Eastern Canadian Gastrointestinal Cancer Consensus Conference 2024
Abstract
:1. Introduction
- Level I: Evidence from randomized controlled trials
- Level II-1: Evidence from controlled trials without randomization
- Level II-2: Evidence from analytic cohorts or case–control studies
- Level II-3: Evidence from comparisons between times or places with and without the intervention
- Level III: The opinion of respected authorities based on clinical experience, descriptive
2. Multidisciplinary Management of Rectal Cancer (Total Neoadjuvant Therapy/Non-Operative Management (NOM))
- We recommend that the management of patients with locally advanced, pMMR rectal cancer be discussed in a multidisciplinary tumor board (MDT) forum that should include colorectal (CRC) surgeons, radiation oncologists, medical oncologists, radiologists, pathologists, and gastroenterologists [Level III]. Important components of an informed patient discussion include the following:
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- The patient’s health status, including comorbidities and their performance status
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- Patient values, goals, and preferences
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- The likelihood of requiring a permanent colostomy or temporary ileostomy
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- The chances of the avoidance of total mesorectal excision (TME) surgery with non-operative treatment approaches
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- The frequency and types of assessments required for NOM (see details for the assessments in the evidence summary below)
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- The risks of local and distant recurrence with NOM
- If sphincter preservation is the objective, patients with cT3/4, cN+ disease should undergo (chemo)radiotherapy as their initial oncologic intervention, followed by consolidation chemotherapy (fluoropyrimidine- + oxaliplatin-based treatment [1]) [Level I]
2.1. Evidence Summary
2.1.1. Non-Operative Management
2.1.2. Total Neoadjuvant Therapy
3. Management of Liver-Only Metastatic Colorectal Cancer (mCRC)
- The management of all patients with liver-only mCRC should be discussed in an MDT forum including HPB surgeons, CRC surgeons, radiologists, interventional radiologists, pathologists, gastroenterologists/hepatologists, medical oncologists, and radiation oncologists [Level III]
- Important components of an informed patient discussion include the following [Level III]:
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- The patient’s health status, including comorbidities and their performance status
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- Synchronous versus metachronous presentation of metastatic disease
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- The patient’s biomarker status, including MMR, RAS, and BRAF status
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- The patient’s values, goals, and preferences
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- The likelihood of cure balanced with the risk of toxicity
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- Consideration of resection of the primary could be considered in either a synchronous or staged technique
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- How to approach “ghost” (vanishing) lesion(s) if the patient has a good response to neoadjuvant treatment
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- The need for neoadjuvant systemic therapy to downstage disease or assess the disease biology
- Resection
- Ablation
- Resection and ablation
- Ablative radiation (stereotactic body radiation therapy)
- Transplant for unresectable disease
- The consideration of available clinical trials
Evidence Summary
4. Systemic Therapy of Biliary Tract Cancers
- Biomarker testing (including NGS and IHC for HER-2 and MMR status) should be completed as part of the diagnostic work-up to identify patients eligible for targeted therapy clinical trials and to inform second-line options [Level I].
- We endorse that biomarker testing should be publicly funded and available for all patients [Level III]
- Clinical trials may be an option and should be discussed with patients
- Best supportive care is also an option and should be discussed with patients
- The role of biomarker profiling is to identify therapeutic options, including clinical trials and accessible targeted treatments
- Patients who harbor an IDH1 mutation should be treated with an IDH1 inhibitor (Ivosidenib) based on randomized phase III evidence [29] [Level I]
- Based on single-arm phase II data, following first-line treatment, the following agents could be considered for the appropriate mutation/alteration [Level II-1]
- Patients who have deficient MMR disease and have not been exposed to immunotherapy in the first-line setting should be considered for treatment with immunotherapy in the second-line setting [36] [Level II-1]
- Patients who harbor other actionable mutations (BRAF, etc.) should be considered for targeted therapy through clinical trials, compassionate access, or other means of access [Level III]
- If no actionable genomic alteration is identified, then FOLFOX should be considered as a treatment option after progression on gemcitabine–cisplatin-based therapy [37] [Level II-1]
- Another potential option based on a randomized phase IIB trial also demonstrating an overall survival benefit is NALIRI + 5FU [38] [Level II-1]
- Available clinical trials are an option and should be discussed with patients
- Best supportive care is an option and should be discussed with patients
Evidence Summary
5. Radioligand Therapy (RLT)/Peptide Receptor Radionuclide Therapy (PRRT) Treatment for Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs)
- Decisions regarding PRRT should be integrated into a comprehensive, multidisciplinary treatment plan involving medical oncologists, nuclear medicine, radiation oncology, endocrinologists, oncological surgeons, and pathologists to ensure optimal patient outcomes [Level III]
- RLT/PRRT is an effective treatment option for patients with advanced, well-differentiated neuroendocrine tumors (NETs) expressing somatostatin receptors (SSTRs)
- We endorse the use of PRRT in the following settings:
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- Well-differentiated SSTR-positive GEP-NETs after progression on somatostatin receptor analogs [43] (p. 1) [Level I]
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- A first-line treatment option for patients with well-differentiated grade 2 and 3 SSTR-positive GEP-NETs considering the disease burden and the disease-related symptoms [44] (p. 2) [Level I]
- Eligible patients for PRRT treatment should receive four cycles of PRRT (Lu-DOTATATE) administered every 8 weeks. They should have adequate renal function (creatinine clearance above or equal to 50 mL/min), hepatic function, and bone marrow reserves [43] (p. 1) [Level I]
Evidence Summary
6. Systemic Therapy for Pancreatic and Midgut Well-Differentiated NET Treatment
- The management of pNETs should be discussed in a multidisciplinary forum that includes medical oncologists, hepatobiliary surgeons, radiation oncologists, pathologists, nuclear medicine specialists, and radiologists (including interventional radiologists) to decide the optimal management strategy
- The treatment options for unresectable, locally advanced or metastatic well-differentiated pNETs are the following:
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- Somatostatin analogs (SSAs): The standard first-line treatment for patients with well-differentiated pNETs [52] [Level I]
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- RLT/PRRT: A treatment option for patients with SSTR-positive disease; it can be used after progression on SSAs or as a first-line treatment in grade 2 or 3 (ki67 > 10%) disease [43] [Level I]
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- Chemotherapy: Chemotherapy with capecitabine plus temozolomide can be used upon progression on SSAs or as a first-line treatment in patients with aggressive disease when a more rapid clinical response is required [53] [Level I]
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- The management of mNETs should be discussed in a multidisciplinary forum that includes medical oncologists, oncological surgeons, radiation oncologists, pathologists, nuclear medicine specialists, and radiologists to decide the optimal management strategy
- The treatment options for unresectable locally advanced or metastatic well-differentiated mNETs are the following:
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- Chemotherapy: There is insufficient evidence for the routine use of chemotherapy, but it could be considered in the appropriate clinical scenario.
Evidence Summary
7. Management of HER2+ve Gastroesophageal Cancers
- All patients with gastric or GEJ cancer must have the following biomarkers tested reflexively and synchronously [Level I]:
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- HER-2
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- MMR
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- PDL1
- Pembrolizumab, in addition to platinum-based chemotherapy and trastuzumab, is recommended for patients with locally advanced unresectable or metastatic gastric or GEJ adenocarcinoma with a CPS greater than or equal to one (without contraindications to immunotherapy) [62] [Level I]
- Patients who are fit with metastatic or unresectable disease should be considered for enrollment onto clinical trials [Level III]
- We do not endorse the use of HER2-directed therapy in the neoadjuvant or adjuvant setting, except in the context of clinical trials
Evidence Summary
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Leigh, J.; Ahmed, A.; Aubin, F.; Berry, S.; Boucher, M.; Campeau, M.-P.; Colwell, B.; Connors, S.; Corbett, J.; Dadwal, S.; et al. Eastern Canadian Gastrointestinal Cancer Consensus Conference 2024. Curr. Oncol. 2025, 32, 175. https://doi.org/10.3390/curroncol32030175
Leigh J, Ahmed A, Aubin F, Berry S, Boucher M, Campeau M-P, Colwell B, Connors S, Corbett J, Dadwal S, et al. Eastern Canadian Gastrointestinal Cancer Consensus Conference 2024. Current Oncology. 2025; 32(3):175. https://doi.org/10.3390/curroncol32030175
Chicago/Turabian StyleLeigh, Jennifer, Arwa Ahmed, Francine Aubin, Scott Berry, Melanie Boucher, Marie-Pierre Campeau, Bruce Colwell, Stacie Connors, Jessica Corbett, Shivani Dadwal, and et al. 2025. "Eastern Canadian Gastrointestinal Cancer Consensus Conference 2024" Current Oncology 32, no. 3: 175. https://doi.org/10.3390/curroncol32030175
APA StyleLeigh, J., Ahmed, A., Aubin, F., Berry, S., Boucher, M., Campeau, M.-P., Colwell, B., Connors, S., Corbett, J., Dadwal, S., Dudani, S., Elimova, E., Falkson, C., Galvis, L., Goel, R., Gotfrit, J., Hyde, A., Febbraro, M., Laidley, D. T., ... Vickers, M. (2025). Eastern Canadian Gastrointestinal Cancer Consensus Conference 2024. Current Oncology, 32(3), 175. https://doi.org/10.3390/curroncol32030175