NCCN - Metastatic Colorectal Cancer Flashcards
Patient with metastatic Colorectal cancer. What are the 4 approved first-line options (if likely to tolerate therapy)?
FOLFOX
FOLFIRI
CAPEOX
FOLFOXIRI
With or without Bevacizumab or Capecitabine or Panitumumab
Which genetic mutations indicate low liklihood of response to Cetuximab and Panitumumab?
KRAS, NRAS
Which checkpoint inhibitors effective for MSI-High status?
Pembrolizumab, Nivolumab, Ipilimumab
Which genetic mutation can lead to severe toxicity of dihydropyrimidines like 5FU and capecitabine?
DPYD gene
Seen in about 1% of population. Need to dose reduce in order to reduce toxicity in these patients
FOLFOX+Bevacizumab is one of the first-line treatments for mCRC. How should oxaliplatin be managed when peripheral neuropathy is experienced?
NCCN recommends stop-and-go method in which oxaliplatin is held while continuing the rest of the regimen and then can be added back on IF the patient is able to experience a near-complete resolution of neurotoxic symptoms.
Most severe and concerning adverse effect with Panitumumab and Cetuximab?
Severe infusion reactions
Which side effect of Cetuximab and Panitumumab actually predicts increased response and survival for patients?
skin rash
Which biologic agents given in conjunction with first-line treatments for colorectal cancer is effective for left-sided primary tumors?
What about right sided tumors?
Left sided: Cetuximab or Panitumumab
Right sided: Bevacizumab
What is hand-foot syndrome? Which common medication in CRC causes it?
How do you treat it?
Palmar-plantar drythrodysthesia - leakage of capecitabine into small capillaries causes redness, tenderness, and peeling of the palms and soles
Treatment: avoid hot water, increased pressure (jogging, long days of walking), screwdrivers, cutting chopping (stuff where you expose palms to intense pressure). Cooling can help.
Patients form what geographic areas have more side effects to capecitabine?
North Americans
Which medication common to CRC regimens must be used in caution for individuals with Gilbert’s syndrome?
Ironetecan!
It is detoxified by UDP-glucuronosyltransferase. This enzyme is also responsible for conjugating bilirubin. Mutations in this protein’s gene (UGT1A1), cause the common genetic problem Gilbert’s syndrome which leads to occasional jaundice. Patient’s with Gilbert’s will thus have a higher chance of experiencing Irontecan toxicity like neutropenia.
Mechanism of action for Bevacizumab?
Monoclonal antibody that blocks VEGF
Important considerations for patient on Bevacizumab who is being considered for surgery?
May interfere with wound healing.
Bev should be held for 6 weeks before surgery and 6-8 weeks after surgery
When should Pembrolizumab be given as first line therapy for metastatic CRC?
Only for dMMR or MSI-H tumors.
FDA approved 6/2020
