Al B. Benson III
Al B. Benson III
Al B. Benson III
Maxwell T. Vergo and Al B. Benson III
The development of treatment decision strategies to guide the use of adjuvant chemotherapy in patients with stage II colon cancer continues to challenge many oncologists. Clearly, recurrence risk and prognosis for patients with stage II colon cancer can be variable, with subsets of patients with stage II disease at potentially higher risk than some with stage III. Adjuvant chemotherapy seems to produce a consistent relative risk reduction for recurrence across studies. Using clinical calculators to predict individual recurrence risk based on histopathologic and patient data allows this relative risk reduction to be translated into absolute benefit to the patient. In addition, gene expression assays in combination with these histopathologic data may further improve the accuracy of recurrence risk calculations and allow more accurate absolute benefit estimations. This absolute benefit should be discussed with the patient, taking into account the risk of morbidity from chemotherapy and individual preferences to arrive at a shared medical decision regarding adjuvant chemotherapy.
Mary F. Mulcahy and Al B. Benson III
The past 5 years have seen significant developments in the treatment of colorectal cancer (CRC). New chemotherapy agents with activity in CRC have demonstrated an improvement in survival for patients with advanced CRC. Studies now are focusing on combinations and sequences of chemotherapy agents to prolong survival in second- and even third-line therapies. Oral agents have been developed and are being studied in combination chemotherapy regimens. Development of oral combinations should maintain a survival advantage with the added benefit of convenience for the patient. Drugs designed to act on specific cellular protein targets have also shown activity and are being explored further. Researchers continue to pursue immunotherapy and vaccine therapy. Studies are now focusing on how best to use the available agents. These new agents and new combinations of agents and of approaches have led and should continue to lead to improved outcomes in the treatment of patients with CRC.
Brian Vicuna and Al B. Benson III
The treatment of stage II colon cancer is a controversial issue that has persisted for the past decade. Clinicians must understand that accurate assessment of risk factors is the key to identifying patients who will benefit from treatment. Pathologic staging for colon cancer is based on the American Joint Committee on Cancer 6th edition staging system. In addition, distinct pathologic factors characterize a patient at high risk for stage II disease. More recent retrospective data suggest that molecular markers and gene expression microarrays may be valuable as prognostic and predictive tests. Unfortunately, previous research studies were not powered to properly assess efficacy in stage II disease. However, 2 recent clinical trials, National Surgical Adjuvant Breast and Bowel Project C-07 and MOSAIC, have provided more insight into defining the optimal treatment approach. With the development of the newer therapeutic agents, oxaliplatin and bevacizumab, ongoing trials such as Intergroup E5202 should help determine risk versus benefit of chemotherapy in the adjuvant treatment of stage II colon cancer.
Robert W. Carlson, Jonathan K. Larsen, Joan McClure, C. Lyn Fitzgerald, Alan P. Venook, Al B. Benson III and Benjamin O. Anderson
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) are evidence- and consensus-based clinical practice guidelines addressing malignancies that affect more than 97% of all patients with cancer in the United States. The NCCN Guidelines are used extensively in the United States and globally. Use of the guidelines outside the United States has driven the need to adapt the guidelines based on local, regional, or national resources. The NCCN Guidelines Panels created, vetted, and continually update the NCCN Guidelines based on published scientific data on cancer detection, diagnosis, and treatment efficacy. The guidelines are developed within the context of commonly available resources, methods of payment, societal and cultural expectations, and governmental regulations as they exist in the United States. Although many of the cancer management recommendations contained in the NCCN Guidelines apply broadly from a global perspective, not all do. Disparities in availability and access to health care exist among countries, within countries, and among different social groups in the same country, especially regarding resources for cancer prevention, early detection, and treatment. In addition, different drug approval and payment processes result in regional variation in availability of and access to cancer treatment, especially highly expensive agents and radiation therapy. Differences in cancer risk, predictive biomarker expression, and pharmacogenetics exist across ethnic and racial groups, and therefore across geographic locations. Cultural and societal expectations and requirements may also require modification of NCCN Guidelines for use outside the United States. This article describes the adaptation process, using the recent Latin American adaptation of the 2013 NCCN Guidelines for Colorectal Cancer as an example.
Mohamedtaki A. Tejani, Anna ter Veer, Dana Milne, Rebecca Ottesen, Tanios Bekaii-Saab, Al B. Benson III, Deborah Schrag, Stephen Shibata, John Skibber, Martin Weiser, Neal Wilkinson and Steven J. Cohen
Appendiceal malignancies are rare and represent 1% of intestinal tumors in the United States. The role and efficacy of modern systemic therapy in advanced appendiceal adenocarcinoma has not been established. This study analyzed patients with recurrent or metastatic appendiceal adenocarcinoma in the database for Colorectal Cancer (CRC; 2005-2012). This database tracks longitudinal care for patients treated at 8 specialty centers across the Unites States. Study objectives were to describe and evaluate the efficacy of systemic therapy and investigate relationships with clinicopathologic features. Cox regression analysis was performed to identify predictors of progression-free survival (PFS) and overall survival (OS). Of 248 patients with advanced appendiceal carcinoma, 112 (45%) received systemic therapy for measurable disease and are the focus of this report. The most common chemotherapy regimens included FOLFOX with or without bevacizumab (n=39 and n=37, respectively), FOLFIRI (n=15), and single-agent fluoro-pyrimidine (n=10). Among 99 patients evaluable for best response, 39 experienced a response (response rate [RR], 39%) and 36 (36%) had stable disease. The median PFS was 1.2 years (95% CI, 1.0-1.8) and median OS was 2.1 years (95% CI, 1.6-2.3). Patients with non-mucinous histology or high-grade tumors and those who underwent nondebulking surgery had worse PFS and OS. Treatment of advanced appendiceal adenocarcinoma at NCCN Member Institutions commonly incorporates agents used for CRC. RR, PFS, and OS are comparable to those achieved in the treatment of metastatic CRC. Poor prognostic factors include nonmucinous histology or high-grade tumors and history of nondebulking surgery.