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Program Overview
This case-based discussion program is intended for
oncology nurse practitioners and clinical nurse
specialists. Current research on appropriate systemic
treatment sequencing for metastatic colorectal cancer
(mCRC), treatment of the older adult with mCRC, and
the emerging role of neoadjuvant and adjuvant
chemotherapy for patients with resectable or potentially
resectable liver metastases will be highlighted. The
cases will be presented by national key opinion leaders
in colorectal cancer and audience response questions
will be used to stimulate discussions with APN
attendees regarding optimal patient care. Nurse
participants have submitted their own challenging cases
throughout the past 3 months which will be discussed
with colleagues and expert panelists.
Learning Objectives
Upon completion of this program, participants should be
better able to:
- Evaluate the sequencing of systemic treatment for
metastatic colorectal cancer at diagnosis and at time
of disease progression
- Describe the impact of chemotherapy for metastatic
colorectal cancer in the older adult population and
identify special considerations for these patients
- Describe neoadjuvant treatment options and their
associated liver toxicities• Discuss the role of postoperative and/or hepatic
arterial infusion (HAI) treatment following liver
resection
- Describe the advanced practice nurse’s role in
optimizing the outcomes
Program Abstracts
Optimizing Outcomes for Metastatic Colorectal Cancer Patients: An APN Roundtable Discussion
Introduction
Gail Wilkes, MS, RNC, ANP, AOCN®
Although no significant new agents in the treatment of patients with advanced colorectal cancer
(CRC) have been identified this year, advances are being made in individualizing treatment with
current agents and identifying patients for whom aggressive chemotherapy and metastasectomy
may result in cure. More than 55,000 Americans will die of CRC in 2006, and in terms of cancerrelated
mortality, CRC ranks as the second-leading killer in men and third in women. This
program will provide an overview of the current clinical trial data that help us to establish the
evidence base for chemotherapy treatment holidays, sequencing of agents, appropriate
treatment for elderly patients with advanced CRC, and the identification of patients for whom
aggressive neoadjuvant, adjuvant, and surgical therapies in metastasectomy may result in cure.
Case-based discussions will explore the role of the APN in helping patients and their families
understand the clinical data and to make decisions based on their individual strengths and
needs. In addition, the very special role of the APN in providing support and creative strategies
to minimize toxicity and maximize quality of life will be emphasized.
Overview and Clinical Trial Update
Michael J. O'Connell, MD
The treatment of metastatic colorectal cancer has evolved dramatically in recent years with
the availability of multiple active agents in clinical practice including leucovorin-modulated 5-
fluorouracil, capecitabine, irinotecan, oxaliplatin, cetuximab, bevacizumab, and
panitumumab. Objective tumor responses are now seen in 40% to 50% of patients, and
median survival is approaching 2 years. The most commonly used chemotherapy regimens
for first-line treatment are FOLFOX and FOLFIRI, which employ infusional 5-fluorouracil and
leucovorin combined with oxaliplatin or irinotecan, respectively, and CAPOX which
substitutes oral capecitabine for infusional 5-fluorouracil and leucovorin combined with
oxaliplatin. The addition of bevacizumab, a monoclonal antibody against vascular
endothelial growth factor (VEGF), confers an improvement in tumor response rate and
survival over the use of chemotherapy alone. The monoclonal antibodies cetuximab and
panitumumab, which bind the epidermal growth factor receptor (EGFR), have single-agent
activity against colorectal cancer and are approved for use in patients previously treated
with chemotherapy. Recent clinical trials have indicated that a “stop-and-go” strategy, where
treatment is interrupted following tumor response to give the patient a “treatment holiday,”
may be effective in ameliorating chemotherapy toxicity without jeopardizing patient survival.
The longest survival times are seen in patients who have been treated with multiple active
agents over time, although there is no single preferred sequence of treatment regimens.
Elderly patients with good performance status and nutritional condition may tolerate and
benefit from aggressive combination chemotherapy. The choice of therapy in practice
should be individualized according to the clinical status of the patient, comorbid
conditions, and side effects associated with the various treatment
regimens. Ongoing clinical trials are investigating the use of
two monoclonal antibodies (bevacizumab with either cetuximab
or panitumumab) combined with FOLFOX or FOLFIRI.
Special consideration should be given to determining if the
patient with colorectal cancer metastases confined to lung or liver
could be amenable to surgical resection with curative intent. Twenty to
40% of patients undergoing metastasectomy are alive at 5 years.
Neoadjuvant (preoperative) chemotherapy has been shown to improve
resectability of colorectal liver metastases in selected cases, resulting in
prolonged survival for some patients. Intra-arterial chemotherapy with 5-
fluorodeoxyuridine (FUDR), combined with systemic 5-fluorouracil and
leucovorin following hepatic metastasectomy improves 2-year disease-free
survival compared to 5-fluorouracil alone. A current clinical trial is testing the
value of intrahepatic FUDR in this setting compared to more effective
oxaliplatin-based chemotherapy (CAPOX). The safe and effective use of
intrahepatic FUDR requires special expertise and should be given only
in centers experienced with this technique.
Case-Based Discussions: Patients With Unresectable Metastatoc CRC
Gail Wilkes, MS, RNC, ANP, AOCN®
Unfortunately, too many individuals are diagnosed with advanced CRC or progress after
initial treatment for colon and rectal cancers. Individualizing patient treatment discussions is
the focus for presented case studies, which emphasize maximizing survival and quality of
life. We know that patients who receive all the major available drugs survive longer but may
have increased toxicity (Tournigand et al., 2006). Treatment options for reducing toxicity by
alternating less toxic regimens, as well as treatment drug-free holidays will be discussed
(Maindrault-Goebel et al., 2006; Labianca et al., 2006).
Aggressive chemotherapy with molecular targeted therapies have increased response rates
and survival, but bring with them toxicities that require the art and science of advanced
practice nursing to minimize effect on the patient’s quality of life, such as peripheral
neuropathy and rash (Fox, 2006). Data to support prevention and management will be
discussed. The elderly patient with advanced CRC is often offered inadequate therapy
despite evidence showing that eligible elders respond just as well with similar toxicity as
younger patients (Xiao & Lichtman, 2006). This case discussion will review the data, as well
as assessment criteria, to assist in helping appropriate patients receive standard therapy.
Metastatic Colorectal Cancer: Management of Hepatic Metastases
Susan H. Moore, RN, MSN, ANP, AOCN®
After many years of limited options in managing metastatic colorectal cancer (mCRC), the
past 5 years have brought a wealth of new therapeutic choices into the mCRC treatment
arena. The liver is the most common site for the spread of colorectal cancer. Approximately
50% of CRC patients will eventually develop metastatic disease to the liver (Geoghegan &
Scheele, 1999). In addition to systemic chemotherapy and targeted therapy, localized
treatment is also available. Hepatic arterial infusion (HAI) is one option for localized therapy
that may not only stabilize liver metastases, but may result in a cure in a certain subset of
mCRC patients (Kemeny, 2002; Venook, 2003). The sequencing of therapy after diagnosis
of mCRC is important. Options include neoadjuvant systemic chemotherapy and surgical
resection of the liver followed by adjuvant systemic chemotherapy. Combined modalities of
systemic chemotherapy, HAI, and surgery can increase time to progression, median
survival, and improve quality of life (Leonard, Brenner, & Kemeny, 2005; Kemeny et al.,
2006). The neoadjuvant approach has the potential ability to render seemingly unresectable
tumors resectable and can reduce the incidence of recurrent metastatic disease. (Leonard,
Brenner, & Kemeny, 2005). A multimodality decision model to determine resectability in
colorectal hepatic metastases will be discussed as a decision tool (Poston et al., 2005).
Clinicians must carefully assess patient status, comorbidities, concomitant medications,
performance status, expected toxicities of the planned therapies, and – most
importantly – patient preferences, before treatment is initiated. Case presentations
will discuss aggressive treatment options for one patient with
unresectable liver metastases and for a second patient
with resectable lesions.
