New research published by Ou et al in JNCCN—Journal of the National Comprehensive Cancer Network evaluated how an important analysis on adjuvant chemotherapy for advanced colon cancer impacted prescribing patterns. The IDEA collaboration included more than 12,000 patients with stage III colon cancer across 6 randomized phase III trials in a planned pooled analysis to determine how 3 vs 6 months of postsurgery chemotherapy—either a combination of capecitabine/oxaliplatin (CAPOX) or fluorouracil/leucovorin/oxaliplatin (FOLFOX)—impacted patient outcomes. The new report published in JNCCN revealed that after the full publication of the IDEA results by Grothey et al in The New England Journal of Medicine in March 2018, the percentage of patients in this population treated with CAPOX rose from 14% to 48%. Also, 45.2% of patients were prescribed adjuvant therapy for only 3 months after IDEA, compared to just 5.6% before.
“Our study results showed a significant increase in planning for 3 months of adjuvant chemotherapy after the presentation of IDEA. We also observed that more patients were prescribed CAPOX compared to FOLFOX, which had previously been more widely used as the preferred treatment regimen of choice,” said senior author Daniel H. Ahn, DO, of the Mayo Clinic Comprehensive Cancer Center. “The biggest concern with 6 months of chemotherapy is the toxicities from treatment—including low blood counts, kidney and liver dysfunction, and peripheral neuropathy. Patients that receive 6 months of adjuvant chemotherapy are [more] than five times more likely to experience grade 3 or higher peripheral neuropathy. Of course, with 3 months of chemotherapy, we have to be concerned about whether the shortened duration can potentially negatively affect cancer outcomes. Given these nuances, the choice of regimen and duration remains a shared decision.”
Analysis Details
The researchers studied 399 patients who had been diagnosed with stage III colon cancer and were treated with postsurgery chemotherapy at the Mayo Clinic or Emory University Heath System on or after January 1, 2016. Their findings examined the planned type of chemotherapy and duration before the IDEA abstract was first presented in June 2017, after the initial abstract presentation, and after the full manuscript publication in The New England Journal of Medicine.
In addition to seeing a shift toward shorter adjuvant treatment durations and toward the increased use of CAPOX after publication, the analysis showed that the adoption of a shorter chemotherapy period was more prevalent among Black patients.
Expert Commentary
Katrina S. Pedersen, MD, MS
“The IDEA collaborative analysis in stage III colon cancer showing the fairly similar disease-free and overall survival with 3 months of adjuvant CAPOX compared to the prior standard of 6 months of chemotherapy in participants with T3N1 disease felt immediately practice-changing at its presentation and publication in 2017 [and] 2018, [respectively], and the data was incorporated into the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colon Cancer shortly thereafter,” explained Katrina S. Pedersen, MD, MS, Associate Professor of Medicine and a GI medical oncologist at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, who was not involved in this research. “This study provides the first long-term objective evidence that oncologists across several academic health systems agreed and rapidly shifted prescribing patterns, from the majority getting FOLFOX for 6 months to receiving CAPOX or FOLFOX for 3 months.”
The study authors acknowledged that the study’s time period included the COVID-19 pandemic, which may also have played a part in encouraging a shorter duration of chemotherapy.
“At the height of the COVID-19 pandemic, prescribing treatments were influenced to incorporate more oral therapies and less infusion-based visits to minimize exposure to high-risk patients,” said Dr. Ahn.
Dr. Pedersen, a member of the NCCN Guidelines® Panel for Colon Cancer, continued: “Interestingly, the data presented raise the question of what role the COVID-19 pandemic had in accelerating the adoption of CAPOX and what motivated more rapid adoption of 3-month regimens in [Black patients]. I would personally like to see further research to examine if community practice patterns have similarly shifted since IDEA, how prescribing changes have impacted outcomes in [Black] or in higher-risk (T4 or N2) patients, and whether our current era of significant chemotherapy supply chain restrictions have impacted treatment, to help inform future guidelines-based discussions.”
Disclosure: For full disclosures of the study authors, visit jnccn.org.
