treating late stage colorectal cancer dr. saltz
DESCRIPTION
Dr Leonard Saltz presents the July 2012 Fight CRC Webinar - Despite great strides in cancer research, the fact remains that there is still no cure for stage IV (metastatic) disease. There are promising treatment options for patients with late stage disease, but far too many patients will still hear their doctors say, "We are running out of options."TRANSCRIPT
Welcome!
Treating Late Stage Colorectal Cancer Part of Fight Colorectal Cancer’s Monthly Patient Webinar Series
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Fight Colorectal Cancer
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Fight Colorectal Cancer
www.FightColorectalCancer.org877-427-2111
Dr. Leonard SaltzMemorial Sloan Kettering Cancer Center
Chief, Gastrointestinal Oncology
Understanding Colorectal Cancer Treatment Options
Leonard B. Saltz, MD
Chief, Gastrointestinal Oncology
Memorial Sloan Kettering Cancer Center, New York, NY
Disclosures• I have consulted for and/or have research
supported by:
• Roche/Genentech• Bristol Myers Squibb• Imclone• Bayer• Merck• Biothera• Novartis• Sanofi• Immunomedex• Lorus• Morphotek
Overview
• Understanding the language
• Standard chemotherapy options
• Toxicities and quality of life
• New agents
• Life after standard chemo
Terms Requiring Definitions
• Cure• Overall Survival• Median Overall Survival• Progression-free Survival• Response• Stable Disease• Antitumor activity, Benefit• Progression of Disease
Other terms
• “significantly better” – does not necessarily equal:
“substantially better”
• “statistically significantly better”– Does not necessarily equal:
“clinically significantly better”
Anatomy of the Large Intestine
Staging of Colorectal Cancer (CRC)
• Stage I: Not full thickness
• Stage II: Full thickness
• Stage III: Positive nodes
• Stage IV: Distant mets
Colorectal Cancer Cure Rate
• Stage I 95%
• Stage II 80%
• Stage III 65% +
• Stage IV <10%
Intent of Therapy
• Curative
• Adjuvant
• Neo-Adjuvant
• Palliative
Chemotherapy for Metastatic
Disease
1996: Drugs Available for CRC
• 5-FU (5-Fluorouracil)
2012: Drugs Available for CRC
• 5FU (5-Fluorouracil)• Camptosar (Irinotecan)• Eloxatin (Oxaliplatin)• Xeloda (Capecitabine)• Erbitux (Cetuximab)• Avastin (Bevacizumab)• Vectibix (Panitumumab)
– Aflibercept (anticipated late 2012)– Regorafenib (anticipated late 2012)
Combination Chemotherapy for CRC
Anatomy of the “FOLFs”• FOL = folinic acid (a.k.a. leucovorin)• F = 5FU (5-fluorouracil)• OX = oxaliplatin (Eloxatin)
= FOLFOX
• FOL = folinic acid (a.k.a. leucovorin)• F = 5FU (5-fluorouracil)• IRI = irinotecan (Camptosar)
= FOLFIRI
FOLFIRI vs. FOLFOX
Efficacy of First Line Regimen
Tournigand et al, JCO 2004
p=0.9 21.5 m 20.4 mOS
p=0.65 8.1 m 8.5 mPFS
p=0.68 54% 56%RR
FOLFOXFOLFIRI
Oral Chemotherapy
Cautionary Notes
• Just as likely to have side effects as i.v. chemo
• No convenience benefit unless all drugs taken are oral
• Requires a highly motivated patient capable of assuming substantial responsibility
• Difficult if nausea, vomiting, or diarrhea are present or expected
Anti-AngiogenesisThe Angiogenic Switch
1-2 mm
Angiogenic
Switch
Small tumor• Nonvascular• “Dormant”
Larger tumor• Vascular• Metastatic potential
........................
.... ..... .... .....
........................
.... .....
........................
........................
........................
Maturation factors present
Normal and Tumor Blood Vessels
Normal Blood Vessels Tumor Blood Vessels
Reduced integrin expression
Less dependent on cell survival factors
.... ..... Less permeable
Leaky
Preferential expression of v3 v5 & 51
integrins
Fewer pericytes
Growth and survival factors (eg, VEGF)
present
.... .....
Supporting pericytes present
Phase III IFL +/- Avastin in Metastatic
Colorectal Cancer
IFL + Placebo (n = 412)
IFL + Avastin(n=403) P Value
Median overall survival 15.6 m 20.3 m 0.00003
Median Progression-Free Survival
6.2 m 10.6 m <0.00001
Response Rate 35% 45% 0.003
Hurwitz et al.. NEJM 2004
Bevacizumab: Safety concerns
• Gastrointestinal perforation
• Arterial thrombotic events
EGF Receptor Signaling Transduction
MAPK
MEK
Gene TranscriptionCell Cycle Progression
M
G1S
G2
PI3-K
RAS RAF
SOS
GRB2
PTEN AKTSTAT
R
KpY
R
pY
pY
K
Proliferation / Maturation
Survival / Apoptosis
Angiogenesis Metastasis
Cetuximab + Irinotecan)Independent Radiology Review
Irinotecan-Refractory Patients, n=120 (Saltz et al: ASCO 2001)
PR 27 (22.5%) (95% C.I. 15%-31%)SD 9 ( 7%) (minimum 12 weeks)
• Median Dur. of response (n=27): 186 days• Investigator-reported PR= 23 (19%)
Single Agent Cetuximab: Investigator-Reported Response Rate (n=57)
(Saltz et al, JCO 2004)
• PR = 6 (10.5%, 95% CI 4%-22%)• SD = 21 (37%)
– Minimum 12 weeks required for stable disease.
• Independent review confirmed 5 PR’s, for response rate of 8.8%.
“BOND” Trial
• Randomized Phase II trial in Irinotecan-refractory CRC
• Cetux + Irinotecan versus Cetux• 2:1 randomization, 300 pts• 1o endpoint: response rate
Bond Trial: Results(Cunningham et al, NEJM 2004)
Cetux + Irino Cetux
RR 22.9% 10.8%
PFS 4 m 1.6 m
Cetux Trials in Refractory CRC
Response Rate
Cetux + CPT-11 (Saltz, ASCO 2001)
22.5%
Cetux + CPT-11 (Cunningham, NEJM 2004)
22.9%
Cetux (Saltz, JCO 2004)
10.5%
Cetux (Cunningham, NEJM 2004)
10.8 %
CRYSTAL Trialvan Cutsem et al: NEJM 2009
• Randomized phase III trial of first line FOLFIRI +/- weekly cetuximab.
• Measurable metastatic colorectal cancer
• 1217 patients randomized
CRYSTAL TRIAL: EfficacyVan Cutsem: ASCO 2007
FOLFIRI-Cetux
(n=599)
FOLFIRI(n=599)
P value
PFS 8.9 m 8.0 m 0.048
1 yr PFS 34% 23%
RR 47% 39% 0.0038
SD 37% 47%
DCR 84% 86%
Understanding KRAS
• Protein in the cell involved in transmitting signal from receptor on cell surface to the nucleus
• If the gene for KRAS is mutated, then the KRAS protein sends a signal regardless of whether there is a signal from the surface receptor or not
EGF Receptor Signaling Transduction
MAPK
MEK
Gene TranscriptionCell Cycle Progression
M
G1S
G2
PI3-K
RAS RAF
SOS
GRB2
PTEN AKTSTAT
R
KpY
R
pY
pY
K
Proliferation / Maturation
Survival / Apoptosis
Angiogenesis Metastasis
Understanding KRAS
• If KRAS is mutated, Erbitux and Vectibix won’t work, and therefore are not used
• If KRAS is wild-type (non-mutated) then Erbitux or Vectibix might work
• Median overall survival benefit in trials with KRAS wild-type tumors is in range of 3-4 months
CRYSTAL Trial:PFS time by
skin reactions: cetuximab + FOLFIRI
Grade of Skin Rash
0-1 (none or mild)
2 (moderate)
3 (severe)
Progression-free survival 5.4 m 9.4 m 11.3 m
Some Other Toxicities
• Nausea / Vomiting
• Diarrhea
• Fatigue
• Neurotoxicity
MOSAIC: FOLFOX for Stage II – III Colon Cancer: Peripheral Sensory Neuropathy
Andre et al: JCO 2009%
of
trea
ted
pat
ien
ts
48.1
30.9
22.2
1412
8.8
31.4
7.24.2 2.9 1.7 2.1
12.5
1.4 1.2 0.5 0.5 0.50
10
20
30
40
50
60
During Tx 6 months 1 year 2 years 3 years 4 years
Grade 1
Grade 2
Grade 3
27.6 17.4 14.2 11.4
Neurotoxicity from Oxaliplatin• Cold sensitivity
• Numbness and tingling
• Loss of position sense
• Loss of fine motor skill
• Pain
What’s new?
Continuing Avastin
• TML trial shows that continuation of Avastin with 2nd line therapy improves median overall survival by 1.4 months
Aflibercept
• Adding aflibercept to second line FOLFIRI improves median overal survival by 1.5 months.
• Not clear that this offers any advantage over second line Avastin
• No evidence that Aflibercept by itself, or with chemo that has failed, has any benefit
Regorafenib vs Placebo
RegorafenibN=505
PlaceboN=255
Median Overall Survival 6.4 months 5.0 months
Partial Response 1% 0.4%
Stable Disease 43% 15%
DCR* 41.0 15%
*DCR = PR+SD (≥6 weeks after randomization)
Van Cutsem et al: Proc ASCO 2012
What can we do when we’ve used up the standard drugs?
Treatment options after standard care
• Clinical trials
• Supportive care / hospice care
Clinical Trials
• Phase I What is the highest tolerable dose and what are the side effects?
• Phase II Is it safe and active in a defined population?
• Phase III Is it better that standard care?
• Phase IV Post-marketing studies; variations on a theme.
Clinical Trials: Important Concepts:
• Informed consent
• Right to refuse/withdraw
• No hidden agendas
• No hidden placebos
Supportive care
• Important in ALL aspects of cancer care– Pain control– Emotional Support– Nutrition– Exercise– Discussions of end of life care preferences
Seductive Traps• The internet
• Alternative care
• Unproven drugs and procedures– (Beware the rhetorical “what harm could it do?”
A. Venook (Discussant) ASCO 2012
COST of
CARE
The Elephant in the Room
Average Selling Price (ASP) + 6% (about 5 yr old data)
(Patient assumption: 75 kg, 1.8 m2 patient, two weeks Rx)
• 5FU 500 mg/m2 $ 7• Leucovorin 500 mg/m2 $ 47• Xeloda 2000 mg/m2/d $ 1065• Camptosar 180 mg/m2 $ 2135• Eloxatin 85 mg/m2 $ 3296
• Avastin 5 mg/kg $ 2283• Erbitux 250 mg/m2 $ 4964
Impact on Cost of Care: back of the envelope
• Bevacizumab – $2864 per 400 mg vial*– Average weekly dose = 175 mg
• Regorafenib – Sorafenib $8377 / month
• Aflibercept– $$$ unknown
– A Venook, Discussant ASCO 2012
$$ per UCSF pharmacy
$$$ unknown
Cost of Bev beyond progression(Cost of only the bev; no MD, nursing, or pharmacy fees, no other meds)
• $2864 per 400 mg vial -> $7.16 per mg– 175 mg/week x 4.33 weeks/month = 758 mg/month – If vials are shared:
758 mg/month x $7.16/mg = $5427.28 per month,
x 5.7 months = $30,935.50 per patient treated
for 1.4 months OS benefit ->
$30,935.50 x 8.57 = $265,117 per year of life saved
– If vials not shared, then $2864 every 2 weeks for 24.7 weeks (5.7 months) -> $35,370.40 per patient treated
$35,935.40 x 8.57 = $303,124 per year of life saved
– (note: these are not Quality-adjusted)
Colorectal cancer in 2012: my reality check
• These are modest advances• A minority of patients appear to benefit• And the costs are unsustainable
THE CHALLENGE • Actually deliver on promise of personalized
medicine• To do so, we need better tools to predict
outcomes• And it must be affordable
A. Venook, ASCO Discussant 2012
Challenges
• Maintain optimism tempered by, and grounded in, reality
• Select therapies rationally
• Assure availability of appropriate therapies to all patients
Conclusions
• Treatment options for colon cancer patients are better than they were, but not as good as they need to be.
• Please consider participation in clinical trials when they are appropriate. Without your help, we can’t make the progress that we all so desperately need.
Fight Colorectal Cancer
www.FightColorectalCancer.org877-427-2111
Fight Colorectal Cancer
Funding Research DirectlyLisa Dubow Fund
http://fightcolorectalcancer.org/research/lisa-fund
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