A controversial question in mCRC involves second-line treatment for patients who receive FOLFOX/CAPOX with bevacizumab first line. Of particular debate is the common scenario of a patient initially responding to treatment and then developing gradual disease progression, often discovered on imaging with no new symptoms. Most GOs, and Dr Bendell, employ the strategy confirmed by the TML study and switch chemotherapy to an irinotecan-based regimen while continuing bevacizumab. Dr Venook also switches to irinotecan but usually stops bevacizumab. We found minimal use of the VEGF trap ziv-aflibercept.

Bennouna J et al. Continuation of bevacizumab after first progression in metastatic colorectal cancer (ML18147): A randomised phase 3 trial. Lancet Oncol 2013;14(1):29-37. Abstract

Koeberle D et al. Bevacizumab continuation versus no continuation after first-line chemo-bevacizumab therapy in patients with metastatic colorectal cancer: A randomized phase III noninferiority trial (SAKK 41/06). Proc ASCO 2013;Abstract 3503.

Tabernero J et al. Aflibercept versus placebo in combination with fluorouracil, leucovorin and irinotecan in the treatment of previously treated metastatic colorectal cancer: Prespecified subgroup analyses from the VELOUR trial. Eur J Cancer 2014;50(2):320-31. Abstract