From the Guidelines
For a patient who has progressed on FOLFOX adjuvant therapy after colon surgery, the next treatment of choice would be FOLFIRI (fluorouracil, leucovorin, and irinotecan) with bevacizumab, as this combination is recommended for patients previously treated with irinotecan-fluoropyrimidine-based chemotherapy alone or oxaliplatin-based therapy 1.
This approach is based on the latest guidelines for the treatment of metastatic colorectal cancer, which suggest that a second-line treatment with an antiangiogenic combined with chemotherapy, regardless of whether the first-line treatment included bevacizumab or not, should be used, independently of the RAS mutational status and the primary tumor location 1.
Key considerations for this treatment choice include:
- The patient's performance status and tolerance to previous therapy
- Molecular testing of the tumor to guide the use of targeted agents such as cetuximab or panitumumab in RAS wild-type tumors, or encorafenib plus cetuximab in BRAF V600E-mutated tumors 1
- The potential use of alternative antiangiogenic agents such as aflibercept or ramucirumab in combination with FOLFIRI, as an alternative to bevacizumab 1
In terms of specific dosing, the standard FOLFIRI regimen includes irinotecan 180 mg/m² IV on day 1, leucovorin 400 mg/m² IV on day 1, followed by fluorouracil 400 mg/m² IV bolus on day 1, then 2400-3000 mg/m² as a 46-hour continuous infusion, repeated every 2 weeks, with bevacizumab 5-10 mg/kg IV every 2 weeks 1.
Ultimately, the choice of second-line therapy should be individualized based on the patient's specific clinical and molecular characteristics, as well as their preferences and values.
From the Research
Next Treatment of Choice
For a patient who progressed on FOLFOX adjuvant therapy after colon surgery, the next treatment of choice can be considered based on the following options:
- FOLFIRI regimen: This regimen, which includes irinotecan, fluorouracil, and leucovorin, can be considered as a next-line treatment option 2.
- Rechallenge with oxaliplatin-based regimen: A rechallenge with an oxaliplatin-based regimen, such as FOLFOXIRI or FOLFIRINOX, can also be considered, especially for patients with good performance status 2.
- Anti-angiogenesis inhibitors or anti-EGFR antibodies: The addition of anti-angiogenesis inhibitors or anti-EGFR antibodies to FOLFIRI can be considered, although the efficacy of these combinations may vary depending on factors such as tumor sidedness and timing of recurrence 3.
Key Considerations
When selecting the next treatment of choice, the following factors should be considered:
- Patient performance status: Patients with good performance status may be more likely to tolerate and benefit from rechallenge regimens or combination therapies 2.
- Tumor characteristics: Tumor sidedness and KRAS mutation status may influence the efficacy of certain treatments, such as anti-EGFR antibodies 4, 5.
- Previous treatment history: The patient's previous treatment history, including the use of adjuvant FOLFOX or CAPOX, should be taken into account when selecting the next treatment of choice 3.