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Generic irinotecan being used as first-line treatment
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Irinotecan (CPT-11) recently went off patent and is now available in a generic form. This has led to some of my partners using it as first-line treatment for their metastatic colorectal cancer patients. Previously all of us had been using oxaliplatin first line, and single agent irinotecan or FOLFIRI second line. The Tournigand phase 3 study of FOLFIRI followed by FOLFOX 6 or vice versa suggested that overall survival and efficacy were similar with both approaches. Similar results were found in the Colucci study of upfront Doulliard-type infusional-5FU and irinotecan or FOLFOX4.
The upshot is that side effect profiles and patient preferences should drive the decision about which agent to use first. The studies above do not include biologics, but I think that most providers feel comfortable making the jump to assuming equivalence between FOLFIRI+bev and FOLFOX+bev. In oncology, we rarely make decisions based on dollars and cents, but also, we have not had the option of generics available to us until very recently either. It may be possible that some patients may only need or get access to irinotecan (maybe they go to surgery, maybe their performance status declines too quickly to allow for a trial of FOLFOX), in which case you may save the collective "us" a few bucks. The sticky wicket is the issue of genotyping for UGT1A1 mutations prior to receiving irinotecan, and the cost associated with that.