Evaluation of FOLFOX or CAPOX reintroduction with or without bevacizumab in relapsed colorectal cancer patients treated with oxaliplatin as adjuvant chemotherapy (REACT study)

Differences in prognosis and underuse of adjuvant chemotherapy between elderly and non-elderly patients in stage III colorectal cancer

Aim

We aimed to clarify the use of adjuvant chemotherapy and the prognosis of elderly colorectal cancer patients compared with non-elderly patients, and the usefulness of sarcopenia as an indicator for the introduction and completion of adjuvant chemotherapy.

Methods

Between 2013 and 2021, 215 patients with pStage III disease were included. We investigated perioperative clinicopathological factors, adjuvant chemotherapy details, and prognosis. Preoperative sarcopenia status was evaluated using computed tomography images. Elderly patients were defined as those aged ≥70 years.

Results

We included 121 (56.3%) and 94 (43.7%) non-elderly and elderly patients, respectively. Among the elderly patients, 47 had sarcopenia. There were no significant differences in the incompletion rate of adjuvant chemotherapy between elderly and non-elderly patients (27.1%/16.2%, P = 0.119). The most common reason for the discontinuation of adjuvant chemotherapy was side effects, regardless of age. The respective 3-year-disease free survival of patients with no/completed/incomplete adjuvant chemotherapy were 65.5%, 80.2%, and 57.7% for non-elderly patients (P = 0.045) and 73.4%, 70.6%, and 71.6% for elderly patients (P = 0.924). The number of elderly patients with sarcopenia was significantly higher in patients without adjuvant chemotherapy (P = 0.004) and those with incomplete adjuvant chemotherapy (P = 0.004). The 3-year-disease free survival of elderly sarcopenic patients without and with adjuvant chemotherapy were 78.3% and 59.2%, respectively (P = 0.833).

Conclusion

Elderly patients did not show a benefit of adjuvant chemotherapy regardless of whether they had completed adjuvant chemotherapy, unlike non-elderly patients. Moreover, the evaluation of preoperative sarcopenia in elderly colorectal cancer patients may be useful in determining the indication for adjuvant chemotherapy.

Efficacy of Retreatment with Oxaliplatin-Based Regimens in Metastatic Colorectal Cancer Patients: The RETROX-CRC Retrospective Study

Background: oxaliplatin with fluoropyrimidine is a “mainstay” regarding the upfront treatment of metastatic colorectal cancer (mCRC). In contrast, the efficacy and safety of oxaliplatin-based regimens in late-care settings have been poorly reported. Methods: we identified a real-world mCRC patient cohort who were re-treated with oxaliplatin, and in which clinicopathological features were retrospectively analyzed to identify efficacy–predictive determinants (RETROX-CRC study). Results: of 2606 patients, 119 fulfilled the eligibility criteria. Oxaliplatin retreatment response rate (RR) and disease control rate (DCR) were 21.6% (CI 14.4–31.0%), and 57.8% (CI 47.7–67.4). A trend towards better RR and DCR was observed among patients who had first oxaliplatin in an adjuvant setting; a poorer outcome was observed if two or more intervening treatments were delivered. Median progression-free survival (PFS) was 5.1 months (95%CI 4.3–6.1), reducing to 4.0 months (95%CI 3.07–5.13) if oxaliplatin was readministered beyond third-line (HR 2.02; 1.25–3.25; p = 0.004). Safety data were retrieved in 65 patients (54.6%); 18.5% (12/65) and 7.7% (5/65) had G3–4 toxicities. Toxicities led to discontinuation in 34/119 (28.6%). Conclusions: oxaliplatin retreatment produced further RR in around one-fifth of patients and DCR 57.8%. Efficacy decreased in more pre-treated patients and around one-third of patients discontinued treatment due to adverse events. Translational studies improving patient selection are warranted.

Phase II study of an oxaliplatin-based regimen for relapsed colon cancer patients treated with oxaliplatin-based adjuvant chemotherapy (INSPIRE study)

Background

The aim of this study was to evaluate the efficacy and safety of first-line chemotherapy with re-introduction of oxaliplatin (OX) more than 6 months after adjuvant chemotherapy including OX.

Methods

Stage II/III colon cancer patients with neuropathies of grade ≤ 1 who relapsed more than 6 months after adjuvant chemotherapy including OX were considered eligible. Eligible patients were treated with 5-fluorouracil, l-leucovorin and OX plus molecularly targeted agents or capecitabine and OX plus bevacizumab (BV) or S-1 and OX plus BV. The primary endpoint was the progression-free survival (PFS), and the secondary endpoints were the overall survival (OS), response rate (RR) and toxicity.

Results

A total of 50 patients were enrolled between September 2013 and May 2019. Twelve patients received 5-fluorouracil, l-leucovorin and OX (FOLFOX) plus BV, 21 patients received capecitabine and OX plus BV, 10 patients received S-1 and OX plus BV and 7 patients received FOLFOX plus cetuximab or panitumumab. The median PFS was 11.5 months (95% confidence interval [CI] 8.3–16.0), the median OS was 45.4 months (95% CI 37.4–NA), and the RR was 56.0% (95% CI 42.3–68.8). Adverse events of grade ≥ 3 that occurred in ≥ 5% of cases were neutropenia in 6 patients (12%), peripheral sensory neuropathy in 5 patients (10%), diarrhea in 4 patients (8%), hypertension in 4 patients (8%), anorexia in 3 patients (6%) and allergic reactions in 3 patients (6%).

Conclusions

First-line chemotherapy with re-introduction of OX more than 6 months after adjuvant chemotherapy including OX can be used safely with expected efficacy for relapsed colon cancer patients.

The efficacy of adjuvant chemotherapy for resected high-risk stage II and stage III colorectal cancer in frail patients

BACKGROUND

The number of frail patients with colorectal cancer (CRC) has increased. Despite evidence-based treatment guidelines, a large proportion of patients with resected CRC do not receive adjuvant chemotherapy in daily practice. This retrospective study aimed to examine the effect of adjuvant chemotherapy for CRC according to frailty.

METHODS

We retrospectively analyzed data from 507 consecutive patients with curatively resected high-risk stage II or stage III CRC between 2009 and 2016. Frailty was assessed using the Clinical Frailty Scale (CFS): 1 (very fit) to 9 (terminally ill), and frailty was defined as CFS ≥ 4. Recurrence-free survival (RFS) and overall survival (OS) were compared between surgery alone and adjuvant chemotherapy in frail and non-frail patients. A cox proportional hazards model was used to calculate hazard ratios (HRs), controlling for potential confounders.

RESULTS

Of the 507 patients, 194 (38%) were frail. There were no significant interactions between frailty and adjuvant chemotherapy regarding RFS (P_interaction = 0.59) and OS (P_interaction = 0.81). In multivariable analyses, associations of adjuvant chemotherapy with longer RFS and OS in frail patients (RFS, HR: 0.33, 95% CI 0.15-0.63; OS, HR: 0.23, 95% CI 0.08-0.54) were comparable to non-frail patients (RFS, HR: 0.36, 95% CI 0.22-0.58; OS, HR: 0.34, 95% CI 0.15-0.69). Frail patients receiving adjuvant chemotherapy were younger and had better nutritional status than those undergoing surgery alone (all P < 0.005).

CONCLUSION

Selected frail patients with CRC may experience a similar survival benefit from adjuvant chemotherapy as non-frail patients. Clinical trials are needed to establish adjuvant chemotherapy for CRC in frail patients.

Oxaliplatin retreatment in metastatic colorectal cancer: Systematic review and future research opportunities

BACKGROUND

Oxaliplatin represents a main component of cytotoxic treatment regimens in colorectal cancer (CRC). Given its efficacy, oxaliplatin is frequently re-administered in the context of the continuum of care in metastatic CRC (mCRC). However, efficacy and tolerability of this therapeutic strategy has not been comprehensively assessed.

METHODS

We performed a systematic review of the literature on September 19th 2020, according to PRISMA criteria 2009. The research was performed on PubMed, ASCO Meeting Library, ESMO library and ClinicalTrials.gov for citations or ongoing trials.

RESULTS

64 records were retrieved and 13 included in the systematic review: 8 full-text articles, 4 abstracts and 1 ongoing clinical trial. According to readministration timing, studies were classified as rechallenge/reintroduction (n = 8) or stop & go/intermittent therapeutic strategies (n = 4). The studies presented wide heterogeneity in terms of efficacy (Response Rate 6-31%; Disease Control Rate 39-79%; median Progression-Free Survival 3.1-7 months). Those patients who received retreatment after prior adjuvant oxaliplatin or exploiting a stop-&-go strategy appeared to achieve better outcomes. However, no formal comparisons on treatment outcomes were feasible. The most frequent grade 3 or higher adverse events were hematologic toxicities (5-27%), peripheral neuropathy (5-14%) and hypersensitivity reactions (5-20%).

CONCLUSIONS

Retreatment with oxaliplatin for mCRC is practiced based on scarce and heterogeneous data indicating efficacy and manageable toxicity. The best strategy to exploit this approach remains to be defined, and the most promising research avenue to improve therapeutic index of oxaliplatin is represented by selection of responder patients whose tumors harbor molecular defects in the DNA damage repair pathway.