dirk Arnold Instituto CUF de Oncologia, Lisbon, Portugal A 68 year old..former teacher.... ESMO Preceptorship Programme Colorectal Cancer Valencia 12-13

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ESMO Preceptorship Programme

A 68 year old…..former teacher....

Dirk Arnold Instituto CUF de Oncologia, Lisbon, Portugal Colorectal Cancer– Valencia – 12-13 May 2017

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ESMO Preceptorship Programme

A 68 year old…..former teacher....

Dirk Arnold Instituto CUF de Oncologia, Lisbon, Portugal Colorectal Cancer– Valencia – 12-13 May 2017

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Disclosures

  • Participate on Advisory Board with:

Bayer, Merck, Roche, Lilly, sanofi, Servier, Sirtex, Terumo

  • Speaker and Chairman for educational events with:

Bayer, Merck, Lilly, Servier, Terumo

  • Investigator and researcher in data generating activities,

(partly) supported and sponsored by Bayer, Roche, Mologen

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Patient profile and presentation

Patient details

  • 68-year-old woman
  • Former teacher
  • Single
  • Enjoys hiking

Patient presented with

  • Constipation and weight loss
  • ECOG PS 0

Colonoscopy/biopsy

  • Adenocarcinoma in right

transversal colon Laboratory tests

  • CEA: 168ng/mL

CT scans

  • no distant metastases
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Initial management: Surgical procedure

  • Tumor near right flexure extended right hemicolectomy
  • Pathology:
  • pT3 N1 M0
  • 2 of 19 lymph nodes positive
  • RAS wild type
  • Post-operative CEA: 15 ng/ml
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Initial management: Surgical procedure

  • Tumor near right flexure extended right hemicolectomy
  • Pathology:
  • pT3 N1 M0
  • 2 of 19 lymph nodes positive
  • RAS wild type
  • Post-operative CEA: 15 ng/ml
  • Adjuvant treatment refused
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At 6 month follow-up visit: CT scan

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  • Tumor near right flexure extended right hemicolectomy
  • Pathology:
  • pT3 N1 M0
  • 2 of 19 lymph nodes positive
  • RAS wild type
  • Post-operative CEA: 15 ng/ml
  • Adjuvant treatment refused

Where are we now?

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Where are we now?

  • Tumor near right flexure extended right hemicolectomy
  • Pathology:
  • pT3 N1 M0
  • 2 of 19 lymph nodes positive
  • RAS wild type
  • Post-operative CEA: 15 ng/ml
  • Adjuvant treatment refused
  • Now relapsed within 6 months
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Where are we now?

  • Tumor near right flexure extended right hemicolectomy
  • Pathology:
  • pT3 N1 M0
  • 2 of 19 lymph nodes positive
  • RAS wild type
  • Post-operative CEA: 15 ng/ml
  • Adjuvant treatment refused
  • Now relapsed within 6 months
  • Hepatic, nodal and (suspected) peritoneal disease
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SLIDE 12

Where are we now?

  • Tumor near right flexure extended right hemicolectomy
  • Pathology:
  • pT3 N1 M0
  • 2 of 19 lymph nodes positive
  • RAS wild type
  • Post-operative CEA: 15 ng/ml
  • Adjuvant treatment refused
  • Now relapsed within 6 months
  • Hepatic, nodal and (suspected) peritoneal disease
  • CEA 223 mg/nl
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Where are we now?

  • Tumor near right flexure extended right hemicolectomy
  • Pathology:
  • pT3 N1 M0
  • 2 of 19 lymph nodes positive
  • RAS wild type
  • Post-operative CEA: 15 ng/ml
  • Adjuvant treatment refused
  • Now relapsed within 6 months
  • Hepatic, nodal and (suspected) peritoneal disease
  • CEA 223 mg/nl
  • No symptoms, medically fit
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Key questions in management of our patient

  • What is our treatment goal?
  • „Cure“  „palliative“  oligometastatic stabilization“?
  • Which treatment intensity is needed?
  • No treatment (yet)  mono  doublet  triplet
  • What is the best regimen then ??
  • Which chemotherapy? Which monoclonal antibody?
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  • What is our treatment goal?
  • „Cure“  „palliative“  oligometastatic stabilization“?
  • Which treatment intensity is needed?
  • No treatment (yet)  mono  doublet  triplet
  • What is the best regimen then ??
  • Which chemotherapy? Which monoclonal antibody?

Key questions in management of our patient

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  • What is our treatment goal?
  • „Cure“  „palliative“  oligometastatic stabilization“?
  • Which treatment intensity is needed?
  • No treatment (yet)  mono  doublet  triplet
  • What is the best regimen then ??
  • Which chemotherapy? Which monoclonal antibody?

Key questions in management of our patient

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  • What is our treatment goal?
  • „Cure“  „palliative“  oligometastatic stabilization“?
  • Which treatment intensity is needed?
  • No treatment (yet)  mono  doublet  triplet
  • What is the best regimen then ??
  • Which chemotherapy? Which monoclonal antibody?

Key questions in management of our patient

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Memory: Some factors that may impact

  • n our decision making
  • Relapse within 6 months
  • Primary at right flexure, UICC III
  • RAS wild type
  • Medically fit, no comorbidities
  • Adjuvant treatment refused
  • Liver mets and lymph nodes enlarged
  • Suspected peritoneal carcinomatosis
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Memory: Some factors that may impact

  • n our decision making
  • Relapse within 6 months
  • Primary at right flexure, UICC III
  • RAS wild type
  • Medically fit, no comorbidities
  • Adjuvant treatment refused
  • Liver mets and lymph nodes enlarged
  • Suspected peritoneal carcinomatosis
  • BRAF wild type
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Start with FOLFOX/bevacizumab CT scans at 5.5 months

  • “Minor response” (stable disease

according to RECIST)

  • No tumour-related symptoms
  • CEA normalized
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What change would suggest? – Continue bevacizumab plus 5-FU/LV and discontinue

  • xaliplatin

– Continue bevacizumab alone and discontinue FOLFOX – Switch from FOLFOX to FOLFIRI – Stop all treatment – Role of local treatment (liver)?

Treatment decision after 5.5 months FOLFOX-bevacizumab and mild neuropathy (2°)

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What change would suggest? – Continue bevacizumab plus 5-FU/LV and discontinue

  • xaliplatin

– Continue bevacizumab alone and discontinue FOLFOX – Switch from FOLFOX to FOLFIRI – Stop all treatment – Role of local treatment (liver)?

Treatment decision after 5.5 months FOLFOX-bevacizumab and mild neuropathy (2°)

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What change would suggest? – Continue bevacizumab plus 5-FU/LV and discontinue

  • xaliplatin

– Continue bevacizumab alone and discontinue FOLFOX – Switch from FOLFOX to FOLFIRI – Stop all treatment – Role of local treatment (liver)?

Treatment decision after 5.5 months FOLFOX-bevacizumab and mild neuropathy (2°)

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AIO: Arnold, et al. ASCO 2014; Hegewisch-Becker et al., Lancet Oncol 2015 DCCG: Koopman, et al., ASCO 2014; Simkens et al., Lancet 2015

De-escalation maintenance strategies: Progression-free survival (PFS)

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AIO: Arnold, et al. ASCO 2014; Hegewisch-Becker et al., Lancet Oncol 2015 DCCG: Koopman, et al., ASCO 2014; Simkens et al., Lancet 2015

De-escalation maintenance strategies: Overall survival (OS)

HR nihil vs. FP/Bev: exploratory, n.s. HR nihil vs. FP/Bev: 0.83; p=0.06

Median OS: 18.1 vs. 21.6 mos (+3.5 mos.)

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Maintenance with Bevacizumab and/without FP: Combined analysis; update

Arnold et al., ASCO 2016 (oral presentation) Stein et al., Clin Colorectal Cancer 2016

PFS OS

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0. 10. 20. 30. 40. 0. 10. 20. 30. 40. FP/Bev. Bev. Ø.Tx. Patientenanzahl in % (Mittelwert1) Patientenanzahl in % (Mittelwert1)

@ wk 24: % of patients with at least 10 IP „overall HRQoL“ improvement @ wk 24: % of patients with at least 10 IP „overall HRQoL“ deterioration

Quidde et al., Ann Oncol 2016

AIO 0207: Quality of life analyses

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Thank you for listening

Dirk Arnold

Instituto CUF de Oncologia Lisboa, Portugal

dirk.arnold@jmellosaude.pt