It describes the need to practice multidisciplinary team to establish therapeutic strategy for patients with metastatic colorectal cancer

1. “mCRC”
Do we need the oncologist?
Mohamed Abdulla M.D.
Prof. of Clinical Oncology
Cairo University
Gastrohep – 2016
Cairo Conrad Hotel
09/12/2016

2. Member of Advisory Board, Consultant, and Speaker for:
• Amgen, Astellas, AstraZeneca, Hoffman la Roche, Janssen Cilag,
Merck Serono, Novartis, Pfizer, Mundipharma, MSD
• The content of this presentation does not relate to any product of a
commercial interest
Speaker Disclosures:

3. Management of Met. CRC:
Playing a Strategic Game:
The King Should
SURVIVE
SURVIVA
L
What You Have to Play?
Surgery,
Pharmaceuticals,
Interventional
Radiology, …
How to Play?
Sequence and
Treatment Lines
Try to be Creative Research

4. Colon Cancer:
Basic Facts & Figures:
• 2nd & 3rd most common cancers in females and males.
• 9% of cancer related deaths.
• 90% occurring around the age of 40 – 50 years.
• OAS for entire patients = 65%.
• Metastatic disease: 5-year OAS = 10%.
• Organ limited metastatic disease: 5-year OAS > 40%
• Median survival of metastatic disease > 24 - 30 months.
• Improved OAS with exposure to all available drugs.
• Unified global ideal treatment algorhytm is still
controversial.

5. Colorectal Cancer:
“Not only one scenario”
Operable
M0
Metastatic
Resection
+/-
Adjuvant
Resectable
Convertible
Beyond
Conversion
OAS & QoL
Intervention
Metastatic
Non
Metastatic
Resectable
NAT 
Surgery
Advanced
TNAT 
Surgery

6. Gold Standard of Practice Principles :
Surgery is the cornerstone in curative
management of Gastrointestinal Malignancies
However,

7. Who Should Receive Adjuvant Th:
60 m30 m0 monthStage
% Survival% Survival% Survival
93.296.1100I
84.791.0100IIa
72.280.2100IIb
83.491.4100IIIa
64.177.3100IIIb
52.367.1100IIIc
43.057.3100IIId
26.843.1100IIIe
8.117.3100IV
O’ConnellJB, Maggard MA, Ko CY: Colon Cancer Survival Rates with The New American Joint
Committee on Cancer, Sixth Edition Staging. J Natl Cancer Inst 2004;96:1423.
LNs = > 12

8. Curves showing significant improvement in overall survival in arm A [open diamonds, 5-
fluorouracil (5-FU)/leucovorin] compared with arm B (filled squares, 5-FU/levamisole) (P =
0.0035).
H. T. Arkenau et al. Ann Oncol 2003;14:395-399
Adjuvant 5-Fu
Surgery

9. MOSAIC Study: 6-Y OAS; by Treatment Arm:
J Clin Oncol. 2009,27:3109-3116

10. Median OS
Months
1980s 1990s 2000s
BSC
5-FU
Irinotecan1
Capecitabine2
Oxaliplatin3
Bevacizumab4
Cetuximab5,6
Panitumumab
7 Aflibercept8
Regorafenib
9
30
25
20
15
10
5
0
1. Cunningham D, et al. Lancet. 1998;352(9138):1413-1418. 2. Van Cutsem E, et al. Br J Cancer.
2004;90(6):1190-1197. 3. Rothenberg M, et al. J Clin Oncol. 2003;21(11):2059-2069.
4. Hurwitz H, et al. N Engl J Med. 2004;350(23):2335-2342. 5. Cunningham D, et al. N Engl J Med.
2004;351(4):337-345. 6. Van Cutsem E, et al. N Engl J Med. 2009;360(14):1408-1417.
7. Van Cutsem E, et al. J Clin Oncol. 2007;25(13):1658-6164. 8. Van Cutsem E et al. J Clin Oncol.
2012;30(28):3499-3506. 9. Grothey A, et al. Lancet. 2013;381(9863):303-312.
Choice of Systemic Therapy in M1 disease::

11. Local Recurrence in Rectal Cancer
Following Surgery Alone:
Clinical Colorectal Cancer, Vol. 4, No. 4, 233-240, 2004

12. Adjuvant Radiation Therapy in Rectal
Cancer:
Clinical Colorectal Cancer, Vol. 4, No. 4, 233-240, 2004

13. Neoadjuvant Therapy:
The German Study: A Shifting Concept
N Engl J Med 2004;351:1731-40.

14. Radiation & Medical Oncologist
It is also Important

15. Local Recurrence: Better Insight:
Circumferential
Margins
Number Local Recurrence
Rate
P
> 2 mm 987 3.3% < 0.0001
1 – 2 mm 100 8.5% 0.02
< 1 mm 227 13.1 0.08
Int. J. Radiation Oncology Biol. Phys., Vol. 55, No. 5, pp. 1311–1320, 2003

16. CRM or LNs:

18. MURCERY Trial:
Fiona et al. JCO. 2014:1(32). 34-46.

19. Radiologist
Welcome on Board

20. Cuthbert Dukes 1932: Nodes as a prognostic factor

21. Limitations of the TNM – T3 category forms 80% of rectal cancers

22. Understanding of Molecular Events:
Epidermal Growth Factor
Family of Receptors
Biological Cascade of
Proliferation
Angiogenesis
Invasion, Progression &
Metastases

23. Pathologist
Very Crucial.

24. MDT: Definition
Individual Specialties Together Either Physically or Virtually
Discussing Therapeutic Strategy of a Given Patient

25. It’s MANDATORY!
 Greater accuracy of staging
 Fewer treatment delays
 Better outcome!
Fleissing A, et al. Lancet Oncol. 2006; 7(11): 935 – 943; Du CZ, et al. Worl J Gastroenterol. 2011;17(15):2013-2018;
MacDermid E, et al. Colorectal Dis. 2009;11(3):291-295; Viganò L, et al. Ann Surg Oncol. 2013 Mar;20(3):938-45
MDT: Benefits

26. Met. CRC: Different Presentations, Aims &
Outcomes
Potentially
resectable
LLD of mCRC
Resectable 15-
20%
Unresectable 80-
85%
Resection
Cure 30-40%
Potentially
Resectable 10-
30%
Unresectable 70-
90%
Cth +/-
Others
OAS
Q0L

27. mCRC with LLD: Key Players
Systemic
Therapies Alone
Cures 1 – 2%
of Patients
Surgery
Alone
Cures > 30%
of Patients
Don’t Miss Surgical Intervention
The Race Toward More Responses

28. Results of Hepatic Resection for Patients
with mCRC:
Survival (%)
Author (year) No. Patients Mortality,% Median Survival 1-year 5-year
Hughes et al (86) 607 --- --- --- 33
Gayowski et al (94) 204 0 33 mo 91 32
Scheele et al (95) 469 4 40 mo 83 39
Fong et al (95) 577 4 40 mo 85 35
Jamison et al (97) 280 4 33 mo 84 27
Fong et al (99)
Choti et al (02)
Pawlik et al (05)
1001
226
557
3
1
1
42 mo
46 mo
74 mo
---
96
97
36
40
58
Hughes KS, et al. Surgery. 1986;100(2):278-284. Gayowski TJ, et al. Surgery. 1994;116(4):703-710. Scheele J, et al. World J Surg. 1995;19(1):59-71. Fong Y, et
al. Ann Surg. 1995;222(4):426-434.; Jamison RL, et al. Arch Surg. 1997;132:505–510. Fong Y, et al. Ann Surg 1999;230:309-318; Choti MA, et al. Ann Surg.
2002;235(6):759-766; Pawlik TM, et al. Ann Surg. 2005;241(5):715-722.

30. MDT Outcome:

31. Take Home Message:
• mCRC is a real burden in daily practice.
• Surgical resection of organ limited disease 
Cure “The Race Toward Surgery”.
• Changing landscape of disease  Cure of
advancing & metastatic diseasebecame
possible.
• Routine practice of MDT should be
encouraged to get the beneficial outcome.

32. Thank You