Dr Leonard Saltz presents the July 2012 Fight CRC Webinar - Despite great strides in cancer research, the fact remains that there is still no cure for stage IV (metastatic) disease. There are promising treatment options for patients with late stage disease, but far too many patients will still hear their doctors say, "We are running out of options."

1. Welcome!
Treating Late Stage Colorectal Cancer
Part of Fight Colorectal Cancer’s Monthly Patient Webinar Series
Our webinar will begin shortly
www.FightColorectalCancer.org
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2. Fight Colorectal Cancer
1. Tonight’s speaker: Dr. Leonard Saltz
2. Archived webinars: Link.FightCRC.org/Webinars
3. Follow up survey to come via email. Get a free Blue Star of
Hope pin when you tell us how we did tonight.
4. Ask a question in the panel on the right side of your screen
5. Or call the Fight Colorectal Cancer Answer Line at 877-427-2111
www.FightColorectalCancer.org
877-427-2111

3. Fight Colorectal Cancer
Upcoming Webinars
Hospice vs Palliative Care
Dr. Jim Meadows, Tennessee Oncology
September 19, 2012
8 - 9:30 PM Eastern time
Sex After Rectal Cancer
Dr. Joel Tepper, UNC
October 17, 2012
8 - 9:30 PM Eastern time
Register at
www.FightColorectalCancer.org
1-877-427-2111

4. Fight Colorectal Cancer
Disclaimer
The information and services provided by Fight Colorectal
Cancer are for general informational purposes only.
The information and services are not intended to be substitutes
for professional medical advice, diagnosis, or treatment.
If you are ill, or suspect that you are ill, see a doctor
immediately. In an emergency, call 911 or go to the nearest
emergency room.
Fight Colorectal Cancer never recommends or endorses any
specific physicians, products or treatments for any condition.
www.FightColorectalCancer.org
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5. Fight Colorectal Cancer
Dr. Leonard Saltz
Memorial Sloan Kettering Cancer Center
Chief, Gastrointestinal Oncology
www.FightColorectalCancer.org
877-427-2111

6. Understanding Colorectal
Cancer Treatment Options
Leonard B. Saltz, MD
Chief, Gastrointestinal Oncology
Memorial Sloan Kettering Cancer
Center, New York, NY

7. Disclosures
• I have consulted for and/or have research
supported by:
• Roche/Genentech
• Bristol Myers Squibb
• Imclone
• Bayer
• Merck
• Biothera
• Novartis
• Sanofi
• Immunomedex
• Lorus
• Morphotek

8. Overview
• Understanding the language
• Standard chemotherapy options
• Toxicities and quality of life
• New agents
• Life after standard chemo

9. Terms Requiring Definitions
• Cure
• Overall Survival
• Median Overall Survival
• Progression-free Survival
• Response
• Stable Disease
• Antitumor activity, Benefit
• Progression of Disease

10. Other terms
• “significantly better”
– does not necessarily equal:
“substantially better”
• “statistically significantly better”
– Does not necessarily equal:
“clinically significantly better”

11. Anatomy of the Large Intestine

12. Staging of Colorectal Cancer (CRC)
• Stage I: Not full thickness
• Stage II: Full thickness
• Stage III: Positive nodes
• Stage IV: Distant mets

13. Colorectal Cancer Cure Rate
• Stage I 95%
• Stage II 80%
• Stage III 65% +
• Stage IV <10%

14. Intent of Therapy
• Curative
• Adjuvant
• Neo-Adjuvant
• Palliative

15. Chemotherapy for Metastatic
Disease

16. 1996: Drugs Available for CRC
• 5-FU (5-Fluorouracil)

17. 2012: Drugs Available for CRC
• 5FU (5-Fluorouracil)
• Camptosar (Irinotecan)
• Eloxatin (Oxaliplatin)
• Xeloda (Capecitabine)
• Erbitux (Cetuximab)
• Avastin (Bevacizumab)
• Vectibix (Panitumumab)
– Aflibercept (anticipated late 2012)
– Regorafenib (anticipated late 2012)

18. Combination Chemotherapy for CRC
Anatomy of the “FOLFs”
• FOL = folinic acid (a.k.a. leucovorin)
• F = 5FU (5-fluorouracil)
• OX = oxaliplatin (Eloxatin)
= FOLFOX
• FOL = folinic acid (a.k.a. leucovorin)
• F = 5FU (5-fluorouracil)
• IRI = irinotecan (Camptosar)
= FOLFIRI

19. FOLFIRI vs. FOLFOX
Efficacy of First Line Regimen
FOLFIRI FOLFOX
RR 56% 54% p=0.68
PFS 8.5 m 8.1 m p=0.65
OS 20.4 m 21.5 m p=0.9
Tournigand et al,
JCO 2004

20. Oral Chemotherapy
Cautionary Notes
• Just as likely to have side effects as i.v. chemo
• No convenience benefit unless all drugs taken
are oral
• Requires a highly motivated patient capable of
assuming substantial responsibility
• Difficult if nausea, vomiting, or diarrhea are
present or expected

21. Anti-Angiogenesis
The Angiogenic Switch
Angiogenic
Switch
1-2 mm
Small tumor Larger tumor
• Nonvascular • Vascular
• “Dormant” • Metastatic potential

22. Normal and Tumor Blood Vessels
Normal Blood Vessels Tumor Blood Vessels
Growth and survival
...
........ ...
Maturation factors present ..
... .......
factors (eg, VEGF)
Less dependent on cell ..
... present
survival factors ...
.......
... .
....
... ..... .. .
..... .........
. .. .
Leaky
.. .. .
........
.....
. Less permeable ..
.. Fewer pericytes
Supporting pericytes ...
.......
present
.
....
.
Preferential
Reduced integrin
expression of
expression
v 3 v 5 &
5 1 integrins

23. Phase III IFL +/- Avastin in Metastatic
Colorectal Cancer
IFL + Placebo IFL + Avastin
(n = 412) (n=403) P Value
Median overall
survival
15.6 m 20.3 m 0.00003
Median
Progression-Free 6.2 m 10.6 m <0.00001
Survival
Response Rate 35% 45% 0.003
Hurwitz et al.. NEJM 2004

24. Bevacizumab: Safety concerns
• Gastrointestinal perforation
• Arterial thrombotic events

25. EGF Receptor Signaling Transduction
R R
RAS RAF
K K SOS
PI3-K pY pY
GRB2
pY MEK
STAT
PTEN AKT
MAPK
Gene Transcription
Cell Cycle Progression
G2 M
S G1
Proliferation / Survival /
Angiogenesis Metastasis
Maturation Apoptosis

26. Cetuximab + Irinotecan)
Independent Radiology Review
Irinotecan-Refractory Patients, n=120
(Saltz et al: ASCO 2001)
PR 27 (22.5%) (95% C.I. 15%-31%)
SD 9 ( 7%) (minimum 12 weeks)
• Median Dur. of response (n=27): 186 days
• Investigator-reported PR= 23 (19%)

27. Single Agent Cetuximab: Investigator-Reported
Response Rate (n=57)
(Saltz et al, JCO 2004)
• PR = 6 (10.5%, 95% CI 4%-22%)
• SD = 21 (37%)
– Minimum 12 weeks required for stable
disease.
• Independent review confirmed 5 PR’s,
for response rate of 8.8%.

28. “BOND” Trial
• Randomized Phase II trial in Irinotecan-
refractory CRC
• Cetux + Irinotecan versus Cetux
• 2:1 randomization, 300 pts
• 1o endpoint: response rate

29. Bond Trial: Results
(Cunningham et al, NEJM 2004)
Cetux + Irino Cetux
RR 22.9% 10.8%
PFS 4m 1.6 m

30. Cetux Trials in Refractory
CRC
Response
Rate
Cetux + CPT-11 22.5%
(Saltz, ASCO 2001)
Cetux + CPT-11 22.9%
(Cunningham, NEJM 2004)
Cetux 10.5%
(Saltz, JCO 2004)
Cetux 10.8 %
(Cunningham, NEJM 2004)

31. CRYSTAL Trial
van Cutsem et al: NEJM 2009
• Randomized phase III trial of first line FOLFIRI
+/- weekly cetuximab.
• Measurable metastatic colorectal cancer
• 1217 patients randomized

32. CRYSTAL TRIAL: Efficacy
Van Cutsem: ASCO 2007
FOLFIRI- FOLFIRI P value
Cetux (n=599)
(n=599)
PFS 8.9 m 8.0 m 0.048
1 yr PFS 34% 23%
RR 47% 39% 0.0038
SD 37% 47%
DCR 84% 86%

33. Understanding KRAS
• Protein in the cell involved in transmitting
signal from receptor on cell surface to the
nucleus
• If the gene for KRAS is mutated, then the
KRAS protein sends a signal regardless of
whether there is a signal from the surface
receptor or not

34. EGF Receptor Signaling Transduction
R R
RAS RAF
K K SOS
PI3-K pY pY
GRB2
pY MEK
STAT
PTEN AKT
MAPK
Gene Transcription
Cell Cycle Progression
G2 M
S G1
Proliferation / Survival /
Angiogenesis Metastasis
Maturation Apoptosis

35. Understanding KRAS
• If KRAS is mutated, Erbitux and Vectibix won’t
work, and therefore are not used
• If KRAS is wild-type (non-mutated) then Erbitux
or Vectibix might work
• Median overall survival benefit in trials with
KRAS wild-type tumors is in range of 3-4 months

37. CRYSTAL Trial:
PFS time by
skin reactions: cetuximab + FOLFIRI
Grade of Skin 0-1 2 3
Rash (none or mild) (moderate) (severe)
Progression-free
survival 5.4 m 9.4 m 11.3 m

38. Some Other Toxicities
• Nausea / Vomiting
• Diarrhea
• Fatigue
• Neurotoxicity

39. MOSAIC: FOLFOX for Stage II – III Colon
Cancer: Peripheral Sensory Neuropathy
Andre et al: JCO 2009
Grade 1
60 Grade 2
Grade 3
50 48.1
% of treated patients
40
30
31.4 30.9 27.6 17.4 14.2 11.4
22.2
20
14
12.5 12
8.8
10 7.2
4.2 2.9
1.4 1.2 1.7 0.5 2.1
0.5 0.5
0
During Tx 6 months 1 year 2 years 3 years 4 years

40. Neurotoxicity from Oxaliplatin
• Cold sensitivity
• Numbness and tingling
• Loss of position sense
• Loss of fine motor skill
• Pain

41. What’s new?

42. Continuing Avastin
• TML trial shows that continuation of
Avastin with 2nd line therapy improves
median overall survival by 1.4 months

43. Aflibercept
• Adding aflibercept to second line FOLFIRI
improves median overal survival by 1.5
months.
• Not clear that this offers any advantage
over second line Avastin
• No evidence that Aflibercept by itself, or
with chemo that has failed, has any benefit

44. Regorafenib vs Placebo
Regorafenib Placebo
N=505 N=255
Median Overall Survival 6.4 months 5.0 months
Partial Response 1% 0.4%
Stable Disease 43% 15%
DCR* 41.0 15%
*DCR = PR+SD (≥6 weeks after randomization)
Van Cutsem et al: Proc ASCO 2012

45. What can we do when we’ve
used up the standard drugs?

46. Treatment options after
standard care
• Clinical trials
• Supportive care / hospice care

47. Clinical Trials
• Phase I What is the highest tolerable
dose and what are the side
effects?
• Phase II Is it safe and active in a
defined population?
• Phase III Is it better that standard
care?
• Phase IV Post-marketing studies;
variations on a theme.

48. Clinical Trials: Important Concepts:
• Informed consent
• Right to refuse/withdraw
• No hidden agendas
• No hidden placebos

49. Supportive care
• Important in ALL aspects of cancer care
– Pain control
– Emotional Support
– Nutrition
– Exercise
– Discussions of end of life care preferences

50. Seductive Traps
• The internet
• Alternative care
• Unproven drugs and procedures
– (Beware the rhetorical “what harm could it do?”

51. COST
of
CARE
A. Venook (Discussant) ASCO 2012 The Elephant in the Room

52. Average Selling Price (ASP) + 6%
(about 5 yr old data)
(Patient assumption: 75 kg, 1.8 m2 patient, two weeks Rx)
• 5FU 500 mg/m2 $ 7
• Leucovorin 500 mg/m2 $ 47
• Xeloda 2000 mg/m2/d $ 1065
• Camptosar 180 mg/m2 $ 2135
• Eloxatin 85 mg/m2 $ 3296
• Avastin 5 mg/kg $ 2283
• Erbitux 250 mg/m2 $ 4964

53. Impact on Cost of Care: back of the envelope
• Bevacizumab
– $2864 per 400 mg vial*
– Average weekly dose = 175 mg
• Regorafenib
$$$ unknown
– Sorafenib $8377 / month
• Aflibercept $$ per UCSF pharmacy
– $$$ unknown

54. Cost of Bev beyond progression
(Cost of only the bev; no MD, nursing, or pharmacy fees, no other meds)
• $2864 per 400 mg vial -> $7.16 per mg
– 175 mg/week x 4.33 weeks/month = 758 mg/month
– If vials are shared:
758 mg/month x $7.16/mg = $5427.28 per month,
x 5.7 months = $30,935.50 per patient treated
for 1.4 months OS benefit ->
$30,935.50 x 8.57 = $265,117 per year of life saved
– If vials not shared, then $2864 every 2 weeks for 24.7
weeks (5.7 months) -> $35,370.40 per patient treated
$35,935.40 x 8.57 = $303,124 per year of life saved
– (note: these are not Quality-adjusted)

55. Colorectal cancer in 2012: my reality check
• These are modest advances
• A minority of patients appear to benefit
• And the costs are unsustainable
THE CHALLENGE
• Actually deliver on promise of personalized
medicine
• To do so, we need better tools to predict
outcomes
• And it must be affordable
A. Venook, ASCO Discussant 2012

56. Challenges
• Maintain optimism tempered by, and
grounded in, reality
• Select therapies rationally
• Assure availability of appropriate therapies
to all patients

57. Conclusions
• Treatment options for colon cancer
patients are better than they were, but not
as good as they need to be.
• Please consider participation in clinical
trials when they are appropriate. Without
your help, we can’t make the progress that
we all so desperately need.

58. Fight Colorectal Cancer
www.FightColorectalCancer.org
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59. Fight Colorectal Cancer
Funding Research Directly
Lisa Dubow Fund
http://fightcolorectalcancer.org/research/lisa-fund

60. Fight Colorectal Cancer
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