FOLFIRI (folinic acid, fluorouracil, and irinotecan) increases not efficacy but toxicity compared with single-agent irinotecan as a second-line treatment in metastatic colorectal cancer patients: a randomized clinical trial

Xiaowei Zhang, Ran Duan, Yusheng Wang, Xin Liu, Wen Zhang, Xiaodong Zhu, Zhiyu Chen, Wei Shen, Yifu He, Hong Qiang Wang, Mingzhu Huang, Chenchen Wang, Zhe Zhang, Xiaoying Zhao, Lixin Qiu, Jianfeng Luo, Xuedan Sheng, Weijian Guo, Xiaowei Zhang, Ran Duan, Yusheng Wang, Xin Liu, Wen Zhang, Xiaodong Zhu, Zhiyu Chen, Wei Shen, Yifu He, Hong Qiang Wang, Mingzhu Huang, Chenchen Wang, Zhe Zhang, Xiaoying Zhao, Lixin Qiu, Jianfeng Luo, Xuedan Sheng, Weijian Guo

Abstract

Background: FOLFIRI [irinotecan, folinic acid (CF), and fluorouracil] is considered a standard second-line chemotherapy regimen for patients with metastatic colorectal cancer (mCRC) who failed first-line XELOX/FOLFOX regimens. However, it remains unknown whether fluorouracil is still necessary in this case. This trial was designed to test the superiority of FOLFIRI over single-agent irinotecan as a second-line treatment for patients with mCRC.

Methods: This randomized clinical trial was conducted in five hospitals in China. From 4 November 2016 to 17 January 2020, patients aged 18 years or older with histologically confirmed unresectable mCRC and who had failed first-line XELOX/FOLFOX regimens were screened and enrolled. Patients were randomized to receive either FOLFIRI or irinotecan. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS), objective response rate (ORR), and toxicity. Data were analyzed on an intention-to-treat basis.

Results: A total of 172 patients with mCRC were randomly treated with FOLFIRI (n = 88) or irinotecan (n = 84). The median PFS was 104 and 112 days (3.5 and 3.7 months) in the FOLFIRI and irinotecan groups, respectively [hazard ratio (HR) = 1.084, 95% confidence interval (CI) = 0.7911-1.485; p = 0.6094], and there was also no significant difference in OS and ORR between the two groups. The incidence of the following adverse events (AEs) was significantly higher in the FOLFIRI group than in the irinotecan group: any grade AEs including leucopenia (73.9% versus 55.4%), neutropenia (72.7% versus 56.6%), thrombocytopenia (31.8% versus 18.1%), jaundice (18.2% versus 7.2%), mucositis (40.9% versus 14.5%), vomiting (37.5% versus 21.7%), and fever (19.3% versus 7.2%) and grade 3-4 neutropenia (47.7% versus 21.7%).

Conclusion: This is the first head-to-head trial showing that single-agent irinotecan yielded PFS, OS, and ORR similar to FOLFIRI, with a more favorable toxicity profile; therefore, it might be a more favorable standard chemotherapy regimen for mCRC patients who failed first-line XELOX/FOLFOX regimens.

Trial registration: This study is registered with ClinicalTrials.gov, number NCT02935764, registered 17 October 2016, https://ichgcp.net/clinical-trials-registry/NCT02935764.

Keywords: FOLFIRI; chemotherapy; irinotecan; metastatic colorectal cancer.

Conflict of interest statement

Conflict of interest statement: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

© The Author(s), 2022.

Figures

Figure 1.
Figure 1.
Patient flow diagram.
Figure 2.
Figure 2.
Kaplan–Meier survival estimates in the intention-to-treat population. (a) Progression-free survival and (b) overall survival in patients receiving FOLFIRI compared with patients receiving IRI.
Figure 3.
Figure 3.
Forest plots of exploratory subgroup analysis of (a) disease-free survival and (b) overall survival.

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