You are here: Home: CCU 5 | 2006: Charles S Fuchs, MD, MPH

Tracks 1-13

Track 1 Introduction Track 2 Use of irinotecan-containing regimens in the adjuvant setting Track 3 Effects of physical activity on patients with colon cancer Track 4 Influence of regular aspirin use on survival for patients with colon cancer Track 5 Potential mechanisms of aspirin, diet and exercise on risk of cancer recurrence Track 6 Feasibility of prospectively evaluating aspirin, diet or exercise in clinical trials Track 7 Counseling patients about dietary and lifestyle modifications Track 8 Selection of adjuvant chemotherapy for patients with Stage II disease Track 9 Ongoing adjuvant clinical trials incorporating biologic therapies Track 10 Studies evaluating chemotherapy in combination with biologic doublets in the metastatic setting Track 11 Approach to patients with synchronous primary and metastatic colon cancer Track 12 Selection of first-line chemotherapy Track 13 OPTIMOX2: Maintenance therapy or chemotherapy-free intervals after FOLFOX for patients with metastatic disease

 

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Track 3

DR FUCHS: In CALGB-C89803, which was a negative trial in terms of the primary endpoint (Saltz 2004), we provided patients with a 16-page questionnaire about diet and lifestyle. Patients completed the questionnaire, which was validated through various studies such as the Nurses’ Health Study. In the CALGB trial, the surveys were administered midway through adjuvant therapy and about six months after its completion (Meyerhardt 2006a, b).

Compliance with the questionnaire was excellent — about 95 percent of the patients completed it. Physical activity was highly protective and associated with a significant improvement in disease-free survival. The more physically active the patient, the better the disease-free and overall survival (Meyerhardt 2006a).

DR LOVE: Did the physical activity occur during chemotherapy?

DR FUCHS: It was during and after chemotherapy. We measured it at two time points. If the patients walked an average of about six hours per week, they had a 47 percent improvement in disease-free survival (Meyerhardt 2006a).

One might argue that the physically active patients were healthier and the patients who were inactive had occult cancer. We considered that and repeated the analysis by excluding all of the events in the first six months after completing the questionnaire, and we found the same results (Meyerhardt 2006a). We also repeated the analysis for the patients with colon cancer in the Nurses’ Health Study who had completed the same questionnaire, and the findings were identical (Meyerhardt 2006b).

Track 8

DR FUCHS: I use the clinical features we are familiar with, such as perforation and obstruction and the number of lymph nodes sampled. I try to pool together patients I don’t believe would benefit from adjuvant therapy, those with whom I’m comfortable using a f luoropyrimidine alone and those for whom I would use FOLFOX.

In patients with higher-risk disease — those with few lymph nodes analyzed or those with adherence to or invasion of adjacent structures who might have obstruction or perforation — I’m comfortable using FOLFOX. I have to admit, however, that I’m still willing to use f luoropyrimidine monotherapy for patients with more standard-risk disease, although I know some of my colleagues routinely use FOLFOX in all circumstances.

Although the proportional benefit of FOLFOX is fairly consistent across patients with Stage II or Stage III disease, I also want to consider the absolute benefits, in a particularly low-risk setting. Is the addition of oxaliplatin, with its inherent neuropathy risk, necessary in patients for whom the absolute benefit is not so great?

DR LOVE: When you are going to use f luoropyrimidine monotherapy, do you bring up the possibility of capecitabine?

DR FUCHS: I do. The X-ACT study is a compelling effort (Twelves 2005; [3.1]), although the majority of the patients were enrolled in Europe. Dan Haller has clearly demonstrated that the toxicity associated with capecitabine differs on each side of the Atlantic (Haller 2006). Although you can use 2,500 mg/m2 per day in Europe with reasonable tolerability, it is difficult to use those doses in the United States. The quandary is that this is an adjuvant setting and we want to use the standard dose used in the X-ACT trial, yet most patients in North America don’t tolerate that dose.

Track 11

DR FUCHS: I consider the possibility of not sending them to up-front surgery. If the tumor is on the right side, where the risk of obstruction is reasonably low, if they don’t demonstrate any obstructive symptoms and if there isn’t any obvious bleeding and I’m not concerned about perforation, sending them for a resection would just delay the start of systemic therapy.

I would start them on a regimen of chemotherapy with bevacizumab without sending them for a resection. Some are concerned about the possibility that perforation might occur if the primary is in place, but those data have not been borne out.

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Editor:
Neil Love, MD

Interviews:

Axel Grothey, MD
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Daniel G Haller, MD
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Charles S Fuchs, MD, MPH
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Neal J Meropol, MD
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