Colon cancer has undergone significant changes and has seen increasing treatment options. With more and more drugs available and approved for colon cancer we are facing difficult decisions deciding what is the right treatment at the right time.
For patients with newly diagnosed colon cancer we have two chemotherapeutic regimens: a combination of infusional 5-FU with irinotecan (FOLFIRI) or with oxaliplatin (FOLFOX). Both regimens have shown similar efficacy and similar extent of toxicity however there are differences in the quality of toxicity. More often FOLFOX has to be stopped because of its neurotoxicity than because it stopped working.
Dependiing where you are treated in the USA or somewhere else in the world, some prefer FOLFOX and some prefer FOLFIRI for many different reasons. In the USA FOLFOX is more common because of the North American CALGB 9741 study showing significantly more efficacy of FOLFOX compared to bolus 5-FU combined with irinotecan (IFL). However when FOLFIRI and FOLFOX were compared side by sidesite, there was no difference at all.
FOLFOX is sometimes prefered in patients with possible liver resection because of a study that showed less liver toxicity with FOLFOX compared to FOLFIRI.
In addition to FOLFOX and FOLFIRI we have antibodies, one against VEGF and two against EGFR. Since last year we have genetic tests available which can tell us if the antibodies against EGFR will work or not. We have no established markers for Avastin or the chemo cocktails. We have no promising candidates which are tested in clinical trials.
At the University of Southern California we are using biomarkers to decide whether FOLFOX or FOLFIRI are better therapies for an individual. Since both therapies are equal effective, we want to make the decision more rational rather than empiric. We also test the tumor for markers of angiogenesis to better understand what makes the tumor grow and metastasize. We are now testing tumors for all patients with metastatic colon and gastric cancer to make smarter treatment decisions.
One of the markers called ERCC-1 is now being part of the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of non-small cell lung cancer. We are running two clinical trials to validate these findings with the Southwest Oncology Group (SWOG). These tests are available for all patients and oncologists at ResponseGenetics.com and they will bill your insurance. Take advantage of this cutting edge technology.
Disclosure: Dr. Lenz is a consultant for Response Genetics.
October 28, 2009 at 3:13 am, Patsy White said:
Dr. Lenz:
I have written to you about my husband before and thank you for all your advice to me and others. He has been on 2nd line treatment Irinotecan, ERbitux and Avastin since Oct. 2007 with a break from Avastin which was added back in 2009. He had his colon reconnected in Feb 2009 and at that time cancer was still only in lungs and around aorta. After suffering in excruiating pain for 4 days because he was not being given his normal dosage of pain meds, he went into withdrawals. It has been downhill since. For months afterwards, his body would constantly shake then jerk in his sleep. He is finally better and only does it a little now. He has suffered from dehydration and low blood (lost 2 pts which they did not replace in hospital–was given some by our local dr. later) It has taken him 7 months to recover but his CEA has been going up ever since. This week we had CT scans for the first time since before his surgery and it showed that his spots in his lungs and his aorta have grown in size and that he now has a 2″ spot on his liver. Xeloda caused a lot of bad side effects and he was not able to take it. The dr. is going to put him back on Oxilaplatin which worked for him from FEb. 2007 to July 2007 (did not keep spots from growing on lungs however). If doesn’t work, going to add 5FU on pump and then add back Irinotecan as last resort. Was told by lung dr. and surgeon who reconnected colon and removed more of tumor from aorta that those tumors would not kill him that it would be spreading to other parts of the body. If that is the case, why is surgery (or whatever you can do) to take out the one spot on liver not possible. We were told only the above chemo available.
Do you know of other options that someone in his condition could do? I read Eric Pauls comments about all that he was doing for his liver tumor and was not told about these treatments. What do you think about the HAI pump and the other meds he is taking? Are these normally given to colon cancer patients with liver mets?
What do you think about studies that say Erbitux and AVastin should not be given today and can have negative results together?
Have you tried the VIT. K or aspirin to make treatments more effective? Davant?
I apologize for all the questions at one time but this news today reminded me that I have to get back researching. Feel like I should have asked for CT scans to be done sooner and we might would have seen spot on liver and made a treatment change before it got this large.
Stage IV Diagnosed 11/06, 6 of 16 LN, tumor embedded on abdominal aorta, Folfox w/Avastin from Feb 2007 until July 2007 when lung mets found, ERbitux/Irinotecan/Avastin Oct 2007 until Oct 2009 with low doses of Exeloda tried for last 3 months
Thank you again
Patsy White
October 28, 2009 at 3:17 am, Patsy White said:
In my last post, I meant to ask–What do you think about studies that say Erbitux and Avastin should not be given together and that given together they can have negative effects?
Thank you
Patsy
October 28, 2009 at 9:42 am, Heinz-Josef Lenz said:
Dear Patsy, as you can imagine it is not easy to make specific treatment recommendation based on this limited information not seeing the CT scan,laboratory results and so on. I have many patients i treated successfully with irinotecan and erbitux and avastin……so that is a great combination for some patients and appears to have worked for quite a while for your husband. If the tumors are now growing based on the CT scan, you should discuss other treatment options which include clinical trails available for your husband. if cancer is in lung and liver usually we prefer systemic chemotherapy and not local therapies such as intrahepatic therapies or surgical resection. It may behelpful to talk to your oncologists and see what he offers you and may consider a second opinion in a cancer center which offers clinic trials. Hope this helps
November 04, 2009 at 11:51 pm, Linda Stout said:
Dr. Lenz, what is your opinion about this Molecular Profiling Test? Have you used it with any success on any of your patients?
http://www.carisdx.com/pages/targetNow/targetNow.html
Thank you,
Linda
November 06, 2009 at 8:33 pm, Heinz-Josef Lenz said:
molecular profiling is the future…..however there are many companies offering testing but not all tests have similar predictive value. for example immunohistochemistry is difficult and is not shown to predict reliable efficacy so far only ER and PR are used all others have controversial findings. for kras this is an accpeted test. about others we prefer mRNA expression which has shown some promising value and are not included in the NCCN guidelines to be considered and promising
November 14, 2009 at 6:26 pm, Susan said:
I was dx’ed stage 4, mets to the liver, in May ’07, started folfox, erbitux, and avastin (leg 3 of CALGB 80405.) In Jan. ’08 colon and liver resected with “intent to cure”, followed by 6 months folfox and avastin, followed by another 6 months of avastin only. Clear scans until Oct. ’09, an 8mm x 11mm lesion in the liver. My onc. has started me on irinotecan and erbitux, and the surgeon will ablate the lesion in the near future. Do I still have a chance of cure? Susan
December 19, 2009 at 9:18 am, Lynn said:
My 81 year old father has metastasized colon cancer. He was on his 5th chemo tx and because very sick and hospitalized. Was found to have a staph infection in his blood and a severe kidney infection all of which caused severe diarrhea and vomiting. Surgery was done to see if he had a blockage in his colon and due to adhesions his colon was matted together and the surgeon was unable to anything and that he had 2 months to live. He had no bowel movement and nothing by mouth for the next two days and then he sent home. He has been eating popsicles and ice and after 4 weeks of this he had his first bm. Dr says the blockage may have moved. He was told if he ate any solid food it would make his cancer spread. The exact words from the doctor were ” its like adding fuel to the flame”. So, he has not been allowed to eat any food. So, therefore he is dying from malnutrition and by the way, a biopsy was done on his colon and it came back scar tissue. He is getting hungry but from what the doctor said he is afraid to because he doesn’t want to be in any pain. He has not been in any pain at all since leaving the hospital. He has not had any nutrients since Oct 11 and it is now Dec. Why can’t he eat something, anything? He is tired of anything sweet and will not eat his popsicles anymore so he is getting nothing but ice and water for the past 2 weeks.