Oncology On The Go CancerNetwork

In a conversation with CancerNetwork®, Jagoda Misniakiewicz, PharmD, a clinical pharmacy specialist in the Clinical Pharmacy and Outcomes Sciences Department at Hollings Cancer Center of the Medical University of South Carolina, spoke about the use of fruquintinib (Fruzaqla) as a treatment option for those with metastatic colorectal cancer (CRC).






The FDA previously approved fruquintinib as a treatment for those with metastatic CRC and prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy and anti-VEGF therapy in November 2023.1





Misniakiewicz detailed the agent’s mechanism of action as a potent, orally available small molecule kinase inhibitor and its potential to inhibit blood vessel growth, thereby yielding vascular regression, normalization, and construction. Additionally, the clinical benefit of switching from intravenous therapy to this oral treatment appears to extend to any patient who has progressed on prior therapy, although she noted that there are currently no specific biomarkers or tumor characteristics that would make patients suitable candidates for fruquintinib.





The discussion also focused on the efficacy and safety data supporting the clinical utility of fruquintinib in this patient population. Specifically, Misniakiewicz highlighted the “exciting” progression-free survival (PFS) findings from the phase 3 FRESCO-2 trial (NCT04322539), which may affirm fruquintinib as a “promising treatment option” for those with refractory disease. 





According to previous findings from the FRESCO-2 trial published in Lancet Oncology, the median PFS was 3.7 months (95% CI, 3.5-3.8) with fruquintinib plus best supportive care vs 1.8 months (95% CI, 1.8-1.9) with placebo plus best supportive care (HR, 0.32; 95% CI, 0.27-0.39; P .0001).2 Additionally, the median overall survival (OS) was 7.4 months (95% CI, 6.7-8.2) vs 4.8 months (95% CI, 4.0-5.8) in each respective arm (HR, 0.66; 95% CI, 0.55-0.80; P .0001). PFS and OS benefits across various patient subgroups—in which investigators stratified patients based on previous treatment with trifluridine/tipiracil (Lonsurf) or regorafenib (Stivarga), RAS mutation status, and duration of metastatic disease—were comparable with those observed in the intent-to-treat population.





“The truth is that treatment options for metastatic [CRC] are limited, and the approval of fruquintinib will hopefully bridge that gap a little bit,” Misniakiewicz said. “Oral agents have changed the landscape of treatment for patients with cancer. Furthermore, targeted agents allow us to tailor therapy with the goal of improving clinical outcomes while minimizing off target toxicities; fruquintinib will hopefully allow us to do this in patients with metastatic colorectal cancer.”






References





1.        Takeda receives U.S FDA approval of Fruzaqla (fruquintinib) for previously treated metastatic colorectal cancer. News release. Takeda. November 8, 2023. Accessed June 6, 2024. https://bit.ly/3SwkD8U

2.        Dasari A, Lonardi S, Garcia-Carbonero R, et al. Fruquintinib versus placebo in patients with refractory metastatic colorectal cancer (FRESCO-2): an international, multicentre, randomised, double-blind, phase 3 study. Lancet. Published online June 15, 2023. doi:10.1016/S0140-6736(23)00772-9

In a conversation with CancerNetwork®, Terence T. Sio, MD, MS, discussed how technological advancements in radiation oncology have impacted the modern treatment landscape for patients with non–small cell lung cancer (NSCLC).





Sio, a professor of radiation oncology at Mayo Clinic in Phoenix, Arizona, first outlined the use of immunotherapy and other systemic treatment options for this patient population. He detailed how the use of these modalities and other factors such as the risk of radiation-induced pneumonitis often inform the extent of subsequent radiotherapy. Treatment decision making may also involve collaboration with surgeons and medical oncologists as part of a multidisciplinary tumor board, which meets regularly at his institution to determine suitable strategies for those who require more than 1 course of therapy. 





Additionally, Sio spoke about currently prevalent radiotherapy treatment strategies for patients with NSCLC as well as possible toxicities that may be associated with these modalities. In terms of novel technology in the field, he highlighted the development of proton beam radiotherapy and the potential advantages it may offer over other therapies. 





According to Sio, use of proton beam radiotherapy may reduce excess radiation that usually extends beyond the targeted tumor, effectively lowering the risk of adverse effects (AEs) during treatment. Specifically, proton beam radiotherapy may benefit patient subgroups including those who have previously experienced a heart attack or those who are older and frailer. With an adequate treatment plan that encompasses the use of proton beam radiation, Sio stated that it may be possible to treat these subgroups with fewer AEs than those observed in patients who undergo standard radiotherapy. 





“We can actually be helping some of the patients who otherwise may not be able to stand as intensive of a method of combining radiation and chemotherapy for their lung cancer treatments,” Sio said regarding the use of proton beam radiotherapy in this population. “Right now, we have shown that proton [beam radiotherapy] has a role in lung cancer treatments.”

Through elaborate multidisciplinary collaboration, institutions with National Accreditation Program for Rectal Cancer (NAPRC) standards can deliver a “high level of care” in the surgical treatment of patients with rectal cancer, according to Steven Wexner, MD, PhD, and Arielle Kanters, MD.





In a conversation with CancerNetwork®, Wexner and Kanters detailed the history and advancement of the NAPRC as an interdisciplinary initiative to improve the outcomes of those undergoing surgery for rectal cancer.





Wexner is the chair in the Department of Colorectal Surgery and director of the Ellen Leifer Shulman & Steven Shulman Digestive Disease Center at Cleveland Clinic, Florida, the founding chair of the NAPRC for the American College of Surgeons Commission on Cancer, and part of the executive committee of the Commission on Cancer. Kanters is a colorectal surgeon, associate fellowship program director, and surgeon leader of the NAPRC program at Cleveland Clinic Main Campus.





Wexner spoke about the inspiration for developing the NAPRC as a mission to elevate the level of surgical outcomes in patients with rectal cancer across the United States to those he observed in European countries such as the United Kingdom and Scandinavia. He enlisted leaders from organizations including the Society of Surgical Oncology and the College of American Pathologists to outline and apply appropriate standards for surgical care in rectal cancer.





Additionally, Kanters highlighted how enforcing precise guidelines and compliance measures through the NAPRC program facilitates multidisciplinary efforts with colleagues who specialize in radiology and pathology. She stated that these principles help individuals develop their skills across each department, thereby maintaining a high level of treatment for patients with rectal cancer. 






Findings from a study published in the Journal of the American College of Surgeons indicated that mortality and complication rates appeared to be lower for patients who received surgery for rectal cancer at NAPRC-accredited institutions compared with those who were treated at non-accredited practices.





Wexner and Kanters also discussed how potential advancements related to the use of neoadjuvant or adjuvant therapy may further improve patient outcomes in the field. Additionally, they spoke about updated research on immunotherapy and other modalities that they anticipate at the 2024 American Society of Clinical Oncology (ASCO) Annual Meeting.






Reference





Harbaugh CM, Kunnath NJ, Suwanabol PA, Dimick JB, Hendren SK, Ibrahim AM. Association of National Accreditation Program for Rectal Cancer Accreditation with outcomes after rectal cancer surgery. J Amer College Surg. Published March 28, 2024. doi:10.1097/XCS.0000000000001064

In a conversation with CancerNetwork® at Memorial Sloan Kettering Cancer Center (MSKCC), Neil M. Iyengar, MD, spoke about developments and challenges in his career as a medical oncologist and clinical investigator as well as ongoing research efforts in improving outcomes among patients with breast cancer. 





Iyengar, a breast oncologist in in the Department of Medicine at MSKCC and Weill Cornell Medicine in New York City, New York, as well as the co–editor-in-chief of the journal ONCOLOGY®, detailed his work in the emerging field of exercise oncology. Based on preclinical data supporting the potential anti-tumor effects of exercise, he and his colleagues are organizing several clinical trials to validate whether exercise intervention can improve cancer-specific end points. Although some findings may support implementing exercise as part of a cancer treatment plan, Iyengar noted the observational and self-reported nature of the prior data and said that it would be necessary to test exercise intervention in the same way “you would develop any new drug for treating cancer.”





Additionally, Iyengar discussed the fulfillment of ensuring patient care, a passion that has fueled his interest in lifestyle interventions such as exercise oncology. He highlighted how his cancer treatment philosophy extends beyond the goal of reducing tumor volumes to safeguarding the patient’s physical and emotional well-being.





“You can certainly hammer away at a tumor and give all kinds of chemotherapy and anti-cancer therapies, but if that [patient] is feeling miserable and has no quality of life and a short duration of response to that therapy, that’s not necessarily the type of outcome that I would consider to be successful,” Iyengar said. “If you’re able to either control or cure a cancer while also improving a [patient’s] quality of life and general well-being, that’s the kind of outcome that I strive for. When I see that in my patients and in the patients of my colleagues, that certainly brings a lot of fulfillment.”





Iyengar also highlighted how he found excitement and passion in off-hours responsibilities to help achieve work-life balance. Looking ahead, he spoke about data on anti-estrogen agents, antibody drug conjugates, and other breast cancer treatment strategies that he is looking forward to hearing at the 2024 American Society of Clinical Oncology (ASCO) Annual Meeting.

In a discussion with CancerNetwork® at John Theurer Cancer Center, Gregory Charak, MD, highlighted advancements in surgical treatment strategies for patients with colorectal cancer (CRC) as well as other ongoing challenges in the field.





Specifically, Charak, a board-certified colorectal surgeon at Palisades Medical Center and Hackensack University Medical Center of Hackensack Meridian Health, described how minimally invasive strategies such as laparoscopic and robotic surgery have become more prevalent in the field, which have appeared to confer improvements in pain and length of hospital stay for patients. Although these minimally invasive techniques are typically preferred in this population compared with open surgery, Charak stated that he would still employ the latter depending on factors such as tumor size.





Charak also discussed the rise in CRC incidence among younger populations, which has impacted how practices conduct screening. He highlighted that patients who are in their late 20s or 30s receive recommendations to undergo colonoscopy in the event of weight changes or blood appearing in their stool, noting that he would not hesitate to perform screening even if there’s a small but real possibility of disease.





Regarding other treatment modalities in this population, Charak emphasized the potential benefits of neoadjuvant therapy. Administering neoadjuvant treatment with agents including cytotoxic chemotherapy and immunotherapy, for example, may help achieve negative-margin resections, thereby yielding less morbidity for patients.





“It’s a very exciting time to be a surgical oncologist. [There are] tremendous new treatment modalities coming down the pike. Immunotherapy, in particular, is extremely exciting because it’s such an elegant way to treat cancer: to harness and augment the body’s own defense system to eliminate a cancer rather than using cytotoxic chemicals or invasive surgery,” Charak said. “It’s a beautiful thing. If we can get it to apply to more and more tumors and figure out how to make it work, it couldn’t be more exciting.” 

During the 2024 Oncology Nursing Society Congress, CancerNetwork® spoke with multiple registered nurses about research they presented on safely administering treatment options such as CAR T-cell therapy and bispecific T-cell engager (BiTE) therapy in patients with multiple myeloma and other malignancies.






Ishmael Applewhite, BSN, RN-BC, OCN, a registered nurse at the University of Rochester Medical Center, highlighted the management of adverse effects including peripheral neuropathy in patients with multiple myeloma undergoing treatment with ciltacabtagene autoleucel (cilta-cel; Carvykti). He discussed these treatment strategies in the context of a presentation he gave on findings from the phase 3 CARDITUDE-4 trial (NCT04181827), in which investigators assessed treatment with cilta-cel in those who were refractory to lenalidomide (Revlimid).1





According to Applewhite, cilta-cel may offer “another path” aside from standard treatment options such as chemotherapy and give “more time” to patients with multiple myeloma.





Additionally, Leslie Bennett, MSN, RN, a nurse coordinator at Stanford Healthcare, highlighted the importance of identifying and mitigating cranial nerve palsy (CNP) in patients with multiple myeloma who are treated with cilta-cel. At the conference, Bennett presented data on CNP outcomes across various studies, which included the phase 1/2 CARTITUDE-1 trial (NCT03548207), phase 2 CARTITUDE-2 trial (NCT04133636), and phase 3 CARTITUDE-4 trial (NCT04181827).2





According to findings from this presentation, patients had CNP onset at a median of approximately 3 weeks after beginning treatment with cilta-cel. Most cases of CNP tended to occur in male patients.






Kathy Mooney, MSN, RN, ACNS-BC, BMTCN®, OCN®,clinical program director at Johns Hopkins Hospital and Johns Hopkins Health System, spoke about a study designed to evaluate the feasibility and safety of using BiTE therapy to treat those with cancer in an outpatient setting.3 Mooney emphasized multidisciplinary collaboration among nurses, pharmacy providers, and social workers as part of monitoring patients for toxicity as they undergo treatment with BiTE agents.







References





1.        Applewhite I, Elfrink G, Esselmann J, Lonardi C, Florendo E, Sidiqi MH. Efficacy and adverse events after ciltacabtagene autoleucel treatment in the CARTITUDE-4 as-treated population consisting of patients with lenalidomide-refractory multiple myeloma who received 1-3 prior lines of therapy. Presented at: 2024 Oncology Nursing Society Congress; April 24-28, 2024; Washington, DC.

2.        Bennett L, Kruyswijk S, Sidana S, et al. Incidence and management of cranial nerve impairments in patients with multiple myeloma treated with ciltacabtagene autoleucel in CARTITUDE studies. Presented at: 2024 Oncology Nursing Society Congress; April 24-28, 2024; Washington, DC.

3.        Mooney K, Allen N, Anderson K, Zukas A. Taking a BiTE out of hospital admission days using a team approach to managing patients at risk for treatment related toxicities. Presented at: 2024 Oncology Nursing Society Congress; April 24-28, 2024; Washington, DC.