Dr. Goldberg: When I think about managing patients, main principles that I consider are using all the agents that are available, as appropriate. That [involves] testing patients early on in the management of their metastatic disease for KRAS mutations, because those with tumors that have KRAS mutations have one [fewer] option in terms of not being able to use the epidermal growth factor receptor antagonists cetuximab or panitumumab. Using all the chemotherapy agents—
People ask “Should I use bevacizumab first line, or should I use it beyond first line?” And there was data presented this year in the
In the last year, we've had two new drugs that have come on the market, aflibercept and ramucirumab, adding to the targeted agents that we can use with chemotherapy.
Aflibercept is a similar drug [to bevacizumab]. It targets both VEGF1 and VEGF2; [though] bevacizumab just targets VEGF1 and is provided with chemotherapy in the VELOUR trial by Eric Van Cutsem and colleagues that was recently published.3 It again showed a
Studies with ramucirumab that target both VEGF1 and VEGF2 showed an advantage in survival over placebo in patients with gastric cancer.4 We're now seeing studies that are being done in combination with chemotherapy in patients with colorectal cancer, but the data from those studies [have] not yet been released.
And now, of course, we have data with regorafenib in patients who are randomized to that drug versus placebo, and showed an extension in overall survival.5
Narrator: Specifically, overall survival was 5.0 months with placebo versus
Dr. Goldberg: One of the great things about managing patients with metastatic colorectal cancer now is that we have multiple agents, and so we have the opportunity to consider combinations and permutations on putting them together that can be different in individual patients, depending on their treatment goals and their physical status. In the setting of advanced disease, if a patient is not going to have resectable disease because they have multiple lesions in multiple organs, then what you're trying to do is to help people live longer, help them feel better, and not at the price of extensive side effects that compromise their lifestyle. Also sometimes it's nice to