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Chemotherapy for three months demonstrates lower side effects, suggesting its use as standard care compared with six months.
Three months of adjuvant chemotherapy may be superior to six months in patients with colorectal cancer, as it demonstrates lower side effects without compromising efficacy.
Among patients with stage 3 colorectal cancer who received adjuvant combination chemotherapy, six months of chemotherapy is still being offered to those with low-risk disease and is associated with more neuropathy, according to real-world evidence from a retrospective chart review. Additional research on patient preferences and resource costs could increase adoption of shorter-duration adjuvant capecitabine and oxaliplatin (CAPOX) for stage 3 colorectal cancer.
According to study findings published in JCO Oncology Proactive, the International Duration Evaluation of Adjuvant Chemotherapy (IDEA) collaboration, which compared three versus six months of adjuvant chemotherapy in stage 3 colorectal cancer, “showed that outcomes with three months of CAPOX were very similar to the conventional six-month regimen of CAPOX or FOLFOX with regards to [disease-free survival] and [overall survival], raising the possibility of reducing treatment duration without compromising efficacy,” study authors wrote. “Furthermore, a shorter duration of adjuvant chemotherapy was associated with significantly lower rates of [side effects], particularly grade 2 [moderate] or higher neurotoxicity (16% in the three-month group versus 47% in the six-month group).”
Despite these results, published over five years ago, only about half of patients in this contemporary cohort were recommended the shorter duration.
Neuropathy: Damage to the nerves causing weakness, numbness, and pain.
Adjuvant: Additional therapy given after primary treatment to reduce recurrence risk.
Disease-free survival: Length of time a patient lives without disease progression.
Overall survival: Length of time a patient lives after diagnosis.
During this retrospective chart review, patients who received six months of chemotherapy were more likely to report neuropathy (68%) and to stop oxaliplatin early (54%) compared to the three-month group (36% and 31%, respectively). Neuropathy was the most common reason for early adjuvant discontinuation in the six-month group, while gastrointestinal toxicity was most common in the three-month group. After excluding duration of chemotherapy as a factor, mean time from consult to starting chemotherapy was longer for fluorouracil, leucovorin and oxaliplatin (FOLFOX) compared with CAPOX (24 versus 19 days). Of those planned for six months of treatment, 29% had low-risk disease and 52% of low-risk disease patients received CAPOX. Patients aged 70 years or older, well or moderately differentiated and with low-risk disease were significantly associated with three months versus six.
Of a total of 452 patients (median age 65 years), 234 and 218 were planned to receive three and six months of chemotherapy, respectively. In the six-months group, 51% of patients received CAPOX and 49% received FOLFOX. In the three-months group, 97% of patients received CAPOX. Preexisting neuropathy, ileostomy or performance status did not affect treatment choice. Tumors located on the right-side were present in 47% of patients while 14% had poorly differentiated disease. Exclusion criteria included patients with rectal cancer that required neoadjuvant chemotherapy or radiotherapy, stage 2 disease and lacking information regarding diagnosis, staging or treatment.
According to the study, a longer duration of adjuvant chemotherapy can increase health care costs, strain system resources and add time burden for patients. A 2015 Canadian cost-minimization analysis found that replacing adjuvant FOLFOX with CAPOX for stage 3 colorectal cancer may save money for both patients and society. The savings were attributed to fewer chemotherapy visits, less central venous access device use and reduced patient time and travel.
“This study provides real-world evidence regarding adjuvant chemotherapy duration in a contemporary post-IDEA cohort of patients with stage 3 [colorectal cancer],” study authors concluded. “Use of three months of CAPOX remains low, and a significant proportion of patients planned for six months of adjuvant chemotherapy had low-risk disease.”
Reference:
“Three Versus Six Months of Adjuvant Oxaliplatin-Containing Chemotherapy for Patients With Stage III Colorectal Cancer: A Contemporary Real-World Analysis” by Dr. Tharani Krishnan, et al., JCO Oncology Proactive.
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