The invited discussant of the SOLSTICE trial1 was Demetris Papamichael, MB, BS, Consultant Medical Oncologist at the Bank of Cyprus Oncology Centre and Associate Professor at St. George’s Hospital and Medical School, University of London. He said that although the study concluded trifluridine/tipiracil plus bevacizumab was not superior to capecitabine plus bevacizumab, this regimen “may be attractive for subgroups of older patients with metastatic colorectal cancer in view of its treatment and side-effect profile,” as shown in SOLSTICE.
Dr. Papamichael reminded listeners that the elderly and unfit population may have different treatment goals—often this includes tolerability of treatment to maintain emotional and physical strength and quality of life. In comparison to capecitabine plus bevacizumab, trifluridine/tipiracil operates through a different catabolic pathway than fluorouracil, hence lacking the toxicities related to dihydropyrimidine dehydrogenase (DPD), including hand-foot syndrome and cardiotoxicity. It also requires little dose modification for renal impairment, unless severe, which in contrast is fairly common with capecitabine in older patients. Neutropenia is frequent with this regimen but usually does not result in neutropenic fever (grade 3 febrile neutropenia was seen in 2.5% of this arm in SOLSTICE).
Dr. Papamichael continued: “Not all elderly patients are sick and dependent, and this heterogeneity can pose significant problems in everyday clinical practice. I am becoming more and more convinced that some form of geriatric screening should be applied to patients and acted upon.” Geriatric screening can assess frailty (associated with reduced treatment tolerance), reveal other vulnerabilities and morbidities, and help with cognitive evaluation and generally with treatment decision-making. Research has shown that interventions driven by geriatric assessments result in less chemotherapy-related toxicity, he noted.
“Clearly, it’s not realistic to conduct comprehensive geriatric assessment in a busy oncology clinic—and it’s not common to have a team of geriatricians next door, waiting to assess your patients…. However, a screening tool such as the G8 (Geriatric 8 questionnaire) can provide useful information,” Dr. Papamichael commented. A G8 score < 14 has been correlated with overall survival. The screening tool takes about 5 minutes to administer and may identify patients needing intervention, he said.
DISCLOSURE: Dr. Papamichael has served as an advisor to or speaker for Merck Serono, Amgen, Roche, Novartis, Sanofi, Bristol Myers Squibb, and Servier.
REFERENCE
1. André T, Falcone A, Shparyk Y, et al: Trifluridine/tipiracil plus bevacizumab vs capecitabine plus bevacizumab as first line treatment for patients with metastatic colorectal cancer ineligible for intensive therapy: The phase III randomized SOLSTICE study. 2021 ESMO Virtual Plenary. Abstract VP11-2021. Presented December 16, 2021.
