Though the annual Gastrointestinal Cancer Conference (GI ASCO) looked very different compared to previous gatherings, where hundreds of the brightest scientists, clinicians, patient advocates, and industry partners gathered in San Francisco, the same group opened their computers and joined online from around the world from January 15-17, 2021.

Although meeting in person was impossible, the research forged ahead, exciting results were presented, and those in the field continued to engage with just as much energy as previous years.

There are many benefits for patients and caregivers if they attend conferences such as GI ASCO. You will find up-to-date info about diagnostics such as circulating tumor DNA, should chemo be given after surgery... do you even need surgery? How is the microbiome important to recurrence and what can you as a patient do to change your microbiome with diet? Is immunotherapy a treatment to consider? The most up-to-date information to guide a patient's treatment is seen in these conferences and well worth the time to investigate.

Karen Wehling, Stage IV Rectal Cancer Survivor, Fight CRC Research Advocate

What were some of the most exciting findings?

KEYNOTE-177 

Let’s start with KEYNOTE-177. This study continued to investigate the effectiveness of an immunotherapy drug called pembrolizumab in the first line setting. 

First-line setting refers to the initial treatment given.

At GI ASCO 2021, researchers wanted to further understand how pembrolizumab compared to chemotherapy plus bevacizumab (Avastin) or cetuximab (Erbitux) in the first line setting for patients with MSI-H colon and rectal cancer. Their findings were encouraging for patients with this biomarker!

1. Progression free survival (the amount of time a patient’s cancer does not grow or get worse after treatment) for patients on pembrolizumab was better than those on standard of care (SOC) chemotherapy.
2. Pembrolizumab was safer for patients with less treatment associated side effects
3. Patients on pembrolizumab reported greater quality of life than those on SOC chemo.

While this is great news, there are still some factors that need to be researched further. For example, there was a group of people with MSI-H tumors who didn’t initially respond to the therapy. Researchers still need to understand how people with different biomarkers, like BRAF V600e and KRAS/NRAS mutations respond and why.

This study is building on a drug already FDA approved, however more research will be presented at the American Society of Clinical Oncology (ASCO) conference in the summer of 2021. For now, this research is very encouraging for this subgroup of patients.

ctDNA research

Circulating tumor DNA, often referred to as ctDNA, was a big discussion topic this year. ctDNA is a type of DNA (genetic material) that is released from tumor cells when they die. Research has begun to show that ctDNA can be detected after treatment and can be used to predict if someone is at a higher risk for recurrence (their cancer returning).

One study at GI ASCO this year showed that ctDNA was actually better at detecting patients with stage I-III colorectal cancer who were likely to have a recurrence compared to monitoring carcinoembronic antigen (CEA) and radiological imaging, like CT scans.

• In this study, all individuals had surgery to remove their tumors. 
• After surgery, 80% of patients whose test showed that ctDNA was present had their cancer return. 
• Only 13% of those who did not have ctDNA present recurred.

This means patients in this study with ctDNA present were 11 times more likely to have their cancer return compared to those who did not have ctDNA detected.

One of the most important things to consider for patients is how to support those who receive a positive ctDNA test. Because ctDNA doesn’t currently drive treatment decisions, this can leave individuals with feelings of anxiety and fear, knowing that their cancer may return without any actionable steps. Understanding how organizations like Fight CRC and the scientific and clinical community can best support patients from a psychosocial angle is crucial.

Early-Age Onset CRC

This year, Early-Age Onset Colorectal Cancer (EAO CRC) had its own dedicated session aimed at understanding risk factors, disease cause, and quality of life factors. Research focused on a variety of areas such as:

• Understanding factors associated with longer survival in young-onset CRC and older-onset CRC. Researchers found that metastasectomy was the only factor associated with longer survival in both young adults and older adults, highlighting the importance of EAO CRC patients receiving as much resection of metastases as possible.

Metastactomy is the surgical removal of cancer that has metastasized or spread through the body.

• Investigating disparities between different minority racial/ethnic groups. Findings indicated that Non-Hispanic Blacks have worse 5-year survival rates compared to Non-Hispanic Whites and Hispanics.

• Discussing quality of life issues, including fertility preservation and the importance of having these conversations with young survivors early on in diagnosis.

• Tumor sidedness. Researchers found that EAO CRC is more likely to originate on the left side of the colon, and in metastatic disease, left-sided CRC is associated with better overall survival than right-sided CRC.

Learn more about the work Fight CRC is doing to advance research in EAO CRC!

COVID-19 and Health Disparities

Another prevalent theme this year was COVID-19 in cancer care and health disparities. 

Dr. Robert Winn from Virginia Commonwealth University delivered the Keynote presentation titled Old Disparities are New Again and described the intersection between health disparities and cancer in the time of a pandemic. Dr. Winn noted how far we’ve progressed in science and cancer research, but acknowledged that there is still a long way to go in bridging the gap between healthy outcomes in all communities.

Fight CRC’s research presented this year, titled Understanding the impact of COVID-19 on the colorectal cancer community: Barriers and opportunities for care, further highlighted the numerous health inequities that also exist among low-income and rural patient groups, and the unique challenges that people with colorectal cancer face as a result of COVID-19, including treatment disruptions, increased feelings of anxiety, and financial concerns.

Identifying barriers that patients face provides an opportunity to address the nuanced needs of the colorectal cancer community. Clinicians, supportive care providers, and advocacy organizations can work together to increase the quality and access to care, and prepare patients for the future with reliable and accurate resources during a pandemic.

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As an advocacy organization committed to relaying the latest research updates on our path to a cure, we will continue to provide the latest information that empowers our community. While the research still has a long way to go until a cure for CRC is reached, understanding updates such as these can empower our community of champions and ensure that patient needs stay front and center to the work.

If you missed Fight CRC’s webinar diving into this research, you can watch the recording here.

Additional Reading

Maia’s abstract choices: 

LEAP-005: A phase II multicohort study of lenvatinib plus pembrolizumab in patients with previously treated selected solid tumors—Results from the colorectal cancer cohort

The combination of lenvatinib (VEGFR1-3-3 inhibitor) and  pembrolizumab (anti PD-1, immunotherapy, Keytruda) shows  antitumor activity and it is safe in patients with previously treated, advanced MSS CRC (non–MSI-H/pMMR CRC).  The colorectal cohort was expanded to enroll 100 more patients more.

Phase II study evaluating trifluridine/tipiracil + bevacizumab and capecitabine + bevacizumab in first-line unresectable metastatic colorectal cancer (mCRC) patients who are noneligible for intensive therapy (TASCO1): Results of the final analysis on the overall survival.

Lonsurf (TAS-102) plus Avastin (bevacizumab) results in better survival than Xeloda (capecitabine) plus Avastin in mCRC patients who cannot tolerate harsher, first line standard of care chemotherapy treatment for the metastatic setting. 22.31 months vs. 17.67 months. This phase II trial will be followed by phase 3 SOLSTICE trial (NCT03869892) 

Phase II study of pembrolizumab plus capecitabine and bevacizumab in microsatellite stable (MSS) metastatic colorectal cancer (mCRC): Interim analysis.

Pembrolizumab (Keytruda) combined with capecitabine (Xeloda) and bevacizumab (Avastin) result tolerable for MSS mCRC) patients.  Regarding responses: PR, 8%; SD, 59%;  33%; PD.

The efficacy and safety of anlotinib in refractory colorectal cancer: A double-blinded, placebo controlled, randomized phase III ALTER0703 trial.

Anlotinib (AL3818), a multitarget kinase inhibitor (anti-angiogenic)  improves PFS in third-line setting of mCRC and beyond in patients who received 2 or more prior lines of chemotherapy: PFS of 4.14 months with anlotinib versus 1.45 months with placebo. OS had not significance. Phase 3 ALTER0703 (NCT02332499), in China.