The use of irinotecan and oxaliplatin in the treatment of advanced colorectal cancer.

In 2002, the UK National Institute for Clinical Excellence (NICE) issued guidance on the use of irinotecan, oxaliplatin and raltitrexed in advanced colorectal cancer. This guidance recommended that UK patients with advanced colorectal cancer (CRC) receive 5-FU+folinic acid [leucovorin] as first line therapy, and were only eligible for irinotecan if their disease progressed. NICE guidance is adopted worldwide by more than 25 countries in addition to the British National Health Service. This guidance specifically recommended that, 'oxaliplatin could be used in first line treatment if in the opinion of an experienced liver surgeon, a patient might become potentially resectable'. Since 2002, the definition of hepatic resectability with curative intent for these patients has changed radically to encompass any patient in whom a 70% liver resection will achieve total macroscopic removal of all liver disease. Furthermore, compelling evidence has emerged over the last 2 years, which clearly demonstrates the therapeutic superiority of oxaliplatin and irinotecan based regimens over 5FU and leucovorin in the treatment of patients with advanced colorectal cancer. The original guidance was not due for review until 2007, presently NICE are reviewing this guidance prematurely, and new guidance will be issued by the summer of 2005, and clearly this review will have an impact in many countries. This paper summarises the present evidence for the use of these regimens. Most importantly, it is now a prerequisite for liver surgeons to work hand in hand with medical oncologists to obtain maximum survival benefit and increased chance of cure for these patients.