Highlights

In Stage IV colorectal cancer, I think for any trial that is being devised, the best, most meaningful endpoint is overall survival rate; overall survival for this disease is about 2–2.5 years. It’s not 10 years, that’s unachievable, and whatever you do, the endpoint should affect survival.

We know that immunotherapy is better than chemotherapy alone in the front-line setting, in the KEYNOTE-177 trial, so all my [dMMR/MSI-H] patients, pretty much all of them end up getting IO single agent as a front-line therapy, most of them. I usually do Keytruda for those patients, and then there’s a small group of patients who have a lot of tumor burden, impending liver failure, like really bad disease, where I tend to start with chemo, and use the IO in second line. So, if there’s a lot of tumor burden that I need a response right away, then I tend to do chemo first, but that’s just 5–10% of the patients, 90% of them end up getting an immunotherapeutic drug.

So, based on what they received previously, if you had FOLFOX then you get FOLFIRI next, so that’s easy, that’s very simple, that’s a simple decision. The question about the biologic comes into the picture: so all my RAS wild-type patients, if they get cetuximab front-line, I end up using Avastin or biosimilar Avastin in the second line. If they get Avastin front-line, then I do cetuximab or Vectibix [panitumumab] second line. Then, for patients who are RAS mutant patients, I typically do the BEACON regimen with cetuximab, encorafenib, and go from there, maybe vemurafenib.