Difference between revisions of "Colon cancer, RAS wild-type"

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===Regimen {{#subobject:a72hg6|Variant=1}}===
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!style="width: 20%"|Study
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!style="width: 20%"|Years of enrollment
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!style="width: 20%"|[[Levels_of_Evidence#Evidence|Evidence]]
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!style="width: 20%"|Comparator
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|[https://doi.org/10.1093/annonc/mdv490 Hagman et al. 2015 (Nordic ACT2)]
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|2010-2012
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| style="background-color:#1a9851" |Phase III (C)
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|Erlotinib & Bevacizumab
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====Biomarker eligibility criteria====
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*Wild-type KRAS
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====Targeted therapy====
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*[[Bevacizumab (Avastin)]] 7.5 mg/kg IV once on day 1
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'''21-day cycles'''
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===References===
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#'''Nordic ACT2:''' Hagman H, Frödin JE, Berglund Å, Sundberg J, Vestermark LW, Albertsson M, Fernebro E, Johnsson A. A randomized study of KRAS-guided maintenance therapy with bevacizumab, erlotinib or metronomic capecitabine after first-line induction treatment of metastatic colorectal cancer: the Nordic ACT2 trial. Ann Oncol. 2016 Jan;27(1):140-7. Epub 2015 Oct 19. [https://doi.org/10.1093/annonc/mdv490 link to original article] '''contains verified protocol''' [https://pubmed.ncbi.nlm.nih.gov/26483047/ PubMed] NCT01229813
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==Cetuximab monotherapy {{#subobject:afad4f|Regimen=1}}==
 
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Revision as of 02:16, 16 December 2021

Page editor Section editor
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 Ryan Nguyen, DO
University of Illinois at Chicago
Chicago, IL
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 Neeta K. Venepalli, MD, MBA
University of Illinois at Chicago
Chicago, IL

Note: the page has adjuvant and perioperative regimens specific to RAS wild-type colon cancer as well as systemic regimens for the more general category of RAS wild-type colorectal cancer. Also note that most of the regimens were evaluated on patients tested for KRAS mutations only, and that the definition of wild-type has evolved over time. See individual regimen biomarker eligibility criteria for more details.

2 regimens on this page
2 variants on this page


Guidelines

ESMO

Japanese Society for Cancer of the Colon and Rectum

NCCN

Adjuvant therapy

mFOLFOX6

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mFOLFOX6: modified FOLinic acid, Fluorouracil, OXaliplatin

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Alberts et al. 2012 (N0147) 2004-2009 Phase 3 (C) mFOLFOX6 & Cetuximab Might have superior DFS

Preceding treatment

Chemotherapy

  • Fluorouracil (5-FU) 400 mg/m2 IV bolus once on day 1, then 2400 mg/m2 IV continuous infusion over 46 to 48 hours, given second (total dose per cycle: 2800 mg/m2)
  • Folinic acid (Leucovorin) 400 mg/m2 IV over 2 hours once on day 1, given first, with oxaliplatin
  • Oxaliplatin (Eloxatin) 85 mg/m2 IV over 2 hours once on day 1, given first, with folinic acid

14-day cycle for 12 cycles

References

  1. N0147: Alberts SR, Sargent DJ, Nair S, Mahoney MR, Mooney M, Thibodeau SN, Smyrk TC, Sinicrope FA, Chan E, Gill S, Kahlenberg MS, Shields AF, Quesenberry JT, Webb TA, Farr GH Jr, Pockaj BA, Grothey A, Goldberg RM. Effect of oxaliplatin, fluorouracil, and leucovorin with or without cetuximab on survival among patients with resected stage III colon cancer: a randomized trial. JAMA. 2012 Apr 4;307(13):1383-93. link to original article contains verified protocol link to PMC article PubMed NCT00079274

mFOLFOX6 & Cetuximab

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mFOLFOX6 & Cetuximab: modified FOLinic acid, Fluorouracil, OXaliplatin, Cetuximab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Alberts et al. 2012 (N0147) 2004-2009 Phase 3 (E-esc) mFOLFOX6 Might have inferior DFS

Some guidelines do not recommend using cetuximab as adjuvant therapy outside of a clinical trial.

Preceding treatment

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once on day 8
    • Cycles 2 to 12: 250 mg/m2 IV over 2 hours once per day on days 1 & 8

14-day cycle for 12 cycles

References

  1. N0147: Alberts SR, Sargent DJ, Nair S, Mahoney MR, Mooney M, Thibodeau SN, Smyrk TC, Sinicrope FA, Chan E, Gill S, Kahlenberg MS, Shields AF, Quesenberry JT, Webb TA, Farr GH Jr, Pockaj BA, Grothey A, Goldberg RM. Effect of oxaliplatin, fluorouracil, and leucovorin with or without cetuximab on survival among patients with resected stage III colon cancer: a randomized trial. JAMA. 2012 Apr 4;307(13):1383-93. link to original article contains verified protocol link to PMC article PubMed NCT00079274

Perioperative therapy for oligometastatic disease

FOLFIRI

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FOLFIRI: FOLinic acid, Fluorouracil, IRInotecan

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ye et al. 2013 (Fudan 2012-03) 2008-2011 Phase 3 (C) FOLFIRI & Cetuximab Seems to have inferior OS

Note: this trial was only open to KRAS wild-type patients with synchronous liver-confined unresectable metastases.

Chemotherapy

14-day cycles until lesions deemed resectable or up to 12 cycles

References

  1. Fudan 2012-03: Ye LC, Liu TS, Ren L, Wei Y, Zhu DX, Zai SY, Ye QH, Yu Y, Xu B, Qin XY, Xu J. Randomized controlled trial of cetuximab plus chemotherapy for patients with KRAS wild-type unresectable colorectal liver-limited metastases. J Clin Oncol. 2013 Jun 1;31(16):1931-8. Epub 2013 Apr 8. link to original article contains verified protocol PubMed NCT01564810

FOLFIRI & Cetuximab

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FOLFIRI & Cetuximab: FOLinic acid, Fluorouracil, IRInotecan, Cetuximab

Regimen variant #1, weekly cetuximab

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ye et al. 2013 (Fudan 2012-03) 2008-2011 Phase 3 (E-esc) FOLFIRI Seems to have superior OS

Note: this trial was only open to KRAS wild-type patients with synchronous liver-confined unresectable metastases.

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows, given first:
    • Cycle 1: 400 mg/m2 IV once on day 1, then 250 mg/m2 IV once on day 8
    • Subsequent cycles: 250 mg/m2 IV once per day on days 1 & 8

14-day cycles until lesions deemed resectable or up to 12 cycles

Regimen variant #2, bi-weekly cetuximab

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ye et al. 2013 (Fudan 2012-03) 2008-2011 Phase 3 (E-esc) FOLFIRI Seems to have superior OS

Note: this trial was only open to KRAS wild-type patients with synchronous liver-confined unresectable metastases.

Chemotherapy

Targeted therapy

14-day cycles until lesions deemed resectable or up to 12 cycles

References

  1. Fudan 2012-03: Ye LC, Liu TS, Ren L, Wei Y, Zhu DX, Zai SY, Ye QH, Yu Y, Xu B, Qin XY, Xu J. Randomized controlled trial of cetuximab plus chemotherapy for patients with KRAS wild-type unresectable colorectal liver-limited metastases. J Clin Oncol. 2013 Jun 1;31(16):1931-8. Epub 2013 Apr 8. link to original article contains verified protocol PubMed NCT01564810

mFOLFOX6

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mFOLFOX6: modified FOLinic acid, Fluorouracil, OXaliplatin

Regimen variant #1, 400/2800/85, resectable or suboptimally resectable

Study Years of enrollment Evidence Comparator Comparative Efficacy
Primrose et al. 2014 (New EPOC) 2007-2012 Phase 3 (C) mFOLFOX6 & Cetuximab Did not meet primary endpoint of PFS1

1Reported efficacy is based on the 2020 update.
Note: this trial was only open to KRAS wild-type patients with resectable or suboptimally resectable colorectal liver metastases.

Biomarker eligibility criteria

  • KRAS wild-type

Chemotherapy

14-day cycle for 6 cycles, then surgery, then 14-day cycle for 6 cycles

Regimen variant #2, 400/2800/85, unresectable

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ye et al. 2013 (Fudan 2012-03) 2008-2011 Phase 3 (C) mFOLFOX6 & Cetuximab Seems to have inferior OS

Note: this trial was only open to KRAS wild-type patients with synchronous liver-confined unresectable metastases.

Chemotherapy

14-day cycles until lesions deemed resectable or up to 12 cycles

References

  1. Fudan 2012-03: Ye LC, Liu TS, Ren L, Wei Y, Zhu DX, Zai SY, Ye QH, Yu Y, Xu B, Qin XY, Xu J. Randomized controlled trial of cetuximab plus chemotherapy for patients with KRAS wild-type unresectable colorectal liver-limited metastases. J Clin Oncol. 2013 Jun 1;31(16):1931-8. Epub 2013 Apr 8. link to original article contains verified protocol PubMed NCT01564810
  2. New EPOC: Primrose J, Falk S, Finch-Jones M, Valle J, O'Reilly D, Siriwardena A, Hornbuckle J, Peterson M, Rees M, Iveson T, Hickish T, Butler R, Stanton L, Dixon E, Little L, Bowers M, Pugh S, Garden OJ, Cunningham D, Maughan T, Bridgewater J. Systemic chemotherapy with or without cetuximab in patients with resectable colorectal liver metastasis: the New EPOC randomised controlled trial. Lancet Oncol. 2014 May;15(6):601-11. Epub 2014 Apr 7. Erratum in: Lancet Oncol. 2014 Jun;15(7):e253. link to original article PubMed ISRCTN22944367
    1. Update: Bridgewater JA, Pugh SA, Maishman T, Eminton Z, Mellor J, Whitehead A, Stanton L, Radford M, Corkhill A, Griffiths GO, Falk S, Valle JW, O'Reilly D, Siriwardena AK, Hornbuckle J, Rees M, Iveson TJ, Hickish T, Garden OJ, Cunningham D, Maughan TS, Primrose JN; New EPOC investigators. Systemic chemotherapy with or without cetuximab in patients with resectable colorectal liver metastasis (New EPOC): long-term results of a multicentre, randomised, controlled, phase 3 trial. Lancet Oncol. 2020 Mar;21(3):398-411. Epub 2020 Jan 31. link to original article link to PMC article PubMed

mFOLFOX6 & Cetuximab

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mFOLFOX6 & Cetuximab: modified FOLinic acid, Fluorouracil, OXaliplatin, Cetuximab

Regimen variant #1, weekly cetuximab

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ye et al. 2013 (Fudan 2012-03) 2008-2011 Phase 3 (E-esc) mFOLFOX6 Seems to have superior OS

Note: this trial was only open to KRAS wild-type patients with synchronous liver-confined unresectable metastases.

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows, given first:
    • Cycle 1: 400 mg/m2 IV once on day 1, then 250 mg/m2 IV once on day 8
    • Subsequent cycles: 250 mg/m2 IV once per day on days 1 & 8

14-day cycles until lesions deemed resectable or up to 12 cycles

Regimen variant #2, bi-weekly cetuximab

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ye et al. 2013 (Fudan 2012-03) 2008-2011 Phase 3 (E-esc) mFOLFOX6 Seems to have superior OS

Note: this trial was only open to KRAS wild-type patients with synchronous liver-confined unresectable metastases.

Chemotherapy

Targeted therapy

14-day cycles until lesions deemed resectable or up to 12 cycles

References

  1. Fudan 2012-03: Ye LC, Liu TS, Ren L, Wei Y, Zhu DX, Zai SY, Ye QH, Yu Y, Xu B, Qin XY, Xu J. Randomized controlled trial of cetuximab plus chemotherapy for patients with KRAS wild-type unresectable colorectal liver-limited metastases. J Clin Oncol. 2013 Jun 1;31(16):1931-8. Epub 2013 Apr 8. link to original article contains verified protocol PubMed NCT01564810

Advanced or metastatic disease, first-line

CapeOx & Panitumumab

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CapeOx & Panitumumab: Capecitabine, Oxaliplatin, Panitumumab

Regimen

Study Evidence
Papaxoinis et al. 2018 (HE 6A/09) Phase II

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Chemotherapy

Targeted therapy

21-day cycles

References

  1. HE 6A/09: Papaxoinis G, Kotoula V, Giannoulatou E, Koliou GA, Karavasilis V, Lakis S, Koureas A, Bobos M, Chalaralambous E, Daskalaki E, Chatzopoulos K, Tsironis G, Pazarli E, Chrisafi S, Samantas E, Kaklamanos IG, Varthalitis I, Konstantara A, Syrigos KN, Pentheroudakis G, Pectasides D, Fountzilas G. Phase II study of panitumumab combined with capecitabine and oxaliplatin as first-line treatment in metastatic colorectal cancer patients: clinical results including extended tumor genotyping. Med Oncol. 2018 May 31;35(7):101. link to original article contains verified protocol PubMed NCT01215539

FOLFIRI & Bevacizumab

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FOLFIRI & Bevacizumab: FOLinic acid, Fluorouracil, IRInotecan, Bevacizumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Heinemann et al. 2014 (FIRE-3) 2007-2012 Phase 3 (E-switch-ic) FOLFIRI & Cetuximab Did not meet primary endpoint of ORR

Chemotherapy

  • Folinic acid (Leucovorin) 400 mg/m2 IV over 2 hours once on day 1, given first, with irinotecan
  • Fluorouracil (5-FU) 400 mg/m2 IV bolus once on day 1, then 2400 mg/m2 IV continuous infusion over 46 to 48 hours, given third (total dose per cycle: 2800 mg/m2)
  • Irinotecan (Camptosar) 180 mg/m2 IV over 30 to 90 minutes once on day 1, given first, with leucovorin

Targeted therapy

  • Bevacizumab (Avastin) 5 mg/kg IV once on day 1, given second
    • In FIRE-3, initial infusion is over 90 minutes, next over 60 minutes, and subsequently over 30 minutes

14-day cycles

References

  1. FIRE-3: Heinemann V, von Weikersthal LF, Decker T, Kiani A, Vehling-Kaiser U, Al-Batran SE, Heintges T, Lerchenmüller C, Kahl C, Seipelt G, Kullmann F, Stauch M, Scheithauer W, Hielscher J, Scholz M, Müller S, Link H, Niederle N, Rost A, Höffkes HG, Moehler M, Lindig RU, Modest DP, Rossius L, Kirchner T, Jung A, Stintzing S. FOLFIRI plus cetuximab versus FOLFIRI plus bevacizumab as first-line treatment for patients with metastatic colorectal cancer (FIRE-3): a randomised, open-label, phase 3 trial. Lancet Oncol. 2014 Sep;15(10):1065-75. Epub 2014 Jul 31.link to original article PubMed NCT00433927

FOLFIRI & Cetuximab

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FOLFIRI & Cetuximab: FOLinic acid, Fluorouracil, IRInotecan, Cetuximab

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Van Cutsem et al. 2009 (CRYSTAL) 2004-2005 Phase 3 (E-RT-esc) FOLFIRI Superior OS1
Heinemann et al. 2014 (FIRE-3) 2007-2012 Phase 3 (E-switch-ooc) FOLFIRI & Bevacizumab Did not meet primary endpoint of ORR

1Reported efficacy for CRYSTAL is based on the 2012 pooled update and is only for KRAS wild-type tumors.

Biomarker eligibility criteria

  • CRYSTAL: none
  • FIRE-3: Wild-type KRAS, Wild-type NRAS

Chemotherapy

  • Folinic acid (Leucovorin) 400 mg/m2 IV over 2 hours once on day 1, given second, 1 hour after completion of cetuximab, with irinotecan
  • Fluorouracil (5-FU) 400 mg/m2 IV bolus once on day 1, then 2400 mg/m2 IV continuous infusion over 46 hours, given third (total dose per cycle: 2800 mg/m2)
  • Irinotecan (Camptosar) 180 mg/m2 IV over 30 to 90 minutes once on day 1, given second, 1 hour after completion of cetuximab, with leucovorin

Targeted therapy

  • Cetuximab (Erbitux) as follows, given first and completed at least 1 hour before FOLFIRI begins:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once on day 8
    • Cycle 2 onwards: 250 mg/m2 IV over 60 minutes once per day on days 1 & 8

14-day cycles

References

  1. CRYSTAL: Van Cutsem E, Köhne CH, Hitre E, Zaluski J, Chang Chien CR, Makhson A, D'Haens G, Pintér T, Lim R, Bodoky G, Roh JK, Folprecht G, Ruff P, Stroh C, Tejpar S, Schlichting M, Nippgen J, Rougier P. Cetuximab and chemotherapy as initial treatment for metastatic colorectal cancer. N Engl J Med. 2009 Apr 2;360(14):1408-17. link to original article contains verified protocol PubMed NCT00154102
    1. Update: Van Cutsem E, Köhne CH, Láng I, Folprecht G, Nowacki MP, Cascinu S, Shchepotin I, Maurel J, Cunningham D, Tejpar S, Schlichting M, Zubel A, Celik I, Rougier P, Ciardiello F. Cetuximab plus irinotecan, fluorouracil, and leucovorin as first-line treatment for metastatic colorectal cancer: updated analysis of overall survival according to tumor KRAS and BRAF mutation status. J Clin Oncol. 2011 May 20;29(15):2011-9. Epub 2011 Apr 18. link to original article contains verified protocol PubMed
    2. Pooled update: Bokemeyer C, Van Cutsem E, Rougier P, Ciardiello F, Heeger S, Schlichting M, Celik I, Köhne CH. Addition of cetuximab to chemotherapy as first-line treatment for KRAS wild-type metastatic colorectal cancer: Pooled analysis of the CRYSTAL and OPUS randomised clinical trials. Eur J Cancer. 2012 Jul;48(10):1466-75. Epub 2012 Mar 23. link to original article PubMed
    3. Biomarker analysis: Van Cutsem E, Lenz HJ, Köhne CH, Heinemann V, Tejpar S, Melezínek I, Beier F, Stroh C, Rougier P, van Krieken JH, Ciardiello F. Fluorouracil, leucovorin, and irinotecan plus cetuximab treatment and RAS mutations in colorectal cancer. J Clin Oncol. 2015 Mar 1;33(7):692-700. Epub 2015 Jan 20. link to original article PubMed
  2. FIRE-3: Heinemann V, von Weikersthal LF, Decker T, Kiani A, Vehling-Kaiser U, Al-Batran SE, Heintges T, Lerchenmüller C, Kahl C, Seipelt G, Kullmann F, Stauch M, Scheithauer W, Hielscher J, Scholz M, Müller S, Link H, Niederle N, Rost A, Höffkes HG, Moehler M, Lindig RU, Modest DP, Rossius L, Kirchner T, Jung A, Stintzing S. FOLFIRI plus cetuximab versus FOLFIRI plus bevacizumab as first-line treatment for patients with metastatic colorectal cancer (FIRE-3): a randomised, open-label, phase 3 trial. Lancet Oncol. 2014 Sep;15(10):1065-75. Epub 2014 Jul 31. link to original article PubMed NCT00433927

FOLFIRI & Cetuximab (L-Leucovorin)

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FOLFIRI & Cetuximab: L-FOLinic acid, Fluorouracil, IRInotecan, Cetuximab

Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Van Cutsem et al. 2009 (CRYSTAL) 2004-2005 Phase 3 (E-RT-esc) FOLFIRI Superior OS1
Heinemann et al. 2014 (FIRE-3) 2007-2012 Phase 3 (E-switch-ooc) FOLFIRI & Bevacizumab Did not meet primary endpoint of ORR

1Reported efficacy for CRYSTAL is based on the 2012 pooled update and is only for KRAS wild-type tumors.

Biomarker eligibility criteria

  • CRYSTAL: none
  • FIRE-3: Wild-type KRAS, Wild-type NRAS

Chemotherapy

  • Levoleucovorin (Fusilev) 200 mg/m2 IV over 2 hours once on day 1, given second, 1 hour after completion of cetuximab, with irinotecan
  • Fluorouracil (5-FU) 400 mg/m2 IV bolus once on day 1, then 2400 mg/m2 IV continuous infusion over 46 hours, given third (total dose per cycle: 2800 mg/m2)
  • Irinotecan (Camptosar) 180 mg/m2 IV over 30 to 90 minutes once on day 1, given second, 1 hour after completion of cetuximab, with L-leucovorin

Targeted therapy

  • Cetuximab (Erbitux) as follows, given first and completed at least 1 hour before FOLFIRI begins:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once on day 8
    • Cycle 2 onwards: 250 mg/m2 IV over 60 minutes once per day on days 1 & 8

14-day cycles

References

  1. CRYSTAL: Van Cutsem E, Köhne CH, Hitre E, Zaluski J, Chang Chien CR, Makhson A, D'Haens G, Pintér T, Lim R, Bodoky G, Roh JK, Folprecht G, Ruff P, Stroh C, Tejpar S, Schlichting M, Nippgen J, Rougier P. Cetuximab and chemotherapy as initial treatment for metastatic colorectal cancer. N Engl J Med. 2009 Apr 2;360(14):1408-17. link to original article contains verified protocol PubMed NCT00154102
    1. Update: Van Cutsem E, Köhne CH, Láng I, Folprecht G, Nowacki MP, Cascinu S, Shchepotin I, Maurel J, Cunningham D, Tejpar S, Schlichting M, Zubel A, Celik I, Rougier P, Ciardiello F. Cetuximab plus irinotecan, fluorouracil, and leucovorin as first-line treatment for metastatic colorectal cancer: updated analysis of overall survival according to tumor KRAS and BRAF mutation status. J Clin Oncol. 2011 May 20;29(15):2011-9. Epub 2011 Apr 18. link to original article contains verified protocol PubMed
    2. Pooled update: Bokemeyer C, Van Cutsem E, Rougier P, Ciardiello F, Heeger S, Schlichting M, Celik I, Köhne CH. Addition of cetuximab to chemotherapy as first-line treatment for KRAS wild-type metastatic colorectal cancer: Pooled analysis of the CRYSTAL and OPUS randomised clinical trials. Eur J Cancer. 2012 Jul;48(10):1466-75. Epub 2012 Mar 23. link to original article PubMed
    3. Biomarker analysis: Van Cutsem E, Lenz HJ, Köhne CH, Heinemann V, Tejpar S, Melezínek I, Beier F, Stroh C, Rougier P, van Krieken JH, Ciardiello F. Fluorouracil, leucovorin, and irinotecan plus cetuximab treatment and RAS mutations in colorectal cancer. J Clin Oncol. 2015 Mar 1;33(7):692-700. Epub 2015 Jan 20. link to original article PubMed
  2. FIRE-3: Heinemann V, von Weikersthal LF, Decker T, Kiani A, Vehling-Kaiser U, Al-Batran SE, Heintges T, Lerchenmüller C, Kahl C, Seipelt G, Kullmann F, Stauch M, Scheithauer W, Hielscher J, Scholz M, Müller S, Link H, Niederle N, Rost A, Höffkes HG, Moehler M, Lindig RU, Modest DP, Rossius L, Kirchner T, Jung A, Stintzing S. FOLFIRI plus cetuximab versus FOLFIRI plus bevacizumab as first-line treatment for patients with metastatic colorectal cancer (FIRE-3): a randomised, open-label, phase 3 trial. Lancet Oncol. 2014 Sep;15(10):1065-75. Epub 2014 Jul 31. link to original article PubMed NCT00433927

FOLFOX4

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FOLFOX4: FOLinic acid, Fluorouracil, OXaliplatin

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Bokemeyer et al. 2008 (OPUS) 2005-2006 Randomized Phase II (C) FOLFOX4 & Cetuximab Inferior OS1
Douillard et al. 2010 (PRIME) 2006-2008 Phase 3 (C) FOLFOX4 & Panitumumab Seems to have superior PFS2
Qin et al. 2018 (TAILOR-CRC) 2010-NR Phase 3 (C) FOLFOX4 & Cetuximab Seems to have inferior OS

1Reported efficacy for OPUS is based on the 2012 pooled update and is only for KRAS wild-type tumors.
2In PRIME, patients with KRAS wild-type tumors receiving this regimen seem to have inferior OS, based on the 2014 update. Conversely, in KRAS mutants, this regimen seems to have superior PFS.
Note: TAILOR required RAS wild-type (not just KRAS). Note that there is another trial named TAILOR in non-small cell lung cancer, so this one has been dubbed TAILOR-CRC.

Chemotherapy

  • Folinic acid (Leucovorin) 200 mg/m2 IV over 2 hours once per day on days 1 & 2, given first, with oxaliplatin on day 1
  • Fluorouracil (5-FU) 400 mg/m2 IV bolus once per day on days 1 & 2, then 600 mg/m2 IV continuous infusion over 22 hours after each bolus, given second (total dose per cycle: 2000 mg/m2)
  • Oxaliplatin (Eloxatin) 85 mg/m2 IV over 2 hours once on day 1, given first

14-day cycles

References

  1. OPUS: Bokemeyer C, Bondarenko I, Makhson A, Hartmann JT, Aparicio J, de Braud F, Donea S, Ludwig H, Schuch G, Stroh C, Loos AH, Zubel A, Koralewski P. Fluorouracil, leucovorin, and oxaliplatin with and without cetuximab in the first-line treatment of metastatic colorectal cancer. J Clin Oncol. 2009 Feb 10;27(5):663-71. Epub 2008 Dec 29. link to original article contains verified protocol PubMed
    1. Update: Bokemeyer C, Bondarenko I, Hartmann JT, de Braud F, Schuch G, Zubel A, Celik I, Schlichting M, Koralewski P. Efficacy according to biomarker status of cetuximab plus FOLFOX-4 as first-line treatment for metastatic colorectal cancer: the OPUS study. Ann Oncol. 2011 Jul;22(7):1535-46. Epub 2011 Jan 12. link to original article PubMed
    2. Pooled Update: Bokemeyer C, Van Cutsem E, Rougier P, Ciardiello F, Heeger S, Schlichting M, Celik I, Köhne CH. Addition of cetuximab to chemotherapy as first-line treatment for KRAS wild-type metastatic colorectal cancer: Pooled analysis of the CRYSTAL and OPUS randomised clinical trials. Eur J Cancer. 2012 Jul;48(10):1466-75. Epub 2012 Mar 23. link to original article PubMed
  2. PRIME: Douillard JY, Siena S, Cassidy J, Tabernero J, Burkes R, Barugel M, Humblet Y, Bodoky G, Cunningham D, Jassem J, Rivera F, Kocákova I, Ruff P, Błasińska-Morawiec M, Šmakal M, Canon JL, Rother M, Oliner KS, Wolf M, Gansert J. Randomized, phase III trial of panitumumab with infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) versus FOLFOX4 alone as first-line treatment in patients with previously untreated metastatic colorectal cancer: the PRIME study. J Clin Oncol. 2010 Nov 1;28(31):4697-705. Epub 2010 Oct 4. link to original article PubMed NCT00364013
    1. Biomarker analysis: Douillard JY, Oliner KS, Siena S, Tabernero J, Burkes R, Barugel M, Humblet Y, Bodoky G, Cunningham D, Jassem J, Rivera F, Kocákova I, Ruff P, Błasińska-Morawiec M, Šmakal M, Canon JL, Rother M, Williams R, Rong A, Wiezorek J, Sidhu R, Patterson SD. Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer. N Engl J Med. 2013 Sep 12;369(11):1023-34. link to original article PubMed
    2. Update: Douillard JY, Siena S, Cassidy J, Tabernero J, Burkes R, Barugel M, Humblet Y, Bodoky G, Cunningham D, Jassem J, Rivera F, Kocákova I, Ruff P, Błasińska-Morawiec M, Smakal M, Canon JL, Rother M, Oliner KS, Tian Y, Xu F, Sidhu R. Final results from PRIME: randomized phase III study of panitumumab with FOLFOX4 for first-line treatment of metastatic colorectal cancer. Ann Oncol. 2014 Jul;25(7):1346-55. Epub 2014 Apr 8. link to original article PubMed
  3. TAILOR: Qin S, Li J, Wang L, Xu J, Cheng Y, Bai Y, Li W, Xu N, Lin LZ, Wu Q, Li Y, Yang J, Pan H, Ouyang X, Qiu W, Wu K, Xiong J, Dai G, Liang H, Hu C, Zhang J, Tao M, Yao Q, Wang J, Chen J, Eggleton SP, Liu T. Efficacy and tolerability of first-line cetuximab plus leucovorin, fluorouracil, and oxaliplatin (FOLFOX-4) versus FOLFOX-4 in patients with RAS wild-type metastatic colorectal cancer: the open-label, randomized, phase III TAILOR trial. J Clin Oncol. 2018 Oct 20;36(30):3031-9. Epub 2018 Sep 10. link to original article contains protocol PubMed NCT01228734

FOLFOX4 & Cetuximab

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FOLFOX4 & Cetuximab: FOLinic acid, Fluorouracil, OXaliplatin, Cetuximab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Bokemeyer et al. 2008 (OPUS) 2005-2006 Randomized Phase II (E-esc) FOLFOX4 Superior OS1
Qin et al. 2018 (TAILOR-CRC) 2010-NR Phase 3 (E-esc) FOLFOX4 Seems to have superior OS

1Reported efficacy for OPUS is based on the 2012 pooled update and is only for KRAS wild-type tumors.
TAILOR required RAS wild-type (not just KRAS). Note that there is another trial named TAILOR in non-small cell lung cancer, so this one has been dubbed TAILOR-CRC.

Biomarker eligibility criteria

  • OPUS: none
  • TAILOR-CRC: Wild-type KRAS, Wild-type NRAS

Chemotherapy

  • Folinic acid (Leucovorin) 200 mg/m2 IV over 2 hours once per day on days 1 & 2, given second, with oxaliplatin on day 1
  • Fluorouracil (5-FU) 400 mg/m2 IV bolus once per day on days 1 & 2, then 600 mg/m2 IV continuous infusion over 22 hours after each bolus, given third (total dose per cycle: 2000 mg/m2)
  • Oxaliplatin (Eloxatin) 85 mg/m2 IV over 2 hours once on day 1, given second

Targeted therapy

  • Cetuximab (Erbitux) as follows:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once on day 8, given first
    • Cycle 2 onwards: 250 mg/m2 IV over 60 minutes once per day on days 1 & 8, given first

14-day cycles

References

  1. OPUS: Bokemeyer C, Bondarenko I, Makhson A, Hartmann JT, Aparicio J, de Braud F, Donea S, Ludwig H, Schuch G, Stroh C, Loos AH, Zubel A, Koralewski P. Fluorouracil, leucovorin, and oxaliplatin with and without cetuximab in the first-line treatment of metastatic colorectal cancer. J Clin Oncol. 2009 Feb 10;27(5):663-71. Epub 2008 Dec 29. link to original article contains verified protocol PubMed
    1. Update: Bokemeyer C, Bondarenko I, Hartmann JT, de Braud F, Schuch G, Zubel A, Celik I, Schlichting M, Koralewski P. Efficacy according to biomarker status of cetuximab plus FOLFOX-4 as first-line treatment for metastatic colorectal cancer: the OPUS study. Ann Oncol. 2011 Jul;22(7):1535-46. Epub 2011 Jan 12. link to original article PubMed
    2. Pooled Update: Bokemeyer C, Van Cutsem E, Rougier P, Ciardiello F, Heeger S, Schlichting M, Celik I, Köhne CH. Addition of cetuximab to chemotherapy as first-line treatment for KRAS wild-type metastatic colorectal cancer: Pooled analysis of the CRYSTAL and OPUS randomised clinical trials. Eur J Cancer. 2012 Jul;48(10):1466-75. Epub 2012 Mar 23. link to original article PubMed
  2. TAILOR: Qin S, Li J, Wang L, Xu J, Cheng Y, Bai Y, Li W, Xu N, Lin LZ, Wu Q, Li Y, Yang J, Pan H, Ouyang X, Qiu W, Wu K, Xiong J, Dai G, Liang H, Hu C, Zhang J, Tao M, Yao Q, Wang J, Chen J, Eggleton SP, Liu T. Efficacy and tolerability of first-line cetuximab plus leucovorin, fluorouracil, and oxaliplatin (FOLFOX-4) versus FOLFOX-4 in patients with RAS wild-type metastatic colorectal cancer: the open-label, randomized, phase III TAILOR trial. J Clin Oncol. 2018 Oct 20;36(30):3031-9. Epub 2018 Sep 10. link to original article contains protocol PubMed NCT01228734

FOLFOX4 & Panitumumab

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FOLFOX4 & Panitumumab: FOLinic acid, Fluorouracil, OXaliplatin, Panitumumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Douillard et al. 2010 (PRIME) 2006-2008 Phase 3 (E-RT-esc) FOLFOX4 Seems to have superior OS1

1In KRAS wild-type patients, this regimen seems to have superior OS, based on the 2014 update.

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Chemotherapy

Targeted therapy

  • Panitumumab (Vectibix) 6 mg/kg IV once on day 1, given first
    • Infusion times are 1 hour for cycle 1, then if tolerated, 30 minutes for cycle 2 and later

14-day cycles

References

  1. PRIME: Douillard JY, Siena S, Cassidy J, Tabernero J, Burkes R, Barugel M, Humblet Y, Bodoky G, Cunningham D, Jassem J, Rivera F, Kocákova I, Ruff P, Błasińska-Morawiec M, Šmakal M, Canon JL, Rother M, Oliner KS, Wolf M, Gansert J. Randomized, phase III trial of panitumumab with infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) versus FOLFOX4 alone as first-line treatment in patients with previously untreated metastatic colorectal cancer: the PRIME study. J Clin Oncol. 2010 Nov 1;28(31):4697-705. Epub 2010 Oct 4. link to original article PubMed NCT00364013
    1. Biomarker analysis: Douillard JY, Oliner KS, Siena S, Tabernero J, Burkes R, Barugel M, Humblet Y, Bodoky G, Cunningham D, Jassem J, Rivera F, Kocákova I, Ruff P, Błasińska-Morawiec M, Šmakal M, Canon JL, Rother M, Williams R, Rong A, Wiezorek J, Sidhu R, Patterson SD. Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer. N Engl J Med. 2013 Sep 12;369(11):1023-34. link to original article PubMed
    2. Update: Douillard JY, Siena S, Cassidy J, Tabernero J, Burkes R, Barugel M, Humblet Y, Bodoky G, Cunningham D, Jassem J, Rivera F, Kocákova I, Ruff P, Błasińska-Morawiec M, Smakal M, Canon JL, Rother M, Oliner KS, Tian Y, Xu F, Sidhu R. Final results from PRIME: randomized phase III study of panitumumab with FOLFOX4 for first-line treatment of metastatic colorectal cancer. Ann Oncol. 2014 Jul;25(7):1346-55. Epub 2014 Apr 8. link to original article PubMed

mFOLFOX6 & Cetuximab

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mFOLFOX6 & Cetuximab: modified FOLinic acid, Fluorouracil, OXaliplatin, Cetuximab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Venook et al. 2017 (CALGB 80405) 2005-2012 Phase 3 (C) 1. mFOLFOX6-B Did not meet primary endpoint of OS
2. mFOLFOX6, Bevacizumab, Cetuximab Not reported
Aranda et al. 2018 (MACRO-2) 2010-NR Non-randomized portion of RCT

Note: In CALGB 80405, the arm receiving bevacizumab and cetuximab was terminated early.

Biomarker eligibility criteria

  • CALGB 80405: Wild-type KRAS (codons 12 & 13)
  • MACRO-2: Wild-type KRAS (exons 3 & 4), Wild-type NRAS (exons 2 to 4)

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows, given first:
    • Cycle 1: 400 mg/m2 IV once on day 1, then 250 mg/m2 IV once on day 8
    • Subsequent cycles: 250 mg/m2 IV once per day on days 1 & 8

14-day cycles (see below)

Subsequent treatment

References

  1. CALGB 80405: Venook AP, Niedzwiecki D, Lenz HJ, Innocenti F, Fruth B, Meyerhardt JA, Schrag D, Greene C, O'Neil BH, Atkins JN, Berry S, Polite BN, O'Reilly EM, Goldberg RM, Hochster HS, Schilsky RL, Bertagnolli MM, El-Khoueiry AB, Watson P, Benson AB 3rd, Mulkerin DL, Mayer RJ, Blanke C. Effect of First-Line Chemotherapy Combined With Cetuximab or Bevacizumab on Overall Survival in Patients With KRAS Wild-Type Advanced or Metastatic Colorectal Cancer: A Randomized Clinical Trial. JAMA. 2017 Jun 20;317(23):2392-2401. link to original article link to PMC article contains verified protocol PubMed NCT00265850
  2. MACRO-2: Aranda E, García-Alfonso P, Benavides M, Sánchez Ruiz A, Guillén-Ponce C, Safont MJ, Alcaide J, Gómez A, López R, Manzano JL, Méndez Ureña M, Sastre J, Rivera F, Grávalos C, García T, Martín-Valadés JI, Falcó E, Navalón M, González Flores E, Ma García Tapiador A, Ma López Muñoz A, Barrajón E, Reboredo M, García Teijido P, Viudez A, Cárdenas N, Díaz-Rubio E; Spanish Cooperative Group for the Treatment of Digestive Tumours. First-line mFOLFOX plus cetuximab followed by mFOLFOX plus cetuximab or single-agent cetuximab as maintenance therapy in patients with metastatic colorectal cancer: phase II randomised MACRO2 TTD study. Eur J Cancer. 2018 Sep;101:263-272. Epub 2018 Jul 24. link to original article PubMed NCT01161316

mFOLFOXIRI & Cetuximab (L-Leucovorin)

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mFOLFOXIRI & Cetuximab: modified L-FOLinic acid, Fluorouracil, OXaliplatin, IRInotecan, Cetuximab

Regimen

Study Evidence
Cremolini et al. 2018 (MACBETH) Non-randomized portion of RCT

Note: 5-FU instructions are unusual in that no bolus is given.

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Chemotherapy

Targeted therapy

14-day cycle for 8 cycles

Subsequent treatment

  • If deemed resectable: Surgery
  • If deemed unresectable: Cetuximab versus Bevacizumab maintenance

References

  1. MACBETH: Cremolini C, Antoniotti C, Lonardi S, Aprile G, Bergamo F, Masi G, Grande R, Tonini G, Mescoli C, Cardellino GG, Coltelli L, Salvatore L, Corsi DC, Lupi C, Gemma D, Ronzoni M, Dell'Aquila E, Marmorino F, Di Fabio F, Mancini ML, Marcucci L, Fontanini G, Zagonel V, Boni L, Falcone A. Activity and safety of cetuximab plus modified FOLFOXIRI followed by maintenance with cetuximab or bevacizumab for RAS and BRAF wild-type metastatic colorectal cancer: a randomized phase 2 clinical trial. JAMA Oncol. 2018 Apr 1;4(4):529-536. link to original article contains verified protocol link to PMC article PubMed NCT02295930

FOLFOXIRI & Panitumumab

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FOLFOXIRI & Panitumumab: FOLinic acid, Fluorouracil, OXaliplatin, IRInotecan, Panitumumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Modest et al. 2019 (VOLFI) 2011-2016 Randomized Phase II (E-esc) FOLFOXIRI Superior ORR

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Chemotherapy

Targeted therapy

14-day cycle until POD or resectability or to max 12 cycles

References

  1. VOLFI: Modest DP, Martens UM, Riera-Knorrenschild J, Greeve J, Florschütz A, Wessendorf S, Ettrich T, Kanzler S, Nörenberg D, Ricke J, Seidensticker M, Held S, Buechner-Steudel P, Atzpodien J, Heinemann V, Seufferlein T, Tannapfel A, Reinacher-Schick AC, Geissler M. FOLFOXIRI Plus Panitumumab As First-Line Treatment of RAS Wild-Type Metastatic Colorectal Cancer: The Randomized, Open-Label, Phase II VOLFI Study (AIO KRK0109). J Clin Oncol. 2019 Dec 10;37(35):3401-3411. Epub 2019 Oct 14. link to original article contains verified protocol PubMed NCT01328171

Maintenance after first-line therapy

Bevacizumab monotherapy

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Hagman et al. 2015 (Nordic ACT2) 2010-2012 Phase III (C) Erlotinib & Bevacizumab Did not meet primary endpoint of PFS

Biomarker eligibility criteria

  • Wild-type KRAS

Targeted therapy

21-day cycles

References

  1. Nordic ACT2: Hagman H, Frödin JE, Berglund Å, Sundberg J, Vestermark LW, Albertsson M, Fernebro E, Johnsson A. A randomized study of KRAS-guided maintenance therapy with bevacizumab, erlotinib or metronomic capecitabine after first-line induction treatment of metastatic colorectal cancer: the Nordic ACT2 trial. Ann Oncol. 2016 Jan;27(1):140-7. Epub 2015 Oct 19. link to original article contains verified protocol PubMed NCT01229813

Cetuximab monotherapy

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Regimen variant #1, 250 mg/m2 weekly

Study Years of enrollment Evidence Comparator Comparative Efficacy
Aranda et al. 2018 (MACRO-2) 2010-NR Randomized Phase II (E-de-esc) mFOLFOX6 & Cetuximab Non-inferior PFS

Note: regimen details are from ClinicalTrials.gov; they were not present in the abstract or the manuscript.

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Preceding treatment

Targeted therapy

7-day cycles

Regimen variant #2, 500 mg/m2 q2wk

Study Evidence
Cremolini et al. 2018 (MACBETH) Randomized Phase II

Note: this was a non-comparative study.

Biomarker eligibility criteria

  • Wild-type KRAS, Wild-type NRAS

Preceding treatment

Targeted therapy

14-day cycles

References

  1. MACBETH: Cremolini C, Antoniotti C, Lonardi S, Aprile G, Bergamo F, Masi G, Grande R, Tonini G, Mescoli C, Cardellino GG, Coltelli L, Salvatore L, Corsi DC, Lupi C, Gemma D, Ronzoni M, Dell'Aquila E, Marmorino F, Di Fabio F, Mancini ML, Marcucci L, Fontanini G, Zagonel V, Boni L, Falcone A. Activity and safety of cetuximab plus modified FOLFOXIRI followed by maintenance with cetuximab or bevacizumab for RAS and BRAF wild-type metastatic colorectal cancer: a randomized phase 2 clinical trial. JAMA Oncol. 2018 Apr 1;4(4):529-536. link to original article link to PMC article PubMed NCT02295930
  2. MACRO-2: Aranda E, García-Alfonso P, Benavides M, Sánchez Ruiz A, Guillén-Ponce C, Safont MJ, Alcaide J, Gómez A, López R, Manzano JL, Méndez Ureña M, Sastre J, Rivera F, Grávalos C, García T, Martín-Valadés JI, Falcó E, Navalón M, González Flores E, Ma García Tapiador A, Ma López Muñoz A, Barrajón E, Reboredo M, García Teijido P, Viudez A, Cárdenas N, Díaz-Rubio E; Spanish Cooperative Group for the Treatment of Digestive Tumours. First-line mFOLFOX plus cetuximab followed by mFOLFOX plus cetuximab or single-agent cetuximab as maintenance therapy in patients with metastatic colorectal cancer: phase II randomised MACRO2 TTD study. Eur J Cancer. 2018 Sep;101:263-272. Epub 2018 Jul 24. link to original article PubMed NCT01161316

Advanced or metastatic disease, second-line

FOLFIRI & Panitumumab

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FOLFIRI & Panitumumab: FOLinic acid, Fluorouracil, IRInotecan, Panitumumab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Peeters et al. 2010 (20050181) 2006-2008 Phase 3 (E-esc) FOLFIRI Seems to have superior PFS1

1Reported efficacy is for wild-type KRAS, only, and is based on the 2014 update.

Biomarker eligibility criteria

  • None

Chemotherapy

  • Folinic acid (Leucovorin) 400 mg/m2 IV over 2 hours once on day 1, given second, with irinotecan
  • Fluorouracil (5-FU) 400 mg/m2 IV bolus once on day 1, then 2400 mg/m2 IV continuous infusion over 46 to 48 hours, given third (total dose per cycle: 2800 mg/m2)
  • Irinotecan (Camptosar) 180 mg/m2 IV over 30 to 90 minutes once on day 1, given second, with leucovorin

Targeted therapy

14-day cycles

References

  1. 20050181: Peeters M, Price TJ, Cervantes A, Sobrero AF, Ducreux M, Hotko Y, André T, Chan E, Lordick F, Punt CJ, Strickland AH, Wilson G, Ciuleanu TE, Roman L, Van Cutsem E, Tzekova V, Collins S, Oliner KS, Rong A, Gansert J. Randomized phase III study of panitumumab with fluorouracil, leucovorin, and irinotecan (FOLFIRI) compared with FOLFIRI alone as second-line treatment in patients with metastatic colorectal cancer. J Clin Oncol. 2010 Nov 1;28(31):4706-13. Epub 2010 Oct 4. link to original article contains verified protocol PubMed NCT00339183
    1. Update: Peeters M, Price TJ, Cervantes A, Sobrero AF, Ducreux M, Hotko Y, André T, Chan E, Lordick F, Punt CJ, Strickland AH, Wilson G, Ciuleanu TE, Roman L, Van Cutsem E, Tian Y, Sidhu R. Final results from a randomized phase 3 study of FOLFIRI {+/-} panitumumab for second-line treatment of metastatic colorectal cancer. Ann Oncol. 2014 Jan;25(1):107-16. Erratum in: Ann Oncol. 2014 Mar;25(3):757. link to original article PubMed

Irinotecan monotherapy

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Example orders

Regimen variant #1, 180 mg/m2 q2wk

Study Years of enrollment Evidence Comparator Comparative Efficacy
Shi et al. 2019 (CRC009) 2009-2011 Phase 3 (C) Irinotecan & CMAB009 Inferior PFS50%

Chemotherapy

14-day cycles

Regimen variant #2, 300 mg/m2 q3wk

Study Years of enrollment Evidence Comparator Comparative Efficacy
Seymour et al. 2013 (PICCOLO) 2006-2008 Phase 3 (C) Irinotecan & Panitumumab Did not meet primary endpoint of OS

Note: In some trials, this starting dose was intended for patients who were at least 70 years old, had ECOG performance status 2 or more, or had prior pelvic radiation. Patients in N9841 had not previously received irinotecan or oxaliplatin.

Chemotherapy

21-day cycles

Regimen variant #3, 350 mg/m2 q3wk

Study Years of enrollment Evidence Comparator Comparative Efficacy
Seymour et al. 2013 (PICCOLO) 2006-2008 Phase 3 (C) 1. Irinotecan & Cyclosporine
2. Irinotecan & Panitumumab 		Did not meet primary endpoint of OS

Chemotherapy

Supportive medications

21-day cycles

References

  1. PICCOLO: Seymour MT, Brown SR, Middleton G, Maughan T, Richman S, Gwyther S, Lowe C, Seligmann JF, Wadsley J, Maisey N, Chau I, Hill M, Dawson L, Falk S, O'Callaghan A, Benstead K, Chambers P, Oliver A, Marshall H, Napp V, Quirke P. Panitumumab and irinotecan versus irinotecan alone for patients with KRAS wild-type, fluorouracil-resistant advanced colorectal cancer (PICCOLO): a prospectively stratified randomised trial. Lancet Oncol. 2013 Jul;14(8):749-59. Epub 2013 May 29. link to original article link to PMC article contains verified protocol PubMed NCT00389870
  2. CRC009: Shi Y, Li J, Xu J, Sun Y, Wang L, Cheng Y, Liu W, Sun G, Chen Y, Bai L, Zhang Y, He X, Luo Y, Wang Z, Liu Y, Yao Q, Li Y, Qin S, Hu X, Bi F, Zheng R, Ouyang X. CMAB009 plus irinotecan versus irinotecan-only as second-line treatment after fluoropyrimidine and oxaliplatin failure in KRAS wild-type metastatic colorectal cancer patients: promising findings from a prospective, open-label, randomized, phase III trial. Cancer Commun (Lond). 2019 May 24;39(1):28. link to original article link to PMC article contains verified protocol PubMed NCT01550055

Irinotecan & Cetuximab

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Sobrero et al. 2008 (EPIC) 2003-2006 Phase 3 (E-esc) Irinotecan Did not meet primary endpoint of OS

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once per day on days 8 & 15
    • Subsequent cycles: 250 mg/m2 IV over 60 minutes once per day on days 1, 8, 15

Supportive medications

21-day cycles

References

  1. EPIC: Sobrero AF, Maurel J, Fehrenbacher L, Scheithauer W, Abubakr YA, Lutz MP, Vega-Villegas ME, Eng C, Steinhauer EU, Prausova J, Lenz HJ, Borg C, Middleton G, Kröning H, Luppi G, Kisker O, Zubel A, Langer C, Kopit J, Burris HA 3rd. EPIC: phase III trial of cetuximab plus irinotecan after fluoropyrimidine and oxaliplatin failure in patients with metastatic colorectal cancer. J Clin Oncol. 2008 May 10;26(14):2311-9. Epub 2008 Apr 7. link to original article contains verified protocol PubMed NCT00063141

Advanced or metastatic disease, subsequent lines of therapy

Cetuximab monotherapy

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Example orders

Regimen variant #1, weekly

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Saltz et al. 2004 2001 Phase II (RT)
Cunningham et al. 2004 (BOND) 2001-2002 Phase 3 (C) Irinotecan & Cetuximab Inferior TTP
Lenz et al. 2006 (SALVAGE) NR Phase II
Jonker et al. 2007 (NCIC-CTG CO.17) 2003-2005 Phase 3 (E-RT-esc) Best supportive care Superior OS
Siu et al. 2013 (NCIC-CTG/AGITG CO.20) 2008-2011 Phase 3 (C) Brivanib & Cetuximab Did not meet primary endpoint of OS
Price et al. 2014 (ASPECCT) 2010-2012 Phase 3 (C) Panitumumab Non-inferior OS

Targeted therapy

  • Cetuximab (Erbitux) as follows:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once per day on days 8, 15, 22
    • Cycle 2 onwards: 250 mg/m2 IV over 60 minutes once per day on days 1, 8, 15, 22

Supportive medications

28-day cycles

Regimen variant #2, bi-weekly

Study Evidence
Tabernero et al. 2009 Phase I

Note: no primary reference could be found for this exact dosing in monotherapy; in the phase I trial it is described as "the most convenient and feasible dose".

Targeted therapy

  • Cetuximab (Erbitux) 500 mg/m2 IV over 2 hours once on day 1
    • If tolerated, subsequent doses can be given over 1 hour

Supportive medications

14-day cycles

References

  1. Saltz LB, Meropol NJ, Loehrer PJ Sr, Needle MN, Kopit J, Mayer RJ. Phase II trial of cetuximab in patients with refractory colorectal cancer that expresses the epidermal growth factor receptor. J Clin Oncol. 2004 Apr 1;22(7):1201-8. Epub 2004 Mar 1. link to original article PubMed
  2. BOND: Cunningham D, Humblet Y, Siena S, Khayat D, Bleiberg H, Santoro A, Bets D, Mueser M, Harstrick A, Verslype C, Chau I, Van Cutsem E. Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med. 2004 Jul 22;351(4):337-45. link to original article contains verified protocol PubMed
  3. SALVAGE: Lenz HJ, Van Cutsem E, Khambata-Ford S, Mayer RJ, Gold P, Stella P, Mirtsching B, Cohn AL, Pippas AW, Azarnia N, Tsuchihashi Z, Mauro DJ, Rowinsky EK. Multicenter phase II and translational study of cetuximab in metastatic colorectal carcinoma refractory to irinotecan, oxaliplatin, and fluoropyrimidines. J Clin Oncol. 2006 Oct 20;24(30):4914-21. link to original article contains verified protocol PubMed
  4. NCIC-CTG CO.17: Jonker DJ, O'Callaghan CJ, Karapetis CS, Zalcberg JR, Tu D, Au HJ, Berry SR, Krahn M, Price T, Simes RJ, Tebbutt NC, van Hazel G, Wierzbicki R, Langer C, Moore MJ. Cetuximab for the treatment of colorectal cancer. N Engl J Med. 2007 Nov 15;357(20):2040-8. link to original article contains verified protocol PubMed NCT00079066
    1. Subgroup analysis: Karapetis CS, Khambata-Ford S, Jonker DJ, O'Callaghan CJ, Tu D, Tebbutt NC, Simes RJ, Chalchal H, Shapiro JD, Robitaille S, Price TJ, Shepherd L, Au HJ, Langer C, Moore MJ, Zalcberg JR. K-ras mutations and benefit from cetuximab in advanced colorectal cancer. N Engl J Med. 2008 Oct 23;359(17):1757-65. link to original article PubMed
    2. Subgroup analysis: Asmis TR, Powell E, Karapetis CS, Jonker DJ, Tu D, Jeffery M, Pavlakis N, Gibbs P, Zhu L, Dueck DA, Whittom R, Langer C, O'Callaghan CJ. Comorbidity, age and overall survival in cetuximab-treated patients with advanced colorectal cancer (ACRC)--results from NCIC-CTG CO.17: a phase III trial of cetuximab versus best supportive care. Ann Oncol. 2011 Jan;22(1):118-26. Epub 2010 Jul 5. link to original article contains verified protocol PubMed
  5. Phase I: Tabernero J, Ciardiello F, Rivera F, Rodriguez-Braun E, Ramos FJ, Martinelli E, Vega-Villegas ME, Roselló S, Liebscher S, Kisker O, Macarulla T, Baselga J, Cervantes A. Cetuximab administered once every second week to patients with metastatic colorectal cancer: a two-part pharmacokinetic/pharmacodynamic phase I dose-escalation study. Ann Oncol. 2010 Jul;21(7):1537-45. Epub 2009 Nov 25. link to original article PubMed
  6. NCIC-CTG/AGITG CO.20: Siu LL, Shapiro JD, Jonker DJ, Karapetis CS, Zalcberg JR, Simes J, Couture F, Moore MJ, Price TJ, Siddiqui J, Nott LM, Charpentier D, Liauw W, Sawyer MB, Jefford M, Magoski NM, Haydon A, Walters I, Ringash J, Tu D, O'Callaghan CJ. Phase III randomized, placebo-controlled study of cetuximab plus brivanib alaninate versus cetuximab plus placebo in patients with metastatic, chemotherapy-refractory, wild-type K-RAS colorectal carcinoma: the NCIC Clinical Trials Group and AGITG CO.20 Trial. J Clin Oncol. 2013 Jul 1;31(19):2477-84. Epub 2013 May 20. link to original article contains verified protocol PubMed NCT00640471
  7. ASPECCT: Price TJ, Peeters M, Kim TW, Li J, Cascinu S, Ruff P, Suresh AS, Thomas A, Tjulandin S, Zhang K, Murugappan S, Sidhu R. Panitumumab versus cetuximab in patients with chemotherapy-refractory wild-type KRAS exon 2 metastatic colorectal cancer (ASPECCT): a randomised, multicentre, open-label, non-inferiority phase 3 study. Lancet Oncol. 2014 May;15(6):569-79. Epub 2014 Apr 14. link to original article PubMed NCT01001377
    1. Update: Price T, Kim TW, Li J, Cascinu S, Ruff P, Suresh AS, Thomas A, Tjulandin S, Guan X, Peeters M. Final results and outcomes by prior bevacizumab exposure, skin toxicity, and hypomagnesaemia from ASPECCT: randomized phase 3 non-inferiority study of panitumumab versus cetuximab in chemorefractory wild-type KRAS exon 2 metastatic colorectal cancer. Eur J Cancer. 2016 Nov;68:51-59. Epub 2016 Oct 5. link to original article PubMed

Irinotecan & Cetuximab

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Regimen variant #1, 125/250, irinotecan 2 weeks on, 1 week off

FDA-recommended dose

Note: In contrast to BOND, some guidelines list irinotecan as being given on days 1 & 8 of a 21-day cycle. No primary reference could be found for this. Note also that the FDA-recommended dosing is for the cetuximab component; no comment is made about irinotecan dosing.

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once per day on days 8 & 15
    • Subsequent cycles: 250 mg/m2 IV over 60 minutes once per day on days 1, 8, 15

Supportive medications

21-day cycles

Regimen variant #2, 125/250, irinotecan 4 weeks on, 2 weeks off

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Cunningham et al. 2004 (BOND) 2001-2002 Phase 3 (E-RT-esc) Cetuximab Superior TTP

Note that the FDA-recommended dosing is for the cetuximab component; no comment is made about irinotecan dosing.

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once per day on days 8, 15, 22, 29, 36
    • Subsequent cycles: 250 mg/m2 IV over 60 minutes once per day on days 1, 8, 15, 22, 29, 36

Supportive medications

42-day cycles

Regimen variant #3, 150/500, bi-weekly

Study Evidence
Osumi et al. 2018 Phase II

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) 500 mg/m2 IV over 2 hours once on day 1
    • Subsequent doses are given over 60 minutes

Supportive medications

14-day cycles

Regimen variant #4, 180/250, bi-weekly, with response adaptation

Study Evidence
Van Cutsem et al. 2012 (EVEREST) Non-randomized portion of RCT

Chemotherapy

Targeted therapy

21-day course

Subsequent treatment

  • Grade 0 or 1 skin reaction: Continue standard dose versus escalate dose of cetuximab to 500 mg/m2
  • Grade 2 or worse skin reaction: Continue standard dose

Regimen variant #5, 180/500, bi-weekly

Study Evidence
Martín-Martorell et al. 2008 Phase II

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) 500 mg/m2 IV over 2 hours once on day 1
    • If tolerated, subsequent doses can be given over 1 hour

Supportive medications

14-day cycles

Regimen variant #6, 350/250, q3wk irinotecan

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Cunningham et al. 2004 (BOND) 2001-2002 Phase 3 (E-RT-esc) Cetuximab Superior TTP

Note that the FDA-recommended dosing is for the cetuximab component; no comment is made about irinotecan dosing.

Chemotherapy

Targeted therapy

  • Cetuximab (Erbitux) as follows:
    • Cycle 1: 400 mg/m2 IV over 2 hours once on day 1, then 250 mg/m2 IV over 60 minutes once per day on days 8 & 15
    • Subsequent cycles: 250 mg/m2 IV over 60 minutes once per day on days 1, 8, 15

Supportive medications

21-day cycles

References

  1. BOND: Cunningham D, Humblet Y, Siena S, Khayat D, Bleiberg H, Santoro A, Bets D, Mueser M, Harstrick A, Verslype C, Chau I, Van Cutsem E. Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan-refractory metastatic colorectal cancer. N Engl J Med. 2004 Jul 22;351(4):337-45. link to original article contains verified protocol PubMed
  2. Martín-Martorell P, Roselló S, Rodríguez-Braun E, Chirivella I, Bosch A, Cervantes A. Biweekly cetuximab and irinotecan in advanced colorectal cancer patients progressing after at least one previous line of chemotherapy: results of a phase II single institution trial. Br J Cancer. 2008 Aug 5;99(3):455-8. link to original article contains verified protocol link to PMC article PubMed
  3. EVEREST: Van Cutsem E, Tejpar S, Vanbeckevoort D, Peeters M, Humblet Y, Gelderblom H, Vermorken JB, Viret F, Glimelius B, Gallerani E, Hendlisz A, Cats A, Moehler M, Sagaert X, Vlassak S, Schlichting M, Ciardiello F. Intrapatient cetuximab dose escalation in metastatic colorectal cancer according to the grade of early skin reactions: the randomized EVEREST study. J Clin Oncol. 2012 Aug 10;30(23):2861-8. Epub 2012 Jul 2. link to original article contains protocol PubMed
  4. Osumi H, Shinozaki E, Mashima T, Wakatsuki T, Suenaga M, Ichimura T, Ogura M, Ota Y, Nakayama I, Takahari D, Chin K, Miki Y, Yamaguchi K. Phase II trial of biweekly cetuximab and irinotecan as third-line therapy for pretreated KRAS exon 2 wild-type colorectal cancer. Cancer Sci. 2018 Aug;109(8):2567-2575. Epub 2018 Jul 13. link to original article link to PMC article contains verified protocol PubMed UMIN000019893

Panitumumab monotherapy

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Example orders

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Van Cutsem et al. 2007 (20020408) 2004-2005 Phase 3 (E-RT-esc) Best supportive care Superior PFS
Price et al. 2014 (ASPECCT) 2010-2012 Phase 3 (E-RT-switch-ic) Cetuximab Non-inferior OS
Kim et al. 2016 (20100007) 2011-2013 Phase 3 (E-RT-esc) Best supportive care Seems to have superior OS1

1Reported efficacy for 20100007 is based on the 2018 update.

Targeted therapy

14-day cycles

References

  1. 20020408: Van Cutsem E, Peeters M, Siena S, Humblet Y, Hendlisz A, Neyns B, Canon JL, Van Laethem JL, Maurel J, Richardson G, Wolf M, Amado RG. Open-label phase III trial of panitumumab plus best supportive care compared with best supportive care alone in patients with chemotherapy-refractory metastatic colorectal cancer. J Clin Oncol. 2007 May 1;25(13):1658-64. link to original article contains verified protocol PubMed NCT00113763
  2. ASPECCT: Price TJ, Peeters M, Kim TW, Li J, Cascinu S, Ruff P, Suresh AS, Thomas A, Tjulandin S, Zhang K, Murugappan S, Sidhu R. Panitumumab versus cetuximab in patients with chemotherapy-refractory wild-type KRAS exon 2 metastatic colorectal cancer (ASPECCT): a randomised, multicentre, open-label, non-inferiority phase 3 study. Lancet Oncol. 2014 May;15(6):569-79. Epub 2014 Apr 14. link to original article PubMed NCT01001377
    1. Update: Price T, Kim TW, Li J, Cascinu S, Ruff P, Suresh AS, Thomas A, Tjulandin S, Guan X, Peeters M. Final results and outcomes by prior bevacizumab exposure, skin toxicity, and hypomagnesaemia from ASPECCT: randomized phase 3 non-inferiority study of panitumumab versus cetuximab in chemorefractory wild-type KRAS exon 2 metastatic colorectal cancer. Eur J Cancer. 2016 Nov;68:51-59. Epub 2016 Oct 5. link to original article PubMed
  3. 20100007: Kim TW, Elme A, Kusic Z, Park JO, Udrea AA, Kim SY, Ahn JB, Valencia RV, Krishnan S, Bilic A, Manojlovic N, Dong J, Guan X, Lofton-Day C, Jung AS, Vrdoljak E. A phase 3 trial evaluating panitumumab plus best supportive care vs best supportive care in chemorefractory wild-type KRAS or RAS metastatic colorectal cancer. Br J Cancer. 2016 Nov 8;115(10):1206-1214. Epub 2016 Oct 13. link to original article link to PMC article PubMed NCT01412957
    1. Update: Kim TW, Elme A, Park JO, Udrea AA, Kim SY, Ahn JB, Valencia RV, Krishnan S, Manojlovic N, Guan X, Lofton-Day C, Jung AS, Vrdoljak E. Final Analysis of Outcomes and RAS/BRAF Status in a Randomized Phase 3 Study of Panitumumab and Best Supportive Care in Chemorefractory Wild Type KRAS Metastatic Colorectal Cancer. Clin Colorectal Cancer. 2018 Sep;17(3):206-214. Epub 2018 Mar 21. link to original article PubMed
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