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Abstract
Regorafenib (Stivarga®) is an oral small-molecule multiple kinase inhibitor. It is indicated worldwide for patients with metastatic colorectal cancer (mCRC). In the EU and USA it is indicated for patients with mCRC who have been previously treated with, or are not considered candidates for available therapies, including fluoropyrimidine-based chemotherapy, an anti-VEGF therapy and, if RAS wild-type, an anti-EGFR therapy. In Japan, it is indicated for the treatment of unresectable, advanced/recurrent CRC. The addition of regorafenib to best supportive care prolonged median overall survival (OS; by up to 2.5 months) and progression-free survival (PFS; by up to 1.5 months) relative to the addition of placebo in double-blind phase 3 studies (CORRECT and CONCUR) in patients with mCRC who had progressed after failure of standard therapy. Health-related quality of life was not adversely affected with regorafenib relative to placebo. A large open-label phase 3 study (CONSIGN) and several large real-world studies supported the efficacy of regorafenib in this setting. Regorafenib had a generally manageable tolerability profile, which was consistent with the profile of a typical small-molecule multiple kinase inhibitor. Treatment-related adverse events (AEs), mostly of mild or moderate severity, were reported in the majority of patients receiving regorafenib, with dermatological toxicities and liver enzyme elevations among the most common AEs. Although identification of biomarkers/parameters predicting efficacy outcomes with regorafenib will help to individualize therapy, current evidence indicates that regorafenib is a valuable treatment option for patients with refractory mCRC who have a very poor prognosis.
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Affiliation(s)
- Sohita Dhillon
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Van Cutsem E, Martinelli E, Cascinu S, Sobrero A, Banzi M, Seitz JF, Barone C, Ychou M, Peeters M, Brenner B, Hofheinz RD, Maiello E, André T, Spallanzani A, Garcia-Carbonero R, Arriaga YE, Verma U, Grothey A, Kappeler C, Miriyala A, Kalmus J, Falcone A, Zaniboni A. Regorafenib for Patients with Metastatic Colorectal Cancer Who Progressed After Standard Therapy: Results of the Large, Single-Arm, Open-Label Phase IIIb CONSIGN Study. Oncologist 2019; 24:185-192. [PMID: 30190299 PMCID: PMC6369948 DOI: 10.1634/theoncologist.2018-0072] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 07/02/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In the phase III CORRECT trial, regorafenib significantly improved survival in treatment-refractory metastatic colorectal cancer (mCRC). The CONSIGN study was designed to further characterize regorafenib safety and allow patients access to regorafenib before market authorization. METHODS This prospective, single-arm study enrolled patients in 25 countries at 186 sites. Patients with treatment-refractory mCRC and an Eastern Cooperative Oncology Group performance status (ECOG PS) ≤1 received regorafenib 160 mg once daily for the first 3 weeks of each 4-week cycle. The primary endpoint was safety. Progression-free survival (PFS) per investigator assessment was the only efficacy evaluation. RESULTS In total, 2,872 patients were assigned to treatment and 2,864 were treated. Median age was 62 years, ECOG PS 0/1 was 47%/53%, and 74% had received at least three prior regimens for metastatic disease. Median treatment duration was three cycles. Treatment-emergent adverse events (TEAEs) led to dose reduction in 46% of patients. Regorafenib-related TEAEs led to treatment discontinuation in 9%. Grade 5 regorafenib-related TEAEs occurred in <1%. The most common grade ≥3 regorafenib-related TEAEs were hypertension (15%), hand-foot skin reaction (14%), fatigue (13%), diarrhea (5%), and hypophosphatemia (5%). Treatment-emergent grade 3-4 laboratory toxicities included alanine aminotransferase (6%), aspartate aminotransferase (7%), and bilirubin (13%). Ongoing monitoring identified one nonfatal case of regorafenib-related severe drug-induced liver injury per DILI Working Group criteria. Median PFS (95% confidence interval [CI]) was 2.7 months (2.6-2.7). CONCLUSION In CONSIGN, the frequency and severity of TEAEs were consistent with the known safety profile of regorafenib. PFS was similar to reports of phase III trials. ClinicalTrials.gov: NCT01538680. IMPLICATIONS FOR PRACTICE Patients with metastatic colorectal cancer (mCRC) who fail treatment with standard therapies, including chemotherapy and monoclonal antibodies targeting vascular endothelial growth factor or epidermal growth factor receptor, have few treatment options. The multikinase inhibitor regorafenib was shown to improve survival in patients with treatment-refractory mCRC in the phase III CORRECT (N = 760) and CONCUR (N = 204) trials. However, safety data on regorafenib for mCRC in a larger number of patients were not available. The CONSIGN trial, carried out prospectively in more than 2,800 patients across 25 countries, confirmed the safety profile of regorafenib from the phase III trials and reinforced the importance of using treatment modifications to manage adverse events.
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Affiliation(s)
- Eric Van Cutsem
- Digestive Oncology, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Erika Martinelli
- Department of Experimental Medicine, Università degli studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Stefano Cascinu
- Clinica di Oncologia Medica, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Alberto Sobrero
- Medical Oncology, IRCCS Ospedale San Martino IST, Genova, Italy
| | - Maria Banzi
- Department of Oncology and Advanced Technologies, Oncology Unit, Azienda Ospedaliera S. Maria Nuova/IRCCS, Reggio Emilia, Italy
| | - Jean-François Seitz
- Department of Digestive Oncology, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Carlo Barone
- Medical Oncology, University Hospital A. Gemelli, Rome, Italy
| | - Marc Ychou
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Marc Peeters
- Center for Oncological Research, Antwerp University Hospital, Edegem, Belgium
| | - Baruch Brenner
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ralf Dieter Hofheinz
- Interdisciplinary Tumor Center, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Evaristo Maiello
- Department of Oncology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Thierry André
- Service d'Oncologie Médicale, Hôpital Saint-Antoine Paris and Sorbonne Universités, UPMC Paris 06, Paris, France
| | - Andrea Spallanzani
- Department of Oncology and Haematology, Division of Oncology, University Hospital of Modena, Modena, Italy
| | - Rocio Garcia-Carbonero
- Department of Medical Oncology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Yull E Arriaga
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Udit Verma
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Axel Grothey
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christian Kappeler
- Clinical Statistics, Global Clinical Oncology, Bayer AG, Berlin, Germany
| | - Ashok Miriyala
- Benefit Risk Management, Bayer HealthCare Pharmaceuticals, Whippany, New Jersey, USA
| | | | - Alfredo Falcone
- Department of Medical Oncology, University of Pisa, Pisa, Italy
| | - Alberto Zaniboni
- Department of Oncology, Fondazione Poliambulanza, Brescia, Italy
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Bekaii-Saab T, Kim R, Kim TW, O'Connor JM, Strickler JH, Malka D, Sartore-Bianchi A, Bi F, Yamaguchi K, Yoshino T, Prager GW. Third- or Later-line Therapy for Metastatic Colorectal Cancer: Reviewing Best Practice. Clin Colorectal Cancer 2018; 18:e117-e129. [PMID: 30598357 DOI: 10.1016/j.clcc.2018.11.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 02/05/2023]
Abstract
An increasing number of patients with metastatic colorectal cancer (mCRC) are able to receive 3 or more lines of therapy. Treatments in this setting can include regorafenib (an oral multikinase inhibitor), trifluridine/tipiracil hydrochloride (TAS-102), antibodies that target epidermal growth factor receptor for patients with RAS wild-type tumors (if no prior exposure), and, where approved, anti-programmed cell death protein 1 inhibitors for patients with microsatellite instability-high mCRC. Although guidelines describe the available treatment options, few insights are provided to guide selection and sequencing. In this article, we share expert opinion from diverse geographic regions, to offer guidance for best practice when selecting and managing third-line treatment for mCRC. Various factors, including performance status, age, and tumor sidedness, can be used to guide treatment selection. Biomarkers, such as RAS, BRAF, and microsatellite instability, can be useful for treatment stratification. Management of adverse events, to maintain quality of life, is a key consideration and is crucial to best practice in this setting. Common toxicities associated with third-line treatments are hand-foot skin reaction, fatigue, diarrhea, and cytopenias. Patients who receive third-line and later-line treatments should be monitored for these events, especially during the first 2 cycles. Dose modifications can also be used to manage toxicities and to minimize the effect on quality of life, while maximizing treatment benefit. Clinical trials of emerging agents, new treatment combinations, and novel therapies continue the efforts to improve outcomes for patients with mCRC. Sharing expert opinions on best practice for treatment selection and management can ultimately improve outcomes for patients with mCRC.
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Affiliation(s)
| | - Richard Kim
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Tae Won Kim
- Department of Oncology, ASAN Medical Center, University of Ulsan, Seoul, South Korea
| | - Juan Manuel O'Connor
- Department Clinical Oncology, Clinical Oncology Instituto Alexander Fleming, Buenos Aires, Argentina
| | - John H Strickler
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - David Malka
- Department of Cancer Medicine, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Andrea Sartore-Bianchi
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Feng Bi
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kensei Yamaguchi
- Department of Gastroenterological Chemotherapy, The Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Takayuki Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Gerald W Prager
- Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University Vienna, Vienna, Austria.
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