Colorectal Cancer&nbsp;&nbsp;&nbsp;

What systemic therapy (FOLFOX or mFOLFIRINOX) would you use in T3 N1 M1 MMR proficient rectal cancer with solitary liver lesion when going for curative intent ( chemo --> short course RT --> resection of primary and liver met)?

Is there a role for ctDNA?

Would you ever consider foregoing surveillance CT scans for resected stage II or III colon cancer in favor of circulating ctDNA assays?

When treating a high rectal cancer, does your coverage of the caudal mesorectum depend on the surgical plan?

How do you construct the caudal extent of your volume - for example, pelvic floor via RTOG/international consensus vs 4 cm below gross disease via RAP...

How was treatment response assessed on the PROSPECT trial?

Specifically, on re-staging imaging, would the tumor regression be strictly defined by reduction in cranio-caudal direction only, or would other measu...

Do you offer adjuvant chemotherapy to patients with rectal cancer who were on Watch-and-Wait, had local recurrence and underwent resection?

And if so, which one? Does nodal status affect your decision? Is there any evidence for ctDNA in this space?

Is there a role of adjuvant or systemic therapy for patients with resected stage I colon cancer with subsequent local recurrence S/P a second resection and now has NED?

Would you offer chemoRT to a colon cancer case with a resected polyp with positive margins if the patient wishes to avoid surgery?

Would chemoRT be preferred over surgery if there is LVI or PNI?

What are your top takeaways from ASCO GI 2023?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice? ...

8 Answers available

Would you consider the use of EGFR inhibition (cetuximab/panitumumab) in first line in metastatic right-sided RAS/RAF WT colon cancer, if bevacizumab contraindicated?

When treating rectal cancer with neoadjuvant chemoRT, is it appropriate to employ IMRT planning, rather than 3D conformal, for all cases, or should IMRT be reserved for special circumstances?

Would you offer additional systemic treatment to a stage II or III resected colon cancer that received 3 months of adjuvant capecitabine/oxaliplatin and now is presenting with a solitary lung metastasis?

And if so, would you offer it pre or post-metastasectomy? Would time to recurrence or ctDNA play a role?

For patients with rectal cancer being treated along PROSPECT paradigm, would you extrapolate from the IDEA literature and offer 3 months of CAPOX neoadjuvantly, without adjuvant therapy?

How would you approach a stage II colon cancer with negative ctDNA but markedly elevated CEA level post-colectomy?

Would you offer chemotherapy to an elderly patient with MSI-H stage 3 colon cancer who cannot tolerate oxaliplatin?

Would you give adjuvant chemo for a mucinous stage II adenocarcinoma of the colon in the lack of other high-risk clinical pathological features?

For patients with resected colon cancer, to what extent would you adapt adjuvant chemotherapy if ctDNA results don't correspond with your initial treatment recommendation?

How would positive ctDNA results after 12 cycles of adjuvant FOLFOX affect your management for patients with colon cancer?

How do you manage local/mesenteric lymph node recurrence of colon cancer after surgery and adjuvant therapy?

Would you approach with curative intent with locoregional treatment or systemic treatment alone?

Would you offer adjuvant chemotherapy in a patient with MSS colon cancer who only has residual mucin left, without viable cancer cells despite no pre-operative chemotherapy, in the colon and lymph nodes?

Would you treat an unresectable MSI-H colon cancer patient with persistent hepatitis C with immunotherapy?

How, if at all, are you employing ctDNA in the management of patients with colon cancer?

What are your top takeaways in GI Cancers from ASCO 2023?

6 Answers available

Is there a role for further HER2 directed therapies after progression on fam-trastuzumab deruxtecan after a sustained initial response in patients with metastatic HER2+ colorectal cancer?

Would you recommend adjuvant capecitabine and radiation in addition to adjuvant FOLFOX for a patient with resected pT3N2 rectosigmoid adenocarcinoma with other high-risk pathologic features?

In general: when would you recommend adjuvant radiation and capecitabine for a colon cancer?

In what setting do you omit adjuvant radiation therapy in a T3N0 rectal cancer?

The NCCN guidelines categorically recommend adjuvant XRT for a cT1-2N0 rectal adenocarcinoma upstaged to a pT3N0, yet there are multipl...

Would you give adjuvant pembrolizumab in a MSI-H oligometastatic colorectal cancer status-post resection that responded to neoadjuvant ICI?

How would you approach a patient with clinical T3N1 anorectal malignant melanoma referred by a surgeon for neoadjuvant therapy?

Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?

How would you approach a clinical stage 3 sigmoid colon cancer, dMMR/MSI-H with comorbidities and increased risk of surgical complications?

How would you manage a localized melanoma of the anal canal with sphincter involvement, but without nodal or distant disease?

Is there data to support a 3 weeks regimen of panitumumab with maintenance capecitabine in colon cancer?

Would you offer adjuvant chemotherapy or radiation to a resected MSS T3N0 high-rectal lesion with low anterior resection without pre-op therapy?

Staging/pre-op MRI only showed mild non-specific thickening.

How long do you treat with immunotherapy patients with MSI-high T4B initially unresectable colon adenocarcinoma?

And is it different when using pembrolizumab or a combination of ipilimumab/nivolumab?

How do you manage a recurrence of colon cancer within 3-4 months of completion of adjuvant FOLFOX?

Do you add VEGFR/EGFR antibodies? Or switch to another regimen?

Do you offer adjuvant therapy for localized medullary carcinoma of the ascending colon that is MSI-H?

Do you use the same high risk factors as adenocarcinoma when deciding on adjuvant treatment for early stage disease?

Would you include HER2 directed therapy in the treatment of HER2+ small bowel adenocarcinoma?

When do you feel comfortable adding bevacizumab to a BRAF-WT, KRAS-mutated colon cancer patient with previously hemorrhagic brain mets that responded to radiation?

> 30s, female with metastatic colon cancer. Presented with a headache. Metastatic hemorrhagic mets per MRI 10/2022. Had radiation. Kras mutated, Br...

What chemotherapy regimen would you offer a stage III pMMR rectal adenocarcinoma agreeable to TNT but with significant underlying neuropathy?

Will you give perioperative chemotherapy with EGFR inhibitors for stage IV left-sided RAS/BRAF WT colorectal cancer with resectable/borderline resectable liver metastases given discordant PARADIGM vs New EPOC trial results?

How do you reconcile the differences between the two studies?

What adjuvant therapy would you give to a patient with resected pT4bN2M0 MSI-H colon cancer and post-op markedly elevated CEA but no metastatic disease seen on imaging?

When, if at all, is it appropriate to re-challenge a patient with a EGFR inhibitor in metastatic RAS/BRAF WT colon cancer?

Would sidedness matter? Do you use ctDNA assays to evaluate for acquired RAS mutations to guide this decision?

Would you give a fit <40 year old with T3N1b low risk Stage IIIB colon adenocarcinoma 6 months of adjuvant chemo or feel comfortable limiting to 3 months of CAPOX?

Does the patient's young age affect your decision when applying data from the IDEA collaboration?

Would you consider first line FOLFOXIRI and cetuximab or panitumumab for physically fit patients with metastatic RAS/BRAF WT colon cancer?

Instead of FOLFOXIRI and bevacizumab as per TRIBE trial

Will you offer cetuximab or panitumumab with FOLFOX in patients with metastatic left sided RAS/BRAF WT MSS colon cancer instead of bevacizumab?

Do the overall survival results of PARADIGM presented at ASCO 2022 change the standard of care?

What gene mutations do you always test for prior to starting EGFR inhibitor therapy in metastatic colon cancer?

Would you advocate for a targeted gene approach or a fully comprehensive NGS panel?

If an average-risk, physically fit, resected stage II colon cancer patient has a positive signatera result (3.2 MTM/ml), would you recommend adjuvant chemotherapy?

How would you treat a patient with colon cancer that is dMMR/MSI-high with a solitary liver lesion that is deemed resectable?

Would you recommend pembrolizumab prior to surgery? Or after? Is there a role for FOLFOX?

Would you withhold adjuvant FOLFOX in stage III colon cancer if Signatera circulating tumor DNA testing is negative?

What is the role of EGFR inhibitors in patients with metastatic transverse colon cancer?

Would you offer EGFR inhibitors as second line?

Would you consider immunotherapy in high-risk resectable MSI-H colorectal cancer?

Specifically, would you consider either neoadjuvant or adjuvant immunotherapy in this setting, or only after recurrence?

When, if ever, would you initiate chemotherapy for recurrent colorectal cancer based on a positive ctDNA assay alone, such as Signatera, in the absence of tumor on imaging or physical exam?

Which group of Stage III MSI-H colon cancer patients can be excluded from receiving adjuvant chemotherapy?

Would you withhold a fluoropyrimidine in a newly diagnosed patient with metastatic colon cancer who had a STEMI and new diagnosis of ischemic cardiomyopathy within the last 3 months?

In deciding between 3 versus 6 months of adjuvant therapy for colon cancer, how would you factor in the presence of isolated tumor deposits (staged as N1c), but negative lymph nodes?

How do you approach adjuvant chemotherapy in resected T4N0 colon cancer?

How do you treat colorectal cancer with heterogeneous loss of mismatch repair protein expression?

How do you manage colorectal tumors that have components in the colon and rectum on MRI?

For example, portion is seen above and below the mesorectal fascia. Do you feel comfortable treating as colon cancer with surgery upfront?

Is 500 cGy x 5 an appropriate palliative regimen for a patient with a low-lying metastatic rectal cancer with ongoing pain and bleeding despite chemotherapy?

How would you treat metastatic colon CA with BRAF non-V600E mutation?

Would you consider the BEACON regimen (i.e., encorafenib/binimetinib + cetuximab) in this setting?

What are your top takeaways in GI Cancers from ASCO 2022?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?

Do you routinely offer doxycycline or minocycline prophylaxis for cutaneous reactions to EGFR inhibitors such as cetuximab?

If you do not use prophylaxis, what skin care strategy do you employ?

How would you approach treatment for cT4 stage IIIC colorectal cancer that is d-MMR and not amenable to surgery due to volume of disease?

Would you debulk with neoadjuvant therapy to achieve resectability?

6 Answers available

What adjuvant chemotherapy would you recommend in a elderly patient with resected stage III colon cancer with MMR deficiency with MLH1 promoter hypermethlation?

How would you manage anastomotic site recurrence of colon cancer 3 years after resection of a T3N0 tumor without high-risk features?

What is your approach to neoadjuvant chemotherapy for a T3N0 mid-rectal cancer?

How would you treat a patient who got three months of adjuvant CAPOX for T4N0 stage II colon cancer, but had a solitary pulmonary metastasis a year later which was resected?

Would you recommend 6 months of FOLFOX or just surveillance?

How would you treat a young patient with metastatic colorectal cancer who initially tolerated 12 cycles of FOLFOX + bev with disease progression after cycle 3 of maintenance 5-FU + bev?

G1 neuropathy and G3 neutropenia were observed with cycle 12 FOLFOX + bev. Would you reintroduce oxali at a lower dose or switch to irinotecan+EGFRi ...

Would you use encorafenib with cetuximab vs encorafenib alone as second line therapy in a patient with metastatic colon cancer with concomitant KRAS G12V and BRAF V600E mutations identified on liquid biopsy?

Of note - the tumor tissue biopsy NGS did not show KRAS or BRAF mutations. Microsatellite stable. Patient received first line FOLFOXIRI + Avastin .

How would you manage a patient with MSS, KRAS mutated locally advanced rectal adenocarcinoma with a mixed response to neoadjuvant FOLFOX?

This involves the primary site responding but progression with new bone marrow involvement with resulting cytopenias.

Following transanal excision with positive margins for for T1 or T2 rectal cancer, is it more appropriate to proceed with APR or attempt sphincter preservation with RT/Chemo?

If RT/chemo is preferred, what is an acceptable final boost dose?

In what situations can short course RT (5 Gy x 5fx) be used instead of chemoRT for rectal cancer?

6 Answers available

For locally advanced rectal cancer, would you consider utilizing the RAPIDO trial approach of short course radiation followed by neoadjuvant chemotherapy prior to surgery?

Colleagues in surgery have raised concerns about post radiation effects in the pelvis with the ordering of short course RT->chemo ->surgery.

Would you consider neoadjuvant chemoradiation with oral capecitabine for a locally advanced sigmoid adenocarcinoma 20 cm from the anal verge?

What is your approach following R1 resection in a patient who has received total neoadjuvant therapy for rectal cancer?

Would you offer adjuvant chemotherapy for MSI-H Stage II colon cancer with multiple high risk features?

eg LVI/PNI, poorly differentiated? If so, what regimen and for how long?

Which patients with rectal cancer who have not received neoadjuvant treatment do you offer adjuvant radiation to?

Is there a subset of patients you would avoid neoadjuvant CRT and operate first?

How would you approach adjuvant therapy for a high-risk stage III colon cancer which is MSI-high in a patient >70 years of age?

Benefit of oxaliplatin in patients >70 years of age is not proven and only 5FU/capecitabine in a MSI-H tumor is of questionable efficacy. What woul...

How would you treat a mixed neuroendocrine/adenocarcinoma appendiceal tumor with metastasis to the liver?

Would you use a small cell regimen over a more traditional FOLFOX-esque approach?

Would you consider pembrolizumab for a patient with microsatellite stable stage IV colon cancer with high TMB on liquid biopsy who has progressed on all standard therapies?

What regimen would you offer a young fit patient with low grade mucinous adenocarcinoma of the appendix with pseudomyxoma peritonei to attempt to get him to cytoreductive surgery with HIPEC?

Would you recommend a right hemicolectomy for a <1 cm low grade appendiceal goblet cell adenocarcinoma found incidentally during appendectomy without high risk features on pathology?

No high risk features such as: lymphovascular invasion, perforation, or involved margins

How do you screen for colon cancer in patients with Behcet syndrome with colonic involvement?

How would you approach a patient with BRAF V600E mutated dMMR stage II colon cancer?

Would you consider adjuvant chemotherapy?

Would you consider using immunotherapy in mismatch repair proficient metastatic colorectal cancer with PDL1/PDL2 gene amplification?

How do you decide what induction chemotherapy regimen to use for a patient with locally advanced rectal cancer (cT4N1) receiving total neoadjuvant therapy?

Would you use FOLFIRINOX as in Prodige 23 or FOLFOX as in RAPIDO?

Under what circumstances you would consider treating stage II colon cancer with adjuvant chemotherapy?

When would you consider use of ctDNA to help with this decision?

In rectal cancer in patients receiving total neoadjuvant therapy of FOLFOX followed by 5FU-radiation, is there a role for additional adjuvant chemotherapy based on significant residual disease at time of surgery?

When would you consider first line FOLFOXIRI + Bevacizumab for metastatic colon cancer?

How would the sidedness of the tumor, BRAF, RAS,HER2 or MSI status affect your decision?

How would you approach a patient with metastatic colon cancer and BRCA2 mutation in next generation sequencing?

Would you consider using PARP Inhibitor in this situation?

Is there a role for peritoneal debulking in patients with peritoneal metastases from colorectal cancer?

If so, which patients are the best candidates?

What would be your chemotherapy/biologic sequence choice in a RAS wildtype metastatic CRC, for which FOLFOX and bevacizumab was given first line?

Would you use dual agent chemotherapy such as FOLFIRI, combination of chemo with biologic- IRI/Cetux or all 3 drugs simultaneously? How would sidednes...

How would you incorporate ctDNA to follow up a patient status post surgical resection of the primary colon adenocarcinoma and omental deposits after 6 months of FOLFOX?

Would you continue to trend ctDNA to detect early recurrence?

For metastatic colorectal cancer, is it possible for the tumor to be mismatch repair proficient at primary site but mismatch repair deficient at metastatic site?

Do you routinely test for this with a re-biopsy?

For patients who meet criteria to be treated with 3 months of CAPEOX based on IDEA study, is it reasonable to use capecitabine alone for 3 months and drop oxaliplatin during the COVID pandemic?

Given that majority of benefit is derived from the capecitabine, would this be an acceptable option to decrease patient contact with the healthcare sy...

In light of data from PRODIGE7, for patients with peritoneal metastasis from colon cancer, do you still offer HIPEC?

If so, how much systemic therapy would you give before considering surgery?

Would you recommend 3 or 6 months adjuvant chemo for low risk Stage III sigmoid cancer (T3/N1), but with positive LVI and PNI?

Would presence of features considered high risk in stage II sway your interpretation of the IDEA trial?

For a patient with metastatic colon cancer who tested positive for MSI (i.e. MLH1 hypermethylation etc) and BRAF mutation, what would be your preferred choice in the second line setting?

Would you choose to use IO or BRAF directed therapy based on BEACON? Or would you continue to use cytotoxic chemotherapy?

In patients with metastatic colon cancer responding to treatment with FOLFOX / FOLFIRI with bevacizumab who develop a symptomatic PE, do you continue bevacizumab after treating the PE?

Package insert indicates discontinuing bevacizumab in PE and there are no guidelines on re-challenging after acute clot is managed.

How do you sequence chemoradiation and chemotherapy for patients with locally advanced rectal cancer undergoing TNT based upon data from CAO/ARO/AIO-12?

In practice, does starting with chemoradiation followed by chemotherapy result in a significant delay in initiating chemotherapy or a patient's abilit...

How do you choose between regorafenib or TAS-102 in patients with metastatic colorectal carcinoma that has progressed on all prior 5-FU based regimens and anti-EGFR therapy?

Would you consider HER2-directed therapy in a patient with pretreated metastatic right sided colon adenocarcinoma progressed on FOLFOX-bevacizumab if they are both HER2-neu amplified and have a HER2-neu exon 19 mutation?

If so, what agent(s) would you consider given the concurrent amplification and mutation?

When giving FOLFOX/FOLFIRI and skipping 5FU bolus, do you still give leucovorin?

Do you treat rectosigmoid/upper rectal cancers with neoadjuvant chemoradiation?

The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...

When do you recommend adjuvant chemotherapy for adenocarcinoma ex goblet carcinoid with signet ring features status post right hemicolectomy?

Does the pathology outweigh usual staging and risk factors?

Is there evidence to support routine use of adjuvant chemotherapy for resected rectal cancer treated with pre-operative chemoradiation?

The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.

What adjuvant therapy do you recommend for stage III colon cancer patients unable to tolerate 5FU regardless of modality/dose reduction?

How would you treat a patient with small cell ca of the appendix with no evidence of distant mets?

PDL1 is > 50%. There was no perforation or lymph node involvement.

How do the results of BRAF testing change your management of colon cancer?

Has the utility of BRAF in CRC expanded beyond guiding prognosis? Is there a role in non-metastatic CRC?

How would you treat a BRAF mutated and KRAS WT metastatic colon cancer who has progressed after FOLFOX and now Irinotecan + cetuximab + vemurafenib?

When do you consider total neoadjuvant therapy (chemotherapy and chemoradiation) for rectal cancer?

Would you ever choose FOLFOXIRI over FOLFOX for high risk Stage III colon adenocarcinoma with multiple adverse prognostic features?

Does the presence of BRAF mutation affect your decision?

Do you routinely offer aspirin as an adjunct with adjuvant therapy in colorectal cancer?

Do you test for COX-2 and PIK3CA mutations?

With the recent approval of Nivolumab + Ipilimumab in MSI-H Colorectal cancer, how do you decide between this combination and Pembrolizumab?

For rectal cancer with solitary liver metastasis, do you recommend neoadjuvant chemoradiation?

Are these patients better candidates for preop chemotherapy alone?

When do you consider it too late after surgery to offer adjuvant chemotherapy for colon adenocarcinoma?

If a patient with stage II or III colon adenocarcinoma who presents to your clinic 12-16 weeks after surgical resection do you give adjuvant chemother...

Do you treat inguinal lymph nodes for rectal cancers involving the anal canal?

The RTOG contouring atlas doesn't give a consensus on this issue.

What would be your choice and duration of adjuvant therapy for a perforated MSI-H stage II (T4N0) colon cancer?

Is there a change in approach over the past few years? Would there be a role for the 12-gene recurrence score?

When do you perform HER2 testing in patients with colorectal cancer?

What adjuvant treatment would you recommend for stage III colon cancer in a patient >75yo but with a good performance status?

Since some prior subset analyses have suggested that oxaliplatin may not improve outcomes of older patients with colon cancer in the adjuvant settin...

Should immunotherapy be standard of care for metastatic MSI-high colorectal cancer?

Does the recent Hopkins trial of pembrolizumab change your management of these patients?

When do you perform BRAF testing in colon cancer?

Is there a benefit to adjuvant chemotherapy for patients with a solitary liver metastasis from previously treated colorectal cancer?

If so, what is your preferred regimen?

Would you treat the inguinal nodes in a patient who had an adenocarcinoma excised from the anal canal?

In a lesion <2.5 cm from anal verge arising in a tubulovillous adenoma, does the data from Taylor, et. al. Red Journal 2001 apply?

For elderly patients with locally advanced rectal cancer who are not candidates for surgery or chemotherapy, what would be an appropriate palliative regimen?

What dose and upper field border would you use following transanal excision for rectal cancer found to be T2 by final pathology but without LVSI or perineural invasion?

Should standard post operative radiation fields be used, treating up to the L5-S1 interspace? Or is it acceptable to treat a lower field, for ins...

What is the appropriate treatment for a low lying rectal cancer in the setting of prior definitive prostate IMRT?

Fore example for a T3N0 rectal cancer on EUS?

Is it possible to palliate presacral recurrences of rectal cancer in patients who previously received neoadjuvant chemoradiation to the rectum?

In the past, I haven't seen great results in palliating the presacral area. The pain is excruciating for many patients. Is there an effective option f...

For a patient who has undergone preoperative chemoradiation to 50Gy for locally advanced rectal cancer followed by LAR or APR, would you treat a positive margin with radiation therapy?

If so, what dose?

Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?

Are there any indications to choose one over the other?