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NCCN: Newer Drugs Added to Colorectal Cancer Guidelines
By Ed Susman

HOLLYWOOD, FL -- March 14, 2003 -- Doctors should have the option to use
newer drugs in the treatment of recurrent colorectal cancer, according to a new
treatment algorithm written for the National Comprehensive Cancer Network
(NCCN).

"We must use all drugs that are available to treat patients with
colorectal disease," said Dr. Leonard B. Saltz, MD, associate attending
physician at Memorial Sloan-Kettering Cancer Center, New York.

In presenting the updated NCCN guidelines for treatment of colon cancer at
the organization's 8th annual conference, Saltz said recent clinical studies
pointed out that both oxaliplatin and irinotecan offered patients another option
in treatment if their cancer remained uncontrolled.

The new guidelines call for use of several different salvage chemotherapy
combinations following recurrence:

- Bolus or infusional 5-fluorouracil (5FU) plus leucovorin.
- Protracted intravenous infusion of 5FU administered through a pump worn
by the patient for weeks of treatment.
- Bolus or infusional of 5FU plus leucovorin plus irinotecan
- 5FU plus leucovorin plus oxaliplatin.
- Oral capecitabine

Dr. Saltz, in presenting the updated guidelines, said, "FOLFOX [5FU plus
leucovorin plus oxaliplatin] is an appropriate first-line treatment for
metastatic colorectal cancer." He said that either oxaliplatin or irinotecan
could be used as a first-line treatment, or one could follow the other
sequentially.

In contrast, "We don't believe that combining these drugs is a good idea,"
said Dr. Paul F. Engstrom, MD, professor of medicine at Temple University and
senior vice president of the Fox Chance Cancer Center, Philadelphia, PA,
"because we don't know if we would get greater benefit at the risk of getting
greater adverse events." He said studies of the combinations are underway.

However, Engstrom said that any of the treatments would be appropriate.
For, example, doctors might prefer to administer the oral drug capecitabine to
patients who were elderly, frail or had other co-morbidities.

He noted that the new chemotherapy regimens have been able to extend
survival of patients with recurrent colon cancer from about six months to around
18 months.

The guidelines do not suggest the use of irinotecan, oxaliplatin or
capecitabine as adjuvant therapy for stage 3 colon cancer patients. The use of
the drugs enters the treatment algorithm when recurrence of disease occurs or if
the patient presented at stage 4, Engstrom said.

Also new in the guidelines is the use of Positron Emission Tomography
(PET) scans. According to Engstrom, the scans will help determine which patients
should go on to have resection of recurrent colon cancers or who might require
more systemic chemotherapy treatment. He said the imaging studies were also an
important part of planning for further treatment for patients with recurrent or
suspected recurrent rectal cancer.




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