Palliative chemotherapy is the cornerstone of treatment for the majority of patients with metastatic colorectal cancer, with the aim of increasing length and quality of life. Although guidelines outline the available treatment options in the first line, they provide limited guidance on choice and intensity of the chemotherapy backbone. Data from the TRIBE and TRIBE2 studies confirm a survival benefit with triplet FOLFOXIRI and bevacizumab, and this is a preferred option for younger patients with good performance status able to tolerate it. However, the relative benefit of a fluoropyrimidine doublet with oxaliplatin or irinotecan over single-agent fluoropyrimidine with or without a biologic is less certain; the available data demonstrate that single-agent fluoropyrimidine plus a biologic with planned sequencing of subsequent agents can produce similar overall survival outcomes with reduced toxicity. Our analysis of local real-world registry data suggests that this is an underutilized approach, particularly in younger and fitter patients. Established prognostic factors, including patient age, performance status, tumor sidedness, and biomarkers such as RAS/BRAF, are key in treatment selection; patients with left-sided RAS/BRAF wild-type disease or patients with low tumor bulk may be ideal for a less intensive regimen. Further studies are required to confirm the value of less-intensive regimens in the modern era, where the incorporation of biologic therapies has become routine and where non-chemotherapy options are emerging as viable options for molecularly defined patient subsets.

姑息性化疗是大多数转移性结直肠癌患者治疗的基石，目的是延长生活时间和提高生活质量。尽管指南概述了一线可用的治疗方案，但它们对化疗主干的选择和强度提供了有限的指导。来自 TRIBE 和 TRIBE2 研究的数据证实了三联组 FOLFOXIRI 和贝伐单抗的生存获益，对于体能状况良好且能够耐受的年轻患者来说，这是一个首选的选择。然而，氟嘧啶双药联合奥沙利铂或伊立替康相对于氟嘧啶单药联合或不联合生物制剂的相对益处尚不确定。现有数据表明，单药氟嘧啶加一种生物制剂，并计划对后续药物进行测序，可以产生相似的总体生存结果，同时降低毒性。我们对当地真实世界注册数据的分析表明，这是一种未被充分利用的方法，尤其是在年轻和健康的患者中。既定的预后因素，包括患者年龄、体能状态、肿瘤侧向性和 RAS/BRAF 等生物标志物，是治疗选择的关键；患有左侧 RAS/BRAF 野生型疾病的患者或肿瘤体积较小的患者可能是强度较低的治疗方案的理想选择。需要进一步的研究来确认现代低强度方案的价值，