What is the general approach to medical oncology planning for a patient with cancer?

Medical Oncology Treatment Planning

The optimal medical oncology plan requires stratifying patients into treatment intensity groups based on disease characteristics (resectability, tumor burden, growth dynamics, symptoms) and patient factors (performance status, comorbidities), then selecting chemotherapy regimens and targeted agents accordingly, with all decisions made through a multidisciplinary team approach. 1

Patient Stratification Framework

Medical oncology planning begins by categorizing patients into distinct treatment groups that determine therapeutic intensity and goals 1:

Group Classification System

• Group 0: Patients with R0-resectable liver or lung metastases where cure is achievable 1, 2
• Group 1: Potentially resectable metastases after downsizing chemotherapy—treatment aim is conversion to curative resection 1, 2
• Group 2: Intermediate intensity palliative treatment where rapid, reliable tumor regression is critical, particularly for symptomatic disease or imminent complications 1, 2
• Group 3: Sequential/non-intensive treatment for asymptomatic patients without rapid deterioration risk—goal is preventing progression with minimal treatment burden 1, 2

Critical Stratification Factors

The following characteristics determine group assignment 1:

• Disease location: Liver-only or lung-only metastases versus multiple sites 1
• Resectability status: Potentially R0-resectable lesions versus massive disease extension 1
• Growth dynamics: Aggressive versus indolent tumor behavior 1
• Symptom burden: Asymptomatic versus symptomatic disease 1
• Performance status: Ability to tolerate intensive chemotherapy 2, 3

Treatment Selection Algorithm

For Groups 0-1 (Curative or Conversion Intent)

Select the most active induction chemotherapy upfront to maximize downsizing in as many patients as possible 1:

• First-line options: FOLFOX (5-FU/leucovorin/oxaliplatin) or FOLFIRI (5-FU/leucovorin/irinotecan) plus targeted biological agents based on molecular testing 2, 3
• Triplet regimens: FOLFOXIRI (combining 5-FU, irinotecan, and oxaliplatin) demonstrates superior efficacy in terms of response and overall survival compared to doublets 1
• Targeted therapy addition: Anti-VEGF-A antibodies (bevacizumab) combined with chemotherapy improve prognosis, but bevacizumab must be discontinued at least 6 weeks before planned surgery 2

For Group 2 (Intermediate Palliative)

Use very active first-line combination therapy with high likelihood of rapid metastases regression 1:

• Avoid escalation strategies (single agent followed by combination) as first-line treatment may prove ineffective and switching to second-line may occur too late 1
• Standard doublets: 5-FU/leucovorin with either oxaliplatin or irinotecan 1, 2
• Capecitabine can safely substitute IV 5-FU/leucovorin in combination with oxaliplatin without impairing progression-free survival or overall survival 1
• Addition of oxaliplatin increases response rates and progression-free survival by approximately 3 months 2
• Addition of irinotecan delays disease progression by 2 months and improves overall survival by 3 months 2

For Group 3 (Sequential/Non-Intensive)

Begin with single-agent or well-tolerated two-drug combinations using an escalation strategy 1:

• Maximum tumor shrinkage is not the primary aim 1
• Focus on preventing tumor progression with symptom control and life prolongation while minimizing treatment burden 1
• Oral fluoropyrimidines (capecitabine) or infusional 5-FU/leucovorin as initial therapy 1

Molecular Testing Requirements

Before initiating therapy, obtain 2, 3:

• RAS mutational status: Determines eligibility for anti-EGFR targeted agents 2, 3
• MSI/dMMR status: MSI-H/dMMR patients should be considered for PD-1 checkpoint inhibitors 2
• HER2 status (for breast and gastric cancers): Required for trastuzumab eligibility using FDA-approved companion diagnostics 4

Multidisciplinary Team Coordination

All treatment strategies must be developed and discussed within a multidisciplinary team that incorporates the patient's perspective 1:

• The MDT is a prerequisite for optimal management in metastatic cancer 1
• Team composition should include medical oncologists, surgical oncologists, radiation oncologists, pathologists, radiologists, and palliative care specialists 1
• Treatment decisions must be made independent of patient age, but comorbidities and patient characteristics require consideration through shared decision-making 1
• In elderly patients, comprehensive geriatric assessment adds important information to treatment planning 1

Communication and Care Planning

Initial Consultation Structure

At the beginning of patient encounters, explore the patient's understanding of their disease and collaboratively set an agenda 1:

• Use open-ended questions to encourage patients to share what is important to them 1
• Inquire what the patient and family wish to address and explain what you wish to address 1
• Sit down, make eye contact, maintain a calm demeanor, and engage in reflective listening 1
• Get to know the patient as a person—find out about their life before cancer diagnosis and how cancer has changed their life 1

Information Delivery

Provide information that is timely, oriented to the patient's concerns, and check for understanding 1:

• Avoid unnecessary delays in providing information 1
• Use simple language tailored to the patient's educational level and avoid jargon 1
• Communicate with consultants so patients receive coherent recommendations 1
• Document important discussions in the medical record 1

Palliative Care Integration

Integrate palliative care early for patients meeting screening criteria 1:

Screening Triggers for Palliative Care Consultation

• Uncontrolled symptoms or moderate-to-severe distress related to cancer diagnosis/therapy 1
• Serious comorbid physical and psychosocial conditions 1
• Life expectancy ≤12 months 1
• Patient/family concerns about disease course and decision-making 1

Advance Care Planning Timeline

• Life expectancy of years to months: Initiate discussions of personal values and preferences for end-of-life care 1
• Life expectancy of months to weeks: Actively facilitate completion of advance directives (MOLST/POLST) and ensure availability across all care settings 1
• Identify surrogate decision makers early, as delirium and cognitive impairment are prevalent during treatment 1

Treatment Monitoring and Reassessment

Re-evaluate patients after 2-3 cycles of chemotherapy to assess response and adjust therapy 3:

• Treatment should be reassessed every 2 months to verify response and adjust strategy as necessary 2
• Consider surgical or radiation options if major partial response is achieved in previously unresectable disease 3
• Monitor for disease progression using tumor markers and imaging studies (CT scans or MRI) 3
• Significant weight loss (≥7 pounds) is a significant clinical indicator requiring immediate intervention 3

Clinical Trial Participation

Encourage patients to consider clinical trial participation early in their disease course, with preference for enrollment at each line of therapy if available 1:

• Clinical trials represent the best management for cancer patients according to national guidelines 1
• Participation should be especially encouraged throughout the treatment trajectory 1

Common Pitfalls to Avoid

• Do not combine two targeted medications—this combination is not recommended 2
• Do not use escalation strategies in Group 2 patients—risk that first-line treatment proves ineffective and switch occurs too late 1
• Do not delay palliative care consultation—early introduction of expert palliative care helps better control symptoms 1
• Do not continue bevacizumab within 6 weeks of planned surgery—allow adequate washout period 2
• Do not rechallenge with drugs used in early-stage setting unless disease-free interval is ≥12 months and no remaining toxicities exist 1