John L. Marshall, MD</


May 21, 2012

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Spring has sprung. What a beautiful day it is here in Washington, DC. But you know what that means: It's time for the American Society of Clinical Oncology (ASCO®) meeting. This is John Marshall for Medscape, with our annual "what you need to know and what is going to come out at ASCO this year" preview. I am going to focus on colorectal cancer, and I want to divide it into 4 main areas.

The first is new drugs. We have had 7 drugs on the chessboard of colorectal cancer for some time now. We have tried to find new medicines, and finally we have a couple. We have regorafenib, which looks positive in a refractory setting, and aflibercept, which looks positive in the second-line setting. We are going to have 2 new chess pieces on the board. Actually, we might even have a third, so look out for the new drugs that are coming soon.

The second area I want to talk about is perioperative chemotherapy. Our tradition in patients who have metastatic disease is to give some chemotherapy preoperatively, maybe some postoperatively -- chemotherapy around the time of their liver or lung resection. The only study we have on this is by Nordlinger and colleagues.[1] This study showed a small advantage in progression-free survival. What we will see at ASCO this year is a lack of overall survival benefit. This is an abstract, and I am really going to look at the data. The chemotherapy used in that study was FOLFOX [leucovorin, fluorouracil, oxaliplatin], which raises the question of biologics; would they help? I am wondering: With this adjuvant therapy or metastatic disease, should we be thinking differently about how to manage the resectable perioperative patient? Should we be giving chemotherapy or not? Stay tuned for that.

The other big area is the world of maintenance therapy. What is the best thing to "OPTIMOX" or "OPTIMIRI" with? There is a very interesting study known as the DREAM study which randomly assigned patients between bevacizumab alone and bevacizumab plus erlotinib, and we will see what the results of that clinical trial show. It could bring a new medicine, erlotinib, back to the table in colon cancer if that study is indeed positive.

The biggest topic that we will see is, what is the best second-line therapy for metastatic colon cancer, and which biologic agent should we be using? A study will look at bevacizumab beyond progression. We have the epidermal growth factor receptor drugs that have been tested in the second-line window for the KRAS wild-type patients, and we now have aflibercept coming into this window, so we are going to have some choices. We are going to use biologics in the second line pretty much for all patients; which ones win, and how to do that, will be big topics of discussion at ASCO this year. Of course, layered on all of this is more emerging data on molecular profiling -- how to measure KRAS and BRAF, what other biologic markers matter. There are a lot of data to look at. Although the data are not ready for a package to bring to the clinic, we are learning. That field is moving forward.

I hope for a change. Come to ASCO and see the presentations, but if you don't, we will synthesize all the data right here for you on Medscape. This is John Marshall from Georgetown University. I hope to see you at ASCO.


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