18
Table 7. Recommendations on Third-Line and Fourth-Line
Systemic Colorectal Metastatic Treatment
Note: is table pertains to only Maximal settings, with presumption of
lack of these agents in in the other settings
ASCO Resource
Level
Strength of
Recommendation Population Rec # Maximal
RAS wild type, and no prior
anti-EGFR therapy
4.1 Anti-EGFR ±
irinotecan-based
chemotherapy
a
Moderate
any RAS/BRAF 4.2
Regorafenib
b
(if
available) OR
trifluridine + tipiracil
c
(if available)
Weak
dMMR/MSI-H 4.3 Immune checkpoint
inhibitors (if not
previously given)
Moderate
a
e combination of cetuximab with irinotecan is more active than cetuximab alone in irinotecan-
refractory patients
b
Regorafenib is recommended in patients previously treated with fluoropyrimidines, oxaliplatin,
irinotecan, bevacizumab and anti-EGFR therapy (if RAS WT)
c
Trifluridine/tipiracil is recommended in patients previously treated with fluoropyrimidines,
oxaliplatin, irinotecan, bevacizumab and anti-EGFR therapy (if RAS WT)
Treatment
