New Paradigm in Metastatic Colon Cancer Treatment: From Palliation to Potential Cure

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• Cure as a New Goal in Metastatic Colon Cancer
• Personalized Treatment Strategy Based on Molecular Profiling
• Oligometastatic Disease: An Aggressive Curative Approach
• Palliative Care: Balancing Efficacy and Quality of Life
• Advanced Treatment Options and Sequencing
• The Future of Therapy Selection: Beyond Lines of Treatment
• Full Transcript

Cure as a New Goal in Metastatic Colon Cancer

Dr. Heinz-Josef Lenz, MD, states that a fundamental paradigm shift is occurring in metastatic colorectal cancer treatment. The traditional view of stage 4 colon cancer as an incurable condition is changing. According to Dr. Lenz, "Today I can cure a metastatic colorectal cancer patient." This statement reflects dramatic progress in oncology. It signifies that for a subset of patients, the therapeutic goal is no longer just palliation but complete eradication of the disease.

Personalized Treatment Strategy Based on Molecular Profiling

The new strategy moves away from a rigid "lines of therapy" approach. Dr. Heinz-Josef Lenz, MD, emphasizes that treatment must be guided by the molecular profile of the tumor. Key genetic alterations like BRAF, KRAS, and MSI (Microsatellite Instability) dictate how a cancer behaves and responds to treatment. Dr. Heinz-Josef Lenz, MD, explains that clinicians should not wait for the tumor to recur but should instead "follow the temporal molecular profile of the colon cancer tumor during chemotherapy." This dynamic approach allows for real-time adjustments in therapy.

Oligometastatic Disease: An Aggressive Curative Approach

For patients with oligometastatic disease, where cancer has spread only to a limited number of sites like the liver or lung, an aggressive curative strategy is employed. Dr. Heinz-Josef Lenz, MD, outlines the process: clinicians select the most aggressive chemotherapy regimen combined with the most appropriate monoclonal antibody. The goal is to shrink the metastatic tumors sufficiently to allow for a curative resection. This multimodal approach—systemic therapy followed by surgery—offers a chance for long-term survival and cure.

Palliative Care: Balancing Efficacy and Quality of Life

When a cure is not feasible due to widespread metastatic disease, the treatment goal shifts to high-quality palliation. Dr. Heinz-Josef Lenz, MD, notes that in these cases, he would not automatically choose the most aggressive regimen. Instead, the focus is on selecting a highly effective chemotherapy that also has a manageable side effect profile. The objective is to extend life while simultaneously preserving the patient's quality of life. Dr. Anton Titov, MD, and Dr. Lenz agree that effective chemotherapy is itself the best form of palliation for advanced colon cancer.

Advanced Treatment Options and Sequencing

The arsenal against metastatic colon cancer has expanded significantly. Dr. Heinz-Josef Lenz, MD, lists numerous advanced treatment options now available. These include multi-tyrosine kinase inhibitors, oral cytotoxic medications, and various chemotherapy cocktails. Targeted agents like the anti-angiogenesis drug ramucirumab (Cyramza) and EGFR inhibitors provide more tools for personalized therapy. The challenge, as discussed by Dr. Anton Titov, MD, is knowing how to sequence these options effectively at diagnosis and upon progression, which may involve re-biopsying the tumor.

The Future of Therapy Selection: Beyond Lines of Treatment

The old model of sequential "first-line," "second-line," and "third-line" therapies is becoming obsolete. The new paradigm, as described by Dr. Heinz-Josef Lenz, MD, is to treat colon cancer more like a chronic disease. Therapy selection is a continuous process based on the evolving molecular profile of the tumor and the overall condition of the patient. This strategy ensures that treatment is always aligned with the ultimate goals: maximizing survival and maintaining the best possible quality of life for as long as possible.

Full Transcript

The full conversation between Dr. Anton Titov, MD, and Dr. Heinz-Josef Lenz, MD, explores the paradigm shift in metastatic colorectal cancer treatment. Dr. Lenz elaborates on how establishing a clear treatment goal—either cure or palliation—is the first critical step. He details the importance of molecular profiling for BRAF, KRAS, and MSI status to guide therapy. The discussion covers aggressive strategies for oligometastatic disease and the careful balance of efficacy and toxicity for palliative intent. Dr. Lenz concludes by highlighting the vast array of new treatment options, including targeted therapies and chemotherapy combinations, that make this modern, personalized approach possible.

Full Transcript

Leading German-American colorectal cancer oncologist discusses current paradigm shift in strategy of colorectal cancer treatment.

I think we are living in a very interesting time for colon cancer treatment. Today I can cure a metastatic colorectal cancer patient. It doesn't mean all metastatic colon cancer patients are cured. But the goal of metastatic colon cancer therapy would be cure.

How do we use our treatment options at the time of metastatic colon cancer diagnosis? Then if there is tumor progression, what is the next line of treatment options? Should we calculate a new colon cancer treatment strategy?

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Video interview with leading expert in metastatic colorectal cancer treatment from California.

Dr. Anton Titov, MD: Advanced colon cancer treatment options. We spoke a lot about specific colon cancer treatments. We discussed use of molecular markers in personalized colon cancer therapy.

But it's important to put colorectal cancer treatment in context. You published a very important colon cancer treatment options review. Your article suggested that now is the time for a paradigm shift in colorectal cancer treatment options.

Colorectal cancer therapy selection usually is based on so-called "lines of therapy". When "first line" colon cancer chemotherapy fails, then you go to the "second line" of chemotherapy.

You say that now colon cancer treatment should move from line-based approach to a "chronic disease management". We should not wait for colon cancer tumor to recur but we should follow a molecular profile of the tumor. We should follow the temporal molecular profile of colon cancer tumor during chemotherapy.

Could you please describe this paradigm shift in approach to treatment of colon cancer and rectal cancer?

Dr. Heinz-Josef Lenz, MD: Yes, I think we are living in a very interesting time for colon cancer treatment. We understand more and more the behavior of colon cancer. It is associated with certain molecular alterations in the tumor.

We know some tumors have a certain genetic alteration of BRAF or KRAS or MSI (Microsatellite Instability). Then cancer will behave differently. Colon cancer tumors will metastasize to different organs of the body.

It will be very important in our clinical practice to establish a treatment goal for colon cancer patient. Some patients come in with oligometastatic colon cancer. It means colon cancer tumor spread only to the liver or the lung.

In this situation today, I think I can cure a metastatic colorectal cancer patient. It doesn't mean all metastatic colon cancer patients are cured. But the goal of metastatic colon cancer therapy would be cure.

When the goal of colon cancer treatment is cure, you select the most aggressive chemotherapy regimen with the most appropriate monoclonal antibody medication. Then you have a chance to shrink metastatic colon cancer tumor. Then you control the metastatic colon cancer tumor.

Then you do a curative resection of metastatic lesions. Sometimes patients have significant metastatic colon cancer disease. It spreads out in different organs.

Then the goal of colon cancer therapy is palliative care. We will choose a treatment regimen that is highly effective. But palliative colon cancer treatment should also be balanced out with the side effect profiles of medications.

I would not use the most aggressive chemotherapy regimen for palliative care in patients with advanced metastatic colon cancer. I would still use a very effective chemotherapy regimen.

We can now choose between different regimens that have good efficacy but also a very good side effects profile. This allows us to ensure and guarantee a good quality of life for patients with advanced colon cancer.

With a lot of treatment options for colon cancer available now, the challenge will be this. How do we use our treatment options at the time of metastatic colon cancer diagnosis? If there is tumor progression, what is the next line of treatment options?

Should we calculate a new colon cancer treatment strategy? Should we biopsy the metastatic colon cancer tumor again? Now we have more advanced colon cancer treatment options open than ever before.

We can now choose between multi-tyrosine kinase inhibitor, oral cytotoxic medications, or another chemotherapy cocktail. For example, we can use irinotecan vs. oxaliplatin. We can mix them with antibodies such as Ramucirumab (IMC-1121B, Cyramza) or an EGFR inhibitor.

Those medications were not previously used in the first line of colorectal cancer treatment. I think we have now really good options for advanced colon cancer treatment. We can now review and tailor these colorectal cancer therapy options based on the treatment goal.

We can tailor colon cancer treatment to the patient's condition. We have to know what the patient is all about. We can choose treatments to maintain a very good overall survival.

We can maintain a good quality of life for patients with advanced colon cancer. Because our goal with chemotherapy in advanced colon cancer is to extend life. But our goal is also to extend quality of life.

The best palliation in advanced colon cancer is effective chemotherapy. Colon cancer treatment is changing dramatically. Old "line of therapy" strategy is becoming obsolete.

New method to therapy selection is based on molecular profile of the tumor and molecular profile of the patient.