The following colorectal cancer research updates extend from June 15 to July 14, 2020, inclusive and are intended for informational purposes only.
- Phase II LEAP Clinical Trial to Treat mCRC
- Health Canada approves VITRAKVI (Larotrectinib), first tumour agnostic cancer treatment for advanced solid tumours harbouring an NTRK gene fusion
- A Phase II, Open-Label, Multicentre, Study of an Immunotherapeutic Treatment for the MSI High Colorectal Cancer Metastatic Population
- Phase III Study at the Odette Cancer Centre Comparing Arfolitixorin vs. Leucovorin: Both in Combination with 5FU, Oxaliplatin, and Bevacizumab in Patients with Advanced Colorectal Cancer
- Comprehensive Genomic Profiling in Cancer Treatment Decisions: The Possibilities
- FDA Approves Merck’s Keytruda as First-Line Treatment for MSI-H mCRC
- Efficacy of Panitumumab and Cetuximab in Patients with CRC Previously Treated with Bevacizumab
- Preoperative Chemo-Radiation Improves Outcomes for Rectal Cancer
- Onvansertib Precision Medicine Being Developed for KRAS mutant Colon Cancers
- Are ATR Inhibitors The Next Precision Medicine to Improve Cancer Outcomes?
- Common Hypertension Medications May Reduce CRC Risk
- Aspirin, Flavonoid Metabolites May Be Preventing CRC
- Hepatic Artery Infusion Pump (HAIP) Chemotherapy Program – Sunnybrook Hospital
- Living Donor Liver Transplantation for Unresectable Colorectal Cancer Liver Metastases
- “ALPPS” Surgery Opens New Possibilities for Treating Liver Metastases from Colorectal Cancer
- Study Offered at the Odette Cancer Centre to Treat Recurrent Rectal Cancer
- Proximal Serrated Polyps Increase Future Risk of CRC
- Young Adult Colorectal Cancer Clinic Available at Sunnybrook Hospital
- Increasing CRC Incidence Trends Among Younger Adults in Canada
- Treatment Options for CRC Liver & Abdominal Metastases
- Questions Patients Should Ask Their Doctor When Determining Cancer Treatment
- Side Effects of Cancer Treatment: Mouth Sores or Mucositis
- Association between Vitamin D Receptor Single-Nucleotide Polymorphisms and CRC
- Tips for a Healthy Summer Season
- Health Benefits of Berries
- 10 Cancer Prevention Recommendations
- Coronavirus Outbreak: Daily Updates
- Convalescent Plasma Found Safe for Diverse Patients with COVID-19
- French SARS-CoV-2 Guidelines for Cancer Patients
- Cancer Immunotherapy Tied to Severe COVID-19 Outcomes
- New Study Details the Best Types of COVID-19 Face Masks
- Physical and Mental Health Survey of Cancer Survivors During the COVID-19 Pandemic
- Protecting Cancer Patients From COVID-19: Clinical Trial Tests a Novel Immune-Boosting Strategy
- Impact of COVID-19 on Cancer Care
- Cancer Patients & Covid-19: What You Need to Know
- Frequently Asked Questions for COVID-19
DRUGS / SYSTEMIC THERAPIES
- Phase II LEAP Clinical Trial For mCRC (Mar.1/20)
The purpose of this study is to determine the safety and efficacy of combination therapy with pembrolizumab (MK-3475) and Levantine (E7080/MK-7902) in patients with triple-negative breast cancer (TNBC), ovarian cancer, gastric cancer, colorectal cancer (CRC), glioblastoma (GBM), or biliary tract cancers (BTC). Participants will be enrolled in initial tumor-specific cohorts, which will be expanded if adequate efficacy is determined. The trial is available at the Odette Cancer Centre and at the Princess Margaret Cancer Centre in Toronto as well as the following Centres throughout Canada: Abbotsford, BC; Winnipeg, MB; CHU de Quebec. For information, visit the link below.
- Health Canada Approves VITRAKVI (Larotrectinib), First Tumour Agnostic Cancer Treatment For Advanced Solid Tumours Harbouring an NTRK Gene Fusion (Mar.5/20)
Bayer announced that there is now a treatment in Canada for tyrosine receptor kinase fusion protein-driven childhood and adult cancers. Neurotrophic Tyrosine Receptor Kinase (NTRK) gene fusions can result in the production of TRK fusion proteins that can lead to uncontrolled cell growth and cancer. Health Canada issued a Notice of Compliance with Conditions (NOC/c) for VITRAKVI® (Larotrectinib). VITRAKVI® is approved for the treatment of adult and pediatric patients with solid tumours that have an NTRK gene fusion without a known acquired resistance mutation, are metastatic or where surgical resection is likely to result in severe morbidity and have no satisfactory treatment options. Treatment with VITRAKVI® should be initiated following confirmation of an NTRK gene fusion in a tumour specimen using a validated test.
This is the first time Health Canada has approved a tumour agnostic treatment, such that patients with advanced solid tumours harbouring an NTRK gene fusion may be eligible for treatment with VITRAKVI®, across multiple tumour types and ages. VITRAKVI® is a first-in class oral and highly selective TRK inhibitor that may shrink the tumour or may slow or stop it from growing. In the clinical trials that were the basis for this approval, TRK fusion cancer patients treated with Larotrectinib experienced clinical benefit across numerous tumour types, including lung, thyroid, melanoma, GIST (gastrointestinal stromal tumour), colon, soft tissue sarcoma, salivary gland, and infantile fibrosarcoma. The overall response rate (ORR) was 75% (95% CI, 64%, 85%) with 22% of patients experiencing a complete response (CR) to treatment. The ORR observed was 90% in pediatrics and 69% in adults, and responses were rapid and durable.
What is TRK Fusion Cancer?
TRK fusion cancer is rare and occurs when an NTRK gene fuses with another unrelated gene, producing a TRK fusion protein that becomes constitutively active or overexpressed, triggering a signaling cascade. These TRK fusion proteins act as oncogenic drivers promoting cell growth and survival, leading to TRK fusion cancer, regardless where it originates in the body. TRK fusion cancer is not limited to certain types of tissues and can occur in any part of the body. TRK fusion cancer occurs in various adult and pediatric solid tumours with varying frequency, including lung, thyroid, gastrointestinal cancers (colon, cholangiocarcinoma, pancreatic and appendiceal), sarcoma, CNS cancers (glioma and glioblastoma), salivary gland cancers (mammary analogue secretory carcinoma) and pediatric cancers (infantile fibrosarcoma and soft tissue sarcoma). TRK fusion proteins are rare in common cancers (such as colorectal cancer) and common in rare cancers.
NB: The pan Canadian Oncology Drug Review Expert Committee (pERC) has recently issued a funding recommendation in respect of Larotrectinib. It conditionally recommends the reimbursement of Larotrectinib (Vitrakvi) for the treatment of adult and pediatric patients with locally advanced solid tumors that have an NTRK gene fusion This recommendation pertains only to adult and pediatric patients with salivary gland tumours, adult or pediatric patients with soft tissue sarcoma (STS) and pediatric patients with cellular congenital mesoblastic nephroma or infantile fibrosarcoma, without a known acquired resistance mutation, that are metastatic or where surgical resection is likely to result in severe morbidity and have no satisfactory treatment options, only if the following conditions are met:
- Cost-effectiveness being improved to an acceptable level
- Feasibility of adoption (budget impact and access to testing) is addressed
Stay tuned as the expert committee is currently reviewing feedback submissions from various stakeholders.
Please note: the expert review committee has as of October 31st, 2019 issued a final negative funding recommendation in respect of Larotrectinib. Efforts are currently underway to assemble a massive campaign to address this final recommendation by working to secure a sustainable, long-term funding solution for TRK fusion cancer patients.
- Bayer has launched a testing program called FastTRK. As per an information sheet that may be obtained from CCRAN, FastTRK is a clinical testing program for the diagnosis of NTRK gene fusions. Sponsored by Bayer, this is a complimentary service for clinicians to determine whether their patients’ cancer has an NTRK gene fusion. Solid tumour samples from eligible patients (in the form of a solid tumour block or prepared slides) will be tested by immunohistochemistry (IHC) and/or next-generation sequencing (NGS). Currently, Bayer has partnered with LifeLabs and the Kingston Health Sciences Centre (KHSC) to provide NTRK gene fusion testing services for Canadians. The FastTRK program will be supported at least until the end of 2021.
- Bayer will continue to offer the therapy to patients who are identified to have TRK fusion cancers and who are responding to the therapy.
- Bayer will provide a TRAKTION Patient Support Program to assist patients while on the therapy.
- A Phase 2, Open-label, Multicenter, Study of an Immunotherapeutic Treatment for the MSI High Colorectal Cancer Metastatic Population (Mar.12/20)
The purpose of this study is to look at the effectiveness of the vaccine DPX-Survivac in combination with the drugs cyclophosphamide and the immunotherapy Pembrolizumab in patients with solid cancers who are identified to be MSI-High. All patients will receive combination therapy of DPX-Survivac, cyclophosphamide, and pembrolizumab. Patients participating will know which treatment they are receiving. The trial is currently hosted at the Odette Cancer Centre, and a new site is opening at Mt. Sinai Hospital.
- Phase III Study at the Odette Cancer Centre Comparing Arfolitixorin vs. Leucovorin in Combination with 5FU, Oxaliplatin and Bevacizumab in Patients with Advanced Colorectal Cancer (Mar.12/20)
The purpose of this study is to look at the effectiveness of the drug Arfolitixorin in combination with 5-fluorouracil (5FU), oxaliplatin, and bevacizumab in patients with colorectal cancer. Patients with advanced/metastatic colorectal cancer who meet certain criteria may be able to participate. There will be two groups of patients participating in this study;
- one group will receive Arfolitixorin in combination with 5FU), oxaliplatin, and bevacizumab,
- while the other group will receive the drug Leucovorin in combination with 5FU, oxaliplatin, and bevacizumab (standard of care).
The doctor and study staff will not know which group a patient is in. Patients will be randomized to receive one treatment or the other.
Arfolitixorin is Isofol’s proprietary drug candidate being developed to increase the efficacy of standard of care chemotherapy for advanced colorectal cancer. The drug candidate is currently being studied in a global Phase 3 clinical trial. As the key active metabolite of the widely used folate-based drugs, arfolitixorin can potentially benefit all patients with advanced colorectal cancer, as it does not require complicated metabolic activation to become effective.
Treating cancer patients with arfolitixorin – The goals:
- When treating colorectal cancer, for example, arfolitixorin is administered in combination with 5-FU to increase cell mortality in circulating cancer cells and in cancerous tumours.
• Arfolitixorin is administered in conjunction with rescue therapy after high-dose treatment with the cytotoxic agent, methotrexate, in order to suppress the cytotoxic effect in surrounding healthy tissue. The treatment is used for certain types of cancer, such as osteosarcoma, a type of bone cancer. This involves administering arfolitixorin separately, 24 hours after the chemotherapy.
- Comprehensive Genomic Profiling in Cancer Treatment Decisions: The Possibilities (Jun.22/20)
The genomic / immunologic tumour profile, like a fingerprint, distinguishes one person’s cancer from another. This opens up the possibility for considering a personalized approach to cancer treatment that is uniquely tailored to a particular cancer patient. If a known alteration or mutation is detected in a person’s genomic / immunologic tumour profile, an oncologist can determine if there are approved mutation-matched drug treatments available to prescribe to the patient or novel drug therapies in active clinical trials that a person with cancer may wish to consider participating in.
OncoHelix, a Calgary-based company, strives to provide accessible, high-quality, clinical-grade genomic profiling to many groups such as clinical researchers, novel health technology companies and patients via their direct-to-consumer offering. OncoHelix is able to provide consumers direct payment access for Next Generation Sequencing (NGS) testing to determine a person’s cancer genomic profile, in Canadian dollars, utilizing a state-of-the art molecular pathology lab based in Canada, at a lower cost than other US lab providers
OncoHelix will navigate with you and your physician on how to complete the NGS test requisition form. Their navigator will also assist the pathology lab that is storing your specimen, in order to prepare and ship the tumor sample to the molecular lab based in Calgary, Alberta which OncoHelix uses exclusively for this type of diagnostic testing. Within 4 weeks of receipt of the tumor sample at the Calgary lab, a clear and comprehensive report is generated, reviewed by the expert pathology team at the lab and sent to the ordering physician where the results of any detected tumor alterations can be reviewed and potential treatment or clinical trial options can be considered.
- FDA Approves Merck’s Keytruda as First-Line Treatment for MSI-H mCRC (Jun.29/20)
The US Food and Drug Administration approved the anti-PD-1 checkpoint inhibitor pembrolizumab (Merck’s Keytruda) as a first-line treatment for microsatellite instability-high (MSI-H) or mismatch repair deficient (MMR-D) metastatic colorectal cancer (mCRC) patients. Approximately 5% of patients with metastatic colorectal cancer have MSI-H or MMR-D tumors. These patients have improperly functioning DNA repair systems within their cancer cells.
Pembrolizumab is now the first immunotherapy approved as a monotherapy, first-line option for this patient population, without the addition of chemotherapy. The FDA approved pembrolizumab in 2017 for patients with refractory solid tumors that were MSI-H or MMR-D, regardless of their cancer histology. In CRC specifically, the drug is FDA-approved for metastatic or unresectable CRC patients who are MSI-H or MMR-D and who have progressed after chemotherapy treatment with a fluoropyrimidine, oxaliplatin, and irinotecan.
In the Merck-sponsored Keynote-177 trial, metastatic MSI-H colorectal cancer patients who received pembrolizumab lived on average twice as long without their disease progressing compared to those who received the investigators’ choice of chemotherapy alone or a chemotherapy-based regimen that added bevacizumab (Genentech’s Avastin) or cetuximab (Eli Lilly’s Erbitux). Median progression-free survival was 16.5 months in the patients who received pembrolizumab and 8.2 months in patients who received the standard of care. Among the patients who responded to treatment with pembrolizumab, 43% experienced a response lasting two years or longer. As presented at the American Society of Clinical Oncology’s (ASCO) virtual annual meeting in May, pembrolizumab was “much safer” in this population than the chemotherapy-containing regimens. Grade 3 or higher toxicities occurred in 22% of patients receiving pembrolizumab versus 66% in the comparator arm.
“Metastatic colorectal cancer is a serious and life-threatening disease with a poor prognosis. Available current therapy with chemotherapy combinations and other biologics are associated with substantial toxicity,” Richard Pazdur, director of the FDA’s Oncology Center of Excellence, said in a statement. Having a non-chemotherapy option available for selected patients is a noteworthy paradigm shift in treatment.
- Efficacy of Panitumumab and Cetuximab in Patients with CRC Previously Treated with Bevacizumab (Jun.28/20)
Phase-III ASPECCT and randomized phase-II WJOG6510G trials demonstrated the noninferiority of panitumumab (Vectibix), when compared with cetuximab (Erbitux), for overall survival (OS) in patients with chemotherapy-refractory wild-type KRAS exon-2 metastatic colorectal cancer (mCRC). The subgroup had received bevacizumab either prior to panitumumab or cetuximab monotherapy (ASPECCT) or in combination with irinotecan (WJOG6510G). There were 185 and 189 patients in the panitumumab and cetuximab arms, respectively.
The median OS was 12.8 and 10.1 months and the median progression-free survival (PFS) was 4.7 and 4.1 months, in the panitumumab and cetuximab arms, respectively. Panitumumab significantly prolonged the OS and PFS, when compared with cetuximab in the cohort that previously received bevacizumab in the included studies.
- Preoperative Chemo-Radiation Improves Outcomes for Rectal Cancer (Jun.01/20)
Results from a large clinical trial continue to provide confirmatory evidence that treatment with pre-operative radiation significantly decreases local cancer recurrences in patients with rectal cancer that has not spread to distant sites and should be considered the standard of care for this disease. Patients with rectal cancer that has not spread to distant sites in the body may be cured through the complete resection of their cancer. Recently, results from previous clinical trials have demonstrated that radiation prior to surgery decreases cancer recurrences compared to treatment with surgery alone in rectal cancer. A decrease in cancer recurrences often correlates to improved long-term survival.
Pre-operative radiation is intended to shrink cancer and kill undetectable cancer cells that may exist directly outside the site of cancer origin. Current detection methods are not able to find or measure small amounts of cancer cells that exist, therefore increasing the chance that they may be left behind following surgery. These cancer cells are responsible for cancer recurrences. In theory, through shrinking the site of cancer and killing nearby cancer cells, more complete surgical removal of the cancer may be obtained, resulting in fewer recurrences and improving chances for a cure.
According to results of the phase 3 RAPIDO clinical trial released at the 2020 American Society of Clinical Oncology (ASCO) Annual Meeting, pre-operative short-course radiation therapy (RT) followed by chemotherapy should be the new standard of care for treating locally advanced rectal cancer. 920 patients with locally advanced rectal cancer were enrolled in the study and treated between June 2011 and June 2016. One group of patients received short-course RT followed by 6 cycles of CAPOX (capecitabine and oxaliplatin) or 9 cycles of FOLFOX4 chemotherapy followed by surgical removal of the cancer. This was compared to “standard” therapy consisting of capecitabine-based chemo-radiotherapy and surgery.
Patients participating in this trial have now been followed in excess of 4.5 years and the 3 years probability of disease-related treatment failure is 23.7% in the short course RT group compared to 30.4% in the standard treatment group. The improved outcomes were attributed to a lower rate of distant cancer spread and this resulted in a 3-year overall survival rate of 89% for those treated with the pre-surgery short-course RT followed by chemotherapy before surgery.
This trial supports the results from previous multi-institutional clinical trials that compared neoadjuvant treatment with pre-operative radiation plus surgery to surgery alone in patients with rectal cancer that had not spread to distant sites. In an earlier pivotal trial, local cancer recurrences had occurred in only 2.4% of patients treated with pre-operative radiation plus surgery compared to 8.2% of patients treated with surgery alone.
A strategy that utilizes preoperative radiation and chemotherapy reduces the risk of local cancer recurrences in patients with rectal cancer that has not spread to distant sites
- Onvansertib Precision Medicine Being Developed for KRAS Mutant Colon Cancers (Jul.02/20)
The FDA granted Fast Track Designation to Onvansertib, an orally administered, highly selective PLK1 inhibitor that is being developed in patients with KRAS-mutated metastatic colorectal cancer (mCRC). KRAS mutations are the most common oncogenic alteration in all of human cancers and there are currently no effective treatments available for patients with KRAS-mutant cancers.
Onvansertib is being developed by Cardiff Oncology who recently announced an Expanded Access Program (EAP) to access onvansertib in combination with standard-of-care FOLFIRI and bevacizumab for second-line treatment of patients with KRAS-mutated mCRC who are not be able to participate in the ongoing clinical trial. The trial will enroll up to 44 patients with a KRAS mutation and histologically confirmed metastatic and unresectable disease. In addition, patients must have failed treatment or be intolerant of FOLFOX (fluoropyrimidine and oxaliplatin) with or without bevacizumab.
An EAP provides a potential pathway for patients with a serious or life-threatening condition to gain access to an investigational drug for treatment outside of a clinical trial, particularly when no comparable or satisfactory alternative therapy options are available. The Cardiff Oncology EAP is intended for use in combination with FOLFIRI and bevacizumab for the second-line treatment of patients with KRAS-mutated mCRC that has progressed on prior FOLFOX (with or without bevacizumab) therapy.
- Are ATR Inhibitors The Next Precision Medicine to Improve Cancer Outcomes? (Jun.28/20)
A new precision medicine targeting a cancer’s ability to repair its DNA has shown promising results in the first clinical trial of the drug class. Half of the patients given the new drug either alone or with platinum chemotherapy saw their cancer stop growing, and two patients saw their cancer disappear completely. Preclinical studies have shown that cancer cells with defective DNA repair mechanisms or cell cycle checkpoints may be particularly sensitive to treatment with a novel class of drugs called ATR inhibitors.
Berzosertibe is a first-in-class ATR Inhibitor M6620 (VX-970) that blocks a key DNA repair protein called ATR that is undergoing clinical evaluation as a single agent or in combination with chemotherapy in an early phase clinical trial. Targeting a cancer’s ability to repair its DNA is a fundamentally important avenue of cancer research, which has delivered some of the most important advances against the disease in recent years. ATR inhibiting drugs will be evaluated to boost the effect of treatments like chemotherapy that target cancer DNA and expand the range of treatment options and overcome resistance to other targeted treatments.
The drug is now moving forward in clinical trials, and the hope is that it could be developed into a new-targeted treatment for patients and helps overcome resistance to other precision medicines that target DNA repair.
- Common Hypertension Medications May Reduce CRC Risk (Jul.02/20)
According to new research published in the American Heart Association journal, medications commonly prescribed to treat high blood pressure may also reduce patients’ colorectal cancer (CRC) risk. Angiotensin converting enzyme inhibitor (ACE-i) or angiotensin II receptor blocker (ARB) medications are prescribed for conditions such as heart failure, high blood pressure or heart disease. These medications inhibit or block angiotensin, a chemical that causes arteries to become narrow. Doctors commonly prescribe these medications to people with high blood pressure to relax and open blood vessels, thereby lowering blood pressure. Based on the findings of this large study, taking these medications may also reduce colorectal cancer risk.
The roles of ACE inhibitors and ARBs on cancer development are controversial and, in some cases, study findings are conflicting. This is the first study to show the potential beneficial effects of ACE inhibitors and ARBs on CRC development, based on a large group of patients who were CRC-free at the beginning of the study. Researchers reviewed health records of 187,897 adult patients in Hong Kong from 2005 to 2013, with a negative baseline colonoscopy for CRC.
The analysis found that:
- Those who took hypertension medications such as ACE-i or ARBs had a 22% lower risk of developing CRC in the subsequent three years
- Benefits of ACE-i and ARBs were seen in patients 55 or older and those with a history of colon polyps
- The benefit associated with the medications was limited to the first three years after the negative baseline colonoscopy
This is a retrospective study, looking back at whether patients on these medications developed CRC. Researchers note that the results should be verified with a prospective randomized controlled study, which would actively follow patients to determine the potential benefits of these medications on CRC risk.
- Aspirin and Flavonoid Metabolites May Be Preventing CRC (Jul.07/20)
A diet rich in fruits and vegetables and a daily dose of aspirin can help prevent colorectal cancer (CRC). According to associate professor Jayarama Gunaje of SDSU’s Department of Pharmaceutical Sciences, their ability to inhibit cancer cell growth can be a result of the compounds produced when the body breaks down, or metabolizes, aspirin, and flavonoids present in fruits and vegetables.
Only 40 to 50% of aspirin and less than 15% of flavonoids are absorbed in the bloodstream, therefore, substantial amounts reach the intestines, where host and bacterial enzymes degrade the compounds. This process results in simpler phenolic acids, specifically hydroxybenzoic acids (HBAs) that may contribute to CRC prevention. Plants also have the capacity to make these metabolites. Fruits and vegetables are loaded with free HBAs, which act as antioxidants and also help the plants fight infections. Identifying the metabolites and the gut bacteria responsible for degradation of aspirin and flavonoids will help scientists develop probiotics and possibly supplements to help prevent CRC.
Examining Aspirin Metabolites
While investigating how aspirin decreases CRC risk, Gunjae found the parent compounds, aspirin and salicylic acid, had no effect on enzymes called cyclin-dependent kinases that regulate cell division. That led to examining whether the cancer-fighting power might be coming from aspirin and salicylic acid metabolites called dihydroxybenzoic acids. Testing showed that the aspirin metabolite 2,5-dihydroxybenzoic acid was universally effective in inhibiting the growth in colorectal cancer cell lines. The researchers also found that, 2,4,6 trihydroxybenzoic acid (2,4,6-THBA), a derivative of salicylic acid, was capable of inhibiting cyclin-dependent kinases and cancer cell growth.
Based on their finding about aspirin metabolites, researchers began looking for natural sources of 2,4,6-THBA. That led them to focus on the polyphenolic flavonoids in fruits and vegetables. Flavonoids are abundant in fruits and vegetables, such as blackberries, blue berries, red grapes, apples and red onions, and in chocolate, tea and red wine. 2,4,6-THBA, one of the compounds produced when the body metabolizes or breaks down flavonoids, can inhibit cancer cell growth under specific conditions.
When cells are exposed to HBAs generated through bacteria in the gut, this reduces the rate of cancer cell growth. That growth rate reduction likely gives immune cells, such as T cells and natural killer cells, a greater window of opportunity to destroy the cancer cells. When a normal cell contains damaged DNA, mutations can occur. The slowdown in cell proliferation may provide time for the cells to repair their DNA, thereby preventing the accumulation of mutations.
“Cancer prevention involves a partnership between the compounds and microbial species in the gut,” Gunaje said. By proposing the metabolite hypothesis, he and his research group hope to encourage further studies on the role HBAs play in cancer prevention.
- Hepatic Artery Infusion Pump (HAIP) Chemotherapy Program — Sunnybrook Odette Cancer Centre (July 16/20)
The HAIP program is a first-in-Canada for individuals where colon or rectal cancer (colorectal cancer) has spread to the liver and cannot be removed with surgery. The program involves a coordinated, multidisciplinary team approach to care, with close collaboration across surgical oncology, medical oncology (chemotherapy), interventional radiology, nuclear medicine, and oncology nursing. The Hepatic Artery Infusion Pump (HAIP) is a small, disc-shaped device that is surgically implanted just below the skin of the patient and is connected via a catheter to the hepatic (main) artery of the liver. About 95 percent of the chemotherapy that is directed through this pump stays in the liver, sparing the rest of the body from side effects. Patients receive HAIP-directed chemotherapy in addition to regular intravenous (IV) chemotherapy (systemic chemotherapy), to reduce the number and size of tumours. Drs. Paul Karanicolas and Yooj Ko are the program leads and happy to see patients eligible for the therapy.
Presently at Sunnybrook Odette Cancer Centre, HAIP is being used in patients with colorectal cancer that has spread to the liver that cannot be removed surgically and has not spread to anywhere else in the body. Patients who have few (1-5) and very small tumors in the lungs may be considered if the lung disease is deemed treatable prior to HAIP. If you believe you may benefit from this therapy and/or would like to learn more about the clinical trial, your medical oncologist or surgeon may fax a referral to 416-480-6179. For more information on the HAIP clinical trial, please click on the link provided below.
- Living Donor Liver Transplantation for Unresectable Colorectal Cancer Liver Metastases (July 12/20)
Approximately half of all colorectal cancer (CRC) patients develop metastases, commonly to the liver and lung. Surgical removal of liver metastases (LM) is the only treatment option, though only 20-40% of patients are candidates for surgical therapy. Surgical therapy adds a significant survival benefit, with 5-year survival after liver resection for LM of 40-50%, compared to 10-20% 5-year survival for chemotherapy alone. Liver transplantation (LT) would remove all evident disease in cases where the colorectal metastases are isolated to the liver but considered unresectable.
Image Source: https://www.slideshare.net/AhmedAdel65/preoperative
While CRC LM is considered a contraindication for LT at most cancer centers, a single center in Oslo, Norway demonstrated a 5-year survival of 56%. A clinical trial sponsored by the University Health Network in Toronto will offer live donor liver transplantation (LDLT) to select patients with unresectable metastases limited to the liver and are non-progressing on standard chemotherapy. Patients will be screened for liver transplant suitability and must also have a healthy living donor come forward for evaluation. Patients who undergo LDLT will be followed for survival, disease-free survival, and quality of life for 5 years and compared to a control group who discontinue the study before transplantation due to reasons other than cancer progression. Despite the trial’s negative outcome, investigation of HIPEC, and other strategies to prevent peritoneal metastasis, should continue, they concluded in Lancet Gastroenterology & Hepatology. “The 21% peritoneal recurrence noted in the overall study population indicates the magnitude of the clinical problem in locally advanced colon cancer, and therapeutic strategies have to be further explored,” they said. “Outcomes of other trials investigating adjuvant HIPEC are eagerly awaited.”
- “ALPPS” Surgery Opens New Possibilities for Treating Liver Metastases from Colorectal Cancer (Aug.28/19)
Typically referred to as an ALPPS procedure, an associating liver partition and portal vein ligation for staged hepatectomy is one of today’s most advanced treatments for liver cancer and metastasis to the liver from cancers originating in other organs (e.g., colon or rectal cancer). This two-stage surgery makes it possible to treat patients who are not appropriate candidates for traditional liver resection due to multicentric disease and an inadequately small future liver remnant.
Given that the liver is capable of regenerating itself, it may be possible for a surgeon to remove part of the organ when treating liver tumors, provided that enough liver tissue can be left in place. However, when liver tumors have spread extensively throughout the organ or when there are multiple tumors, it can be difficult for a surgeon to preserve adequate amounts of the patient’s original liver tissue. “The ALPPS procedure allows us to treat patients who have a substantial amount of tumor, with both lobes affected by tumor,” says Federico Aucejo, MD, Director of the Liver Cancer Program, Surgical Director of the Liver Tumor Clinic and Co-Director of the Liver Tumor Center of Excellence.
An ALPPS is actually performed as two separate surgeries as follows:
- During the first portion of the procedure, a surgeon blocks off a branch of the portal vein (the main vein that delivers blood to the liver). This makes the liver behave as though part of the organ has been removed, triggering the process of tissue regeneration on the other side. Small surface tumors may be removed during this part of the operation as well. Additionally, a cut on the liver is performed which delineates what the future resection line will be and induces faster and more significant growth of the portion of the liver that will remain.
- During the second part of the procedure, and after performing 3D reconstruction and volumetric analysis to ensure the liver has regenerated enough, roughly one to two weeks after the first operation, a surgeon performs a liver resection, removing the diseased portion of the liver. The remaining part of the liver, which by this point has grown significantly, will be able to compensate and provide all the necessary functions of the liver.
Moffitt Cancer Centre has one of the most robust liver tumor programs in the United States, offering advanced treatments such as ALPPS, and modified approaches that make this procedure an even safer, but equally effective, surgery. This has resulted in improved patient outcomes and quality of life.
RADIATION THERAPIES/INTERVENTIONAL RADIOLOGY
- Study Offered at the Odette Cancer Centre to Treat Recurrent Rectal Cancer (Mar.12/20)
Magnetic resonance-guided focused ultrasound (MRg-FU) is a noninvasive, outpatient modality being investigated for the thermal treatment of cancer. In MRg-FU, a specially designed transducer is used to focus a beam of low-intensity ultrasound energy into a small volume at a specific target site in the body. MR is used to identify and delineate the tumour, focus the ultrasound beam on the target, and provide a real-time thermal mapping to ensure accurate heating of the designated target with minimal effect to the adjacent healthy tissue. The focused ultrasound beam produces therapeutic hyperthermia (40-42°C) in the target field, causing protein denaturation and cell damage. Currently, there is no prospective clinical data reported on the use of MRg-FU in the setting of recurrent rectal cancer. Recurrent rectal cancer is a vexing clinical problem. Current retreatment protocols have limited efficacy. The addition of hyperthermia to radiation and chemotherapy may enhance the therapeutic response. With recent advances in technology, the investigators hypothesize that MRg-FU is technically feasible and can be safely used in combination with concurrent reirradiation and chemotherapy for the treatment of recurrent rectal cancer without increased side-effects. The study is being offered at the Odette Cancer Centre. Here is the link to the study protocol:
- Proximal Serrated Polyps Increase Future Risk of CRC (Jul.10/20)
Although it is widely accepted that patients with serrated polyps (SPs) have an increased risk of developing colorectal cancer (CRC), current guidelines are based on limited evidence regarding the magnitude of risk associated with large (≥1 cm) or small (<1 cm) SPs. The results of a large, retrospective cohort study published in Gastroenterology provide more precise information regarding these associations.
A total of 233,393 individuals were selected for the study, aged 50 to 85 years, and had undergone their first colonoscopy between 2006 and 2016. Greater than one‐half of the patients were at least aged 60 years. There were more females than males, with most of the patients reported as non‐Hispanic white. Approximately one‐third of the examinations were screening colonoscopies, which were performed either at ambulatory endoscopy centres or as inpatient procedures. The patients’ SPs were categorized by size and location [proximal (right sided) vs. distal (left sided)], but not by histological subtype.
Researchers found the following on their first colonoscopy:
- A total of 173,257 patients had no polyp identified.
- A total of 11,505 patients were classified with at least 1 proximal SP.
- A total of 12,080 patients were classified with at least 1 proximal SP and a synchronous adenoma.
- A total of 19,410 patients were classified with at least 1 distal SP.
- A total of 17,141 patients were classified with at least 1 distal SP and a synchronous adenoma.
Among patients with proximal SPs, a total of 1293 were classified as having a large SP and 9808 were classified as having a small SP. Patients with both large and small proximal SPs were placed in the “large SP” group. Distal SPs were not analyzed according to size because the number of patients with large distal SPs alone would have been too small to reach statistically reliable results.
The median follow‐up from 1 year after colonoscopy was 3.6 years. Among the study population, there were 445 cases of incident CRC diagnosed more than 1 year after colonoscopy. The cumulative incidence rates of CRC per 1000 individuals by SP subgroups at 5 years and 10 years after colonoscopy were:
- No polyp: 1.2 at 5 years and 4.7 at 10 years.
- Proximal small SP: 2.5 at 5 years and 14.8 at 10 years.
- Proximal large SP: 6.2 at 5 years and 30.2 at 10 years.
- Distal SP: 1.7 at 5 years and 5.9 at 10 years.
- Proximal SP with synchronous adenoma: 4.2 at 5 years and 26.0 at 10 years.
- Distal SP with synchronous adenoma: 3.0 at 5 years and 12.1 at 10 years.
Findings in this study confirmed that proximal serrated polyps, particularly large ones, are associated with increased risk of colorectal cancer, and therefore warrant close surveillance. They also support the current USMSTF (United States Multi‐Society Task Force) recommendations, including performing colonoscopy at 3 years for large sessile serrated polyps and at a less frequent interval for small sessile serrated polyps.
- Young Adult Colorectal Cancer Clinic Available at Sunnybrook (Mar.12/20)
A recent study led by the University of Toronto doctors has observed a rise in colorectal cancer rates in patients under the age of 50. The study mirrors findings from the U.S., Australia and Europe. The growing colorectal cancer rates in young people come after decades of declining rates in people over 50, which have occurred most likely due to increased use of colorectal cancer screening (through population-based screening programs) which can identify and remove precancerous polyps. Patients diagnosed under the age of 50 have a unique set of needs, challenges and worries. They are unlike those diagnosed over the age of 50. Dr. Shady Ashamalla (colorectal cancer surgical oncologist), and his team at the Sunnybrook Health Sciences Centre understand the needs of this patient population.
Dr. Ashamalla belongs to a multidisciplinary team of experts in the Young Adult Colorectal Cancer Clinic who will work with young colorectal cancer patients, regardless of disease stage, to create an individualized treatment plan to support each patient through their cancer journey. Their needs and concerns will be addressed as they relate to:
- Fertility concerns and issues
- Young children at home
- Dating/intimacy issues
- Challenges at work
- Concerns about hereditary cancer
- Relationships with family and friends
- Psychological stress due to any or all of the above
The team of experts consists of:
- Oncologists (medical, surgical, radiation)
- Social workers
- Nurse navigator
Should a patient wish to be referred to Sunnybrook, they may have their primary care physician, or their specialist refer them to Sunnybrook via the e-referral form, which can be accessed through the link appearing below. Once the referral is received, the Young Adult Colorectal Cancer Clinic will be notified if the patient is under the age of 50. An appointment will then be issued wherein the patient will meet with various members of the team to address their specific set of concerns.
- Increasing CRC Incidence Trends Among Younger Adults in Canada (July 1/20)
Recent analyses in the United States have shown an overall decrease in the incidence of colorectal cancer (CRC) despite contrasting increases in younger age groups. This study examined whether these cohort trends are occurring in Canada. Age-specific trends in colon and rectal cancer incidence in Canada from the National Cancer Incidence Reporting System (1969-1992) and the Canadian Cancer Registry (1992-2012) were analyzed. Birth cohort effects were estimated using 5-year groups starting in 1888. Age-specific prevalence of class I, II and III obesity in Canada was examined from the National Population Health Survey (1994-2001) and the Canadian Community Health Survey (2001-2011).
The reductions in CRC incidence among Canadians are limited to older populations. While reductions among younger age groups (20-50year olds) were observed between 1969 and 1995, rates have returned to and surpassed historical levels. Recent birth cohorts (1970-1990) have the highest incidence rate ratios ever recorded. Trends in obesity prevalence among these birth cohorts in Canada are suggestive of an impact on increasing incidence trends. Obesity prevalence estimates suggest that these trends may continue to increase, which justifies further examination of the associations and impacts of excess adipose tissue among younger populations.
Image Source: https://www.medicalnewstoday.com/articles/284959
- Treatment Options for CRC Liver & Abdominal Metastases (Jun.06/20)
Many individuals with colorectal cancer (CRC) involving the liver conclude that they have no treatment options other than systemic therapy. However, there are several therapeutic options for the treatment of liver metastases that significantly prolong survival, and others being developed in clinical trials. The size of the cancer, the number of metastases, the location of the cancer within the liver, and the ability of the patient to undergo the treatment determines what therapy is used.
Many liver metastases can be effectively treated with surgery, but not all cancer clinics have the expertise to offer surgery as a treatment option. For patients with liver metastases that can be surgically removed, surgery offers a potentially curative treatment approach. To describe long-term survival after surgery for liver metastases, researchers in Canada evaluated the outcomes of 423 surgeries that were conducted between 1991 and 2002.
- Cancer-free survival at one, five, and 10 years was 64%, 27%, and 22%, respectively.
- OS at one, five, and 10 years was 93%, 47%, and 28%, respectively.
- Factors contributing to a worse OS included the presence of cancer on the margins of tissue removed by surgery, large sites of cancer within the liver, several sites of cancer within the liver, and patient age of greater than 60 years.
Researchers concluded that long-term OS of nearly 50% at five years and nearly 30% at 10 years could safely be achieved with the use of surgery to remove liver metastases among patients with CRC.
Chemotherapy Before Surgery
In some patients with inoperable liver metastases, an initial round of chemotherapy or neoadjuvant radiation therapy can be used to shrink the liver metastases enough so that surgery becomes possible. A study conducted in Italy involved 150 patients. 116 had surgery without the need for neoadjuvant chemotherapy, and 34 had initially inoperable liver metastases but became candidates for surgery after neoadjuvant chemotherapy.
- Three-year OS was similar in the two groups.
- Three-year survival without cancer recurrence was lower in patients with initially inoperable liver metastases.
21% of these patients survived for three years without cancer recurrence, compared to fifty percent of the patients who were able to undergo surgery without neoadjuvant chemotherapy.
This study suggests that among patients with initially inoperable liver metastases, those who are able to undergo surgery after neoadjuvant chemotherapy have a high rate of cancer recurrence. Researchers note that the combination of neoadjuvant chemotherapy and surgery appears to result in better survival than chemotherapy alone for these patients.
Surgery Treating a Second Cancer Recurrence in the Liver
Researchers from France conducted a study to evaluate data including 40 patients with CRC who underwent two surgeries for liver metastasis.
- The postoperative mortality rate was 2.5%, which was not significantly different between patients who underwent a second surgery and those who only underwent one surgery.
- OS at three years was 55%.
- OS at five years was 31%.
- Cancer-free survival at three year was 49%.
- Cancer-free survival at five years was 27%.
- The presence of cancer outside of the liver was associated with decreased survival.
- If the duration of time between first and second hepatectomies was less than one year, survival was significantly decreased.
Researchers concluded that a second liver resection because of recurrent liver metastases from CRC is safe and provides a survival benefit similar to that with single hepatectomy. Their analysis suggests that the benefit of treatment is limited in patients who undergo a second hepatectomy within 1 year of the first operation.
Laparoscopy offers a minimally invasive surgical approach to exploring the extent of metastases and confirming (or changing) treatment plans prior to conducting more extensive surgery. Using laparoscopy, physicians can view the inside of the body by inserting a tool through a small incision in the abdomen.
Researchers in Oregon evaluated 136 CRC patients who, based on findings from CT or PET scans, appeared to have treatable metastases confined to the liver. By laparoscopy, 34 of these patients (25%) were found to have untreatable disease. Most of these patients had either very extensive liver metastases or metastases involving other sites in addition to the liver. In all, 48% of laparoscopies resulted in a change of treatment plans. Thus, the use of staging laparoscopy in colorectal cancer patients influences treatment decisions for many patients who appear to have isolated liver metastases. For some patients (such as those who are found by laparoscopy to have untreatable disease), unnecessary and more extensive surgery can be avoided.
Radiofrequency ablation entails the use of an electric current that is passed into a target area (tumors of the liver) through a needle probe. Heat is generated by the electric current at the site of the tumor. This ultimately destroys cancer cells.
The procedure works as follows: conventional imaging methods [i.e. ultrasound, a computerized tomography (CT) scan, or magnetic resonance imaging (MRI)] are utilized to guide the physician in the placement of the needle probe into the cancer. An electrical current is then generated and passed through the probe directly into the cancer cells. These cancer cells are heated by the electrical current to the point of irreversible ablation (destruction). RFA is a useful addition to systemic chemotherapy or precision cancer medicines in patients with CRC and liver metastases.
A trial including 88 patients who were treated with either RFA or surgery to remove their liver metastases showed local recurrences in 5.7% of patients treated with RFA, 7.1% of patients with small metastases located on the periphery of the liver and treated with surgery, and 12.5% of patients with large metastases who were treated with surgery.
Another report concluded RFA to be most effective with smaller metastases. Patients with smaller lesions (less than 3cm) had an average survival of 38 months, patients with medium lesions (3-5 cm) had an average survival of 34 months, and patients with large lesions (greater than 5 cm) had an average survival of 21 months. Multiple lesions also affected the OSl. The presence of 1-3 tumors resulted in a survival period of 29 months, compared to 22 months for patients who had more than 3 tumors.
Chemoembolization and RFA, in combination, are found to be more effective than either treatment alone. Transarterial chemoembolization (TACE) is designed to stop blood flow to the tumor. The lack of blood supply deprives the tumor of oxygen and nutrients, causing cell death. The blood flow is stopped using small particles saturated with chemotherapy drugs that soak the tumor in chemotherapy for a prolonged period. Researchers in China conducted a study, in which patients were randomly assigned to receive treatment with TACE alone, RFA alone, or a combination of TACE and RFA. Response rates that were sustained for six months were highest among patients treated with TACE and RFA (54%) compared with 35% for patients treated with TACE alone and 36% among patients treated with RFA alone.
SIR-Spheres Y-90 microspheres are a medical device used in an interventional radiology procedure known as selective internal radiation therapy (SIRT), or radioembolization, which targets high doses of radiation directly to liver tumors. SIR-Spheres Y-90 are injected into the hepatic artery, which is the main blood supply to the liver via a catheter inserted into the femoral artery through an incision in the groin. The Y-90 resin microspheres become lodged in the smaller blood vessels that surround cancer in the liver, where they deliver a high dose of radiation to the cancer, while sparing healthy liver tissue.
Hyperthermic (or Heated) Intraperitoneal chemotherapy (HIPEC) is a surgical procedure where surgeons pump a powerful dose of heated chemotherapy inside a patient’s abdomen. HIPEC Intraperitoneal (IP) delivers chemotherapy directly into the abdominal cavity, where there is the greatest number of cancer cells. The chemotherapy is administered through a large catheter that is placed into the abdomen during the surgery to remove the cancer. The hot chemotherapy bath circulates throughout the peritoneal cavity and after 90 minutes of the infusion, the chemo is washed out and incisions are closed. HIPEC is mainly used to treat metastases to the peritoneum and appears to be most effective if surgery or other therapy has already reduced the size of any remaining cancer deposits.
Radioembolization is another strategy to optimize the delivery of radiation to liver metastases while sparing healthy tissue. This strategy utilizes radioactive microspheres (small spheres containing radioactive material). The small spheres are injected into vasculature of the liver, where they tend to get lodged in the vasculature responsible for providing blood and nourishment to the cancer cells. While lodged in place, the radioactive substance spontaneously emits radiation to the surrounding cancerous area while minimizing radiation exposure to the healthy portions of the liver.
A current study involving 44 patients had metastatic CRC with inoperable metastases limited to the liver and had disease progression following standard chemotherapy including fluorouracil, oxaliplatin, and irinotecan. Patients were randomized to receive treatment with fluorouracil alone or radioembolization plus fluorouracil. At a median follow-up of 24.8 months, radioembolization plus fluorouracil significantly improved the median time to tumor progression and the time to liver progression. Researchers concluded that radioembolization combined with fluorouracil may benefit metastatic colorectal cancer patients with liver-limited disease who have progressed following prior chemotherapy.
- Questions Patients Should Ask Their Doctor When Determining Cancer Treatment (July 1/20)
Being educated and informed about your cancer diagnosis will help you make the best decisions about your treatment. It is important to get all the information you can early on concerning your evaluation, treatment options, and their possible side effects.
When deciding on treatment, ask your doctor the following:
- What is the goal of treatment? Is it to cure the cancer, prolong survival, or reduce symptoms?
- How does the treatment compare to not receiving treatment or other potential treatments?
- What is the role of clinical trials? Can participation in a trial offer a better outcome than the recommended treatment?
- Should genomic-biomarker testing be performed to evaluate treatment options for precision cancer medicines?
- What are the side effects of treatment?
The following are some additional questions, grouped by topic, which you may wish to ask your nurse or physician:
- Do you typically treat patients with my diagnosis?
- What stage is my cancer?
- Is there anything unique about my cancer that makes my prognosis better or worse?
- Should I get a second opinion?
- To cure my cancer or stop it from growing?
- What are my treatment options?
- How can each treatment option help me achieve my goal of therapy?
- What risks or potential side effects are associated with each treatment?
- What research studies (“clinical trials”) are available?
- Are there any clinical trials that are right for me?
- How long will I receive treatment, how often, and where?
- How will it be given?
- How will I know if the treatment is working?
- How might a disruption in my chemotherapy dose or timing affect my results?
- How and when will I be able to tell whether the treatment is working?
- What are the names of all the drugs I will be taking?
- Can I talk with another of your patients who has received this treatment?
- Are there any resources or Web sites you recommend for more information?
- What types of lab tests will I need?
- Will I need x-rays and scans?
- Can you explain the results of my complete blood count (CBC)?
- Are there tests for the genetic make-up of my cancer?
- Will I benefit from having my cancer evaluated for its genetic make-up?
- How frequently will I get the tests?
Side Effects of Treatment
- What possible side effects should I prepare for?
- When might they start?
- Will they get better or worse as my treatment goes along?
- How can I prepare for them or lessen their impact?
- Are there treatments that can help relieve the side effects? What are they? Do you usually recommend or prescribe them?
- Which risks are most serious?
- Will I require blood transfusions? Why?
- How can I best monitor myself for complications related to either my disease or my treatment?
Protecting Against Infection
- Will my type of chemotherapy put me at risk for a low white blood cell count and infection?
- Can I help protect myself against infection right from the start of chemotherapy, instead of waiting until problems develop?
- Am I at special risk for infection?
- What are the signs of infection?
- How serious is an infection?
- How long will I be at risk for infection?
- What should I do if I have a fever?
- How are infections treated?
- How will my cancer treatment affect my usual activities?
- Will I be able to work?
- Will I need to stay in the hospital?
- Will I need someone to help me at home?
- Will I need help taking care of my kids?
- Are there any activities I should avoid during my chemotherapy?
What to Expect After Treatment
- What happens after I complete my treatment?
- How can I best continue to monitor myself for complications related to either my disease or my treatment?
- What kind of lab tests will I need?
- How frequently should I get those lab tests?
- What types of x-rays and scans will I need?
- How often do I need to come in for checkups?
- When will you know if I am cured?
- What happens if my disease comes back?
- Managing Side Effects of Cancer Treatment (Jun.16/20)
Cancer treatment options are directed at killing or eradicating cancer cells. Unfortunately, cancer treatments may also damage normal, healthy cells that are not affected by the cancer. The result of this damage is a complication, or side effect, of treatment.
Why do side effects occur?
Side effects occur because most cancer treatments cannot distinguish between cancer cells and normal, healthy cells. For example, chemotherapy damages rapidly dividing cells, a trait of cancer cells. In the process, healthy cells that are also rapidly dividing, such as blood cells and the cells lining the mouth and GI tract are also damaged. Newer radiation therapy techniques can reduce, but not eliminate this damage.
Why are side effects important?
Side effects of treatment cause inconvenience, discomfort, and occasionally even fatality to patients. More importantly, side effects may also prevent doctors from delivering the prescribed dose of therapy at the specific time and schedule of the treatment plan, thus limiting a patient’s ability to achieve the best outcome from treatment. In the last 15 years, there has been a great deal of progress in the development of treatments to help prevent and control the side effects of cancer treatment.
- Side Effects of Cancer Treatment: Mouth Sores or Mucositis (Jul.14/20)
Chemotherapy- or radiation-induced damage to the cells lining the mouth, throat and gastrointestinal (GI) tract is called mucositis. This side effect of cancer treatment can significantly affect patient quality of life and may cause delays in treatment. Treatment for mucositis consists of supportive therapies, such as mouthwashes, aimed at reducing discomfort until the cells regenerate themselves and cryotherapy (ice chips) although new medications are under investigation.
What Causes Mouth Sores
Mouth sores are a common side effect of radiation and certain chemotherapy drugs. Chemotherapy and radiation kill rapidly dividing cells including those in the GI tract, the mouth and the throat. Thus, the damage to the cells lining in these areas is called mucositis.
Signs and Symptoms of Mouth Sores
Symptoms of mouth sores commonly occur three to ten days following chemotherapy. You may experience a burning sensation followed by ulcers, and your mouth may appear red (inflammation) with sores (ulcerations). Mouth sores can make chewing and swallowing difficult, thereby interfering with nutrition and food intake, resulting in weight loss. Furthermore, the lining of your mouth serves to protect you against infection, so mouth sores may make you more susceptible to bacterial, fungal, or viral infections in the mouth. Ultimately, mouth sores can become severe enough that it is necessary to reduce your dosage or delay your treatment in order to allow your mouth to heal.
What Treatments Are More Likely to Cause Mouth Sores
While mouth sores can occur with any treatment for cancer, mucositis is more severe if you are treated with the following:
- Stem cell transplants
- Radiation for head and neck cancer
- Combined chemotherapy and radiation therapy
- High-dose treatment
- Frequent dosing schedules, such as weekly chemotherapy
The technique used to administer radiation may also impact the severity and duration of mouth sores. The following radiation techniques tend to produce less severe side effects:
- Hyperfractionated radiation involves lower doses administered more frequently, resulting in less severe side effects.
- Intensity-modulated radiation therapy (IMRT) spares normal tissues, reducing mouth sores, while still delivering the full radiation dose or even an increased dose to the cancer.
What Makes Mouth Sores Worse
Factors contributing to the severity of mouth sores include:
- Poor oral and dental health prior to treatment
- Kidney disease
- Younger or older adults
- Smoking and the use of chewing tobacco during episodes of mucositis
- Harsh foods and alcohol
- Concomitant disease such as diabetes or AIDS
Treating Mouth Sores
The main ways to manage oral mucositis include:
Oral care: Good oral care, defined as frequently rinsing the mouth with saline and brushing teeth 2-3 times per day, may help prevent mouth sores.
Mouthwashes: There are several different mouthwashes in use to reduce mucositis pain from radiation and chemotherapy.
- “Magic Mouthwash”
- Salt and soda mouthwash
- Mouthwash containing sucralfate
Cryotherapy (ice chips): Relief from mouth pain can be achieved by sucking ice chips when the chemotherapy drug is most concentrated in the body. Cryotherapy works by decreasing blood flow to the cells in the mouth, reducing exposure to the drug and decreasing the risk of developing mouth sores. According to a recent Cochran review, sucking ice is the only measure proven to prevent mouth sores.
A current study enrolled 50 patients, half of which were provided with with ice chips to be chewed continuously during oxaliplatin chemotherapy infusions. Patients were encouraged to keep the ice chips in their mouths as long as possible. After the first treatment cycle, only 32% of cryotherapy patients experienced oral symptoms, compared with 72% not chewing the ice chips. By the second cycle, the “oral cryotherapy” patients had significantly fewer oral symptoms, less difficulty eating or drinking cold items, and less difficulty eating or drinking overall than those in the control group.
Other Methods Used to Control Mucositis
GELX ORAL GEL is a bioactive therapy that can build an effective barrier against the pain and inflammation of oral mucositis (OM). It coats exposed nerve endings and open sores soothing oral lesions caused by chemotherapy or radiotherapy and provides a bioactive Zinc-Taurine Complex that hinders and delays the inflammatory response.
Kepivance™ (keratinocyte growth factor, palifermin): Keratinocyte growth factor stimulates the growth of cells, which are involved in protecting the lining of the mouth. Kepivance™ is designed to mimic natural keratinocyte growth factor that is made in the body. By stimulating growth in the cells that line the mouth and GI tract, Kepivance™ may help to reduce mucositis. Kepivance™ is the first FDA-approved drug for the prevention and treatment of OM.
Amifostine (Ethyol®): Ethyol® is a drug that protects against the damage of radiation and is the first drug to be approved by the FDA for the treatment of patients with head and neck cancers receiving radiation therapy. Clinical trials have demonstrated that Ethyol® can reduce dry mouth and may prevent mouth sores. However, more research is needed to prove the affect of this drug on mouth sores.
Among patients with advanced head and neck cancer treated with chemotherapy and radiation therapy, intravenous treatment with a derivative of glutamine may reduce the severity of OM. Glutamine is an amino acid that plays a role in cellular repair.
To evaluate the safety and effectiveness of intravenous administration of a derivative of glutamine-L-alanyl-L-glutamine-researchers in Argentina conducted a clinical trial among 29 patients with advanced head and neck cancer. Half the patients received intravenous L-alanyl-L-glutamine and half the patients received intravenous saline (the placebo).
- Severe OM developed in 14% of patients treated with L-alanyl-L-glutamine and 67% of patients treated with the placebo.
- A feeding tube was required by 14% of patients treated with L-alanyl-L-glutamine and 60% of patients treated with the placebo.
- Patients treated with L-alanyl-L-glutamine reported less pain than patients treated with the placebo.
- L-alanyl-L-glutamine did not appear to produce any adverse side effects.
Researchers conclude that intravenous treatment with the glutamine derivative L-alanyl-L-glutamine may reduce the severity of OM in patients with advanced head and neck cancer.
Laser Therapy Reduces OM in Head and Neck Cancer
Low-level laser therapy (LLLT) may reduce the incidence and severity of OM caused by chemotherapy and/or radiation therapy among patients with head and neck cancer. The laser is directed at affected areas of the mouth and is thought to stimulate healing. Researchers from Brazil recently conducted a trial including 94 patients who were treated with chemotherapy and radiation therapy. One group received LLLT and the other group received a placebo (inactive substitute).
- Severe OM occurred in 48% of the placebo group and 6% of the LLLT group.
- Mouth sores occurred in 83% of the placebo group and 49% of the LLLT group.
- Patients in the LLLT group experienced significantly less pain, fatigue, problems swallowing, and emotional disturbances than those in the placebo group. Importantly, not one patient in the LLLT group had a reduction or delay in treatment.
These results suggest that LLLT may reduce OM among head and neck cancer patients. Direct comparisons of LLLT to other treatments for OM are warranted.(11)
Chemotherapy Drugs That Have Been Reported To Cause Mucositis in 30% or More of Patients are:
- Actinomycin (Cosmegen)
- Busulfan (Myleran®, Busulfex®)
- Cytarabine (Cytosar-U®)
- Daunorubicin (Cerubidine®)
- Docetaxel (Taxotere®)
- Doxorubicin (Adriamycin®, Rubex®)
- Epirubicin (Ellence®)
- Floxuridine (FUDR®)
- Fluorouracil (5-FU, Adrucil®, Carac®, Efudex®, Fluoroplex®)
- Idarubicin (Idamycin®, Idamycin PFS®)
- Isotretinoin (Accutane®)
- Liposomal doxorubicin (Doxil®)
- Methotrexate (Rheumatrex®, Trexall™)
- Mitomycin (Mutamycin®)
- Mitoxantrone (Novantrone®)
- Mechlorethamine (Mustargen®)
- Oprevelkin (Neumega®)
- Paclitaxel (Taxol®, Onxal™)
- Pemetrexed (Alimta®)
- Plicamycin (Mithracin®)
- Procarbazine (Matulane®)
- Teniposide (Vumon®)
- Trimetrexate (Neutrexin®, TMQ®, TMTX®)
- Tretinoin (Vesanoid®)
The Chemotherapy Drugs That Have Been Reported to Cause Mucositis in 10%-29% of Patients are:
- Alemtuzumab (Campath®)
- Asparaginase (Elspar®, Kidrolase®)
- Bleomycin (Blenoxane®)
- Capecitabine (Xeloda®)
- Carboplatin (Paraplatin®)
- Cyclophosphamide (Cytoxan®, Neosar®)
- Etoposide (VePesid®, Toposar®, Etopophos®)
- Gemcitabine (Gemzar®)
- Gemtuzumab ozogamicin (Mylotarg®)
- Hydroxyurea (Hydrea®)
- Interleukin 2 (Proleukin®)
- Irinotecan (Camptosar®)
- Liposomal daunorubicin (DaunoXome®)
- Lomustine (CeeNU®)
- Melphalan (Alkeran®)
- Oxaliplatin (Eloxatin®)
- Pentostatin (Nipent®)
- Rasburicase (Elitek®)
- Thiotepa (Thioplex®)
- Topotecan (Hycamtin®)
- Trastuzumab (Herceptin®)
- Tretinoin (Vesanoid®)
- Vinblastine (Velban®, Alkaban AQ®)
- Vincristine (Oncovin®, Vincasar PFS®)
- Association between Vitamin D Receptor Single-Nucleotide Polymorphisms and CRC (Jun.15/20)
Vitamin D and the vitamin D receptor (VDR), are involved in the regulation of a variety of body metabolic processes, immune function, and oncogenesis. A number of studies demonstrated the association of low vitamin D levels and variations in five common single nucleotide polymorphisms (SNPs) (i.e. FokI, BsmI, Tru9I, ApaI, and TaqI) with the risk of several cancers, including colorectal cancers. However, these associations vary among different populations.
This study included 364 participants in the Thai population. Half of the participants underwent colonoscopy and showed a normal colon without polyps (control group). The other half were newly diagnosed patients with colorectal cancer (CRC) by colonoscopy during the index period, were under treatment, or were followed up at the outpatient clinic (case group). Among the 364 participants, baseline characteristics were not significantly different between the case and control groups, except for the higher proportion of males in the CRC group. The mean vitamin D level was also not significantly different between the case and control groups. None of the five SNPs was associated with CRC development.
- Tips for a Healthy Summer Season (Jul.01/20)
As you enjoy this atypical summer, it’s important to remember a few simple ways to help lower your cancer risk and stay healthy.
Take Care of Your Skin
It’s safe to enjoy the outdoors as long as you are protecting your skin from the sun’s damaging rays. Exposure to ultraviolet (UV) radiation is the primary cause of skin cancer. The majority of skin cancers, however, are highly treatable and even more importantly, highly preventable. The sun can damage your skin in as little as 15 minutes if you aren’t taking precautions.
Here are a few recommendations to help protect yourself and your family:
- Spend time in the shade. Take a break from the sun and seek shade under an umbrella or tree. This will help limit your direct exposure to the sun, especially when UV rays are the strongest between 10am and 4pm.
- Cover up. When possible, wear clothing that covers up your skin. If you are at the beach, try wearing a t-shirt or a cover-up. Wear sunglasses and a wide-brimmed hat that shades your face, ears and back of your neck.
- Use sunscreen. Put on broad-spectrum sunscreen with at least SPF 15 or higher before you go outside, even if it’s cloudy. The UV rays can penetrate some clouds and still cause skin damage. Reapply sunscreen every couple of hours, especially after swimming or sweating.
- Avoid tanning beds. Tanning beds can cause serious long-term skin damage and contribute to skin cancer.
Follow Cancer-Safe Grilling Guidelines
Cooking meat at high temperatures is known to produce cancer-causing chemicals. Polycyclic aromatic hydrocarbons (PAHs) are present in flames that can stick to the surface of meat and heterocyclic amines (HCAs) form in meat when its proteins react to the intense heat of the grill. In lab studies, these substances have been linked to development of cancer through changes to the DNA.
To make summer grilling healthier follow these five steps:
- Mix up the meat. Diets high in red and processed meat increase cancer risk. Try using herbs and sauces to enhance the flavour of chicken and fish that should be added to your plate.
- Marinate. Studies suggest that marinating meat, poultry and fish for at least 30 minutes can reduce the formation of HCAs. Using a mixture that includes vinegar, lemon juice or wine along with oil, herbs and spices seems to be the key.
- Partially pre-cook. You can reduce the time your meat is exposed to flame by partially cooking it in a microwave, oven or stove first.
- Stay low. Cook the meat over a low flame. Doing so can reduce the formation of both HCAs and PAHs and help keep burning and charring to a minimum.
- Add some colour. Grilled vegetables taste great! And by loading up on plant foods, you can cut back on red and processed meats.
Practice Physical Distancing
Although public places are opening up, our public health authorities are stressing that limiting face-to-face contact with others is the best way to reduce the spread of COVID-19. Stay at least 6 feet (about 2 arms’ length) away from other people to help protect yourself and others. People can spread the virus before they know they are sick, so it’s important to keep your distance from others when possible. Practice good hygiene by washing your hands constantly with soap and water for at least 20 seconds, and wear a face mask inside public spaces, and when physical distancing is not possible outside.
- Health Benefits of Berries (Jul.01/20)
Blackberries, blueberries, raspberries and strawberries are all great fruit options that are bursting with antioxidants, vitamins, minerals and fibre, which help reduce risk of cancer and other chronic diseases.
Blueberries are rich in antioxidants and protective plant compounds like anthocyanins and can help fight inflammation. They may improve brain, eye and heart health, and help to reduce cancer risk.
- Choose blueberries that are firm, plump and dry with a dusty blue colour and are uniform in size.
- Avoid berries that are soft, shrivelled or have any sign of mold.
- Refrigerate blueberries for up to 10 days. Wait to wash until ready to eat.
Raspberries contain dietary fibre and polyphenols, which both play an important role in a cancer-protective diet. 1 cup of raspberries contains 8g of fibre. AICR recommends eating at least 30g of dietary fibre per day as part of a healthy eating pattern to lower cancer risk.
- Choose raspberries that are firm, plump and dry.
- Avoid wet or moldy berries.
- Do not wash raspberries until ready to eat. Refrigerate for use within 1-2 days.
Blackberries are another great source of dietary fibre. One cup of blackberries contains 8g of fibre and these berries are high in vitamin C. You can pair blackberries with almonds or walnuts for an easy, high-fibre snack.
- Choose blackberries that are shiny.
- Avoid blackberries that are bruised or leaking.
- Refrigerate blackberries for 3-6 days. Wait to wash until ready to eat.
Strawberries are an excellent source of vitamin C and manganese and are rich in plant compounds, like polyphenols.
- Choose strawberries that are shiny and firm with a bright red colour. Caps should be fresh, green and intact.
- Avoid shrivelled, mushy or leaky strawberries.
- Do not wash strawberries until ready to eat. Store in refrigerator for 1-3 days.
Tips for Adding More Berries Into Your Diet:
- Add on top of cereal, oatmeal or yogurt
- Toss into a salad
- Throw a handful into a smoothie
- Add to ice water for a naturally sweetened fruit infused water
- Ten Cancer Prevention Recommendations (Jun.29/20)
The American Institute for Cancer Research (AICR) has taken the latest research and made 10 Cancer Prevention Recommendations.
- Be a Healthy Weight. Try to keep your weight in the healthy range and avoid weight gain in adult life.
- Be Physically active. Be physically active as part of everyday life—walk more and sit less.
- Eat a Diet Rich in Whole Grains, Vegetables, Fruits, and Beans. Make whole grains, vegetables, fruits and pulses (legumes) such as beans and lentils a major part of your normal diet.
- Limit Consumption of “Fast Foods” and Other Processed Foods That are High In Fat, Starches, or Sugars. Limiting these products helps you control your calorie intake and makes it easier to maintain a healthy weight.
- Limit Consumption of Red and Processed Meat. Eat no more than moderate amounts (12-18 ounces per week) of red meat, such as beef, pork, and lamb. Eat little, if any, processed meat.
- Limit Consumption of Sugar-Sweetened Drinks. Drink mostly water and unsweetened drinks.
- Limit Alcohol Consumption. For cancer prevention, it’s best not to drink alcohol.
- Do Not Use Supplements for Cancer Prevention. Aim to meet your nutritional needs through diet alone.
- For Mothers: Breastfeed Your Baby, If You Can. Breastfeeding is beneficial for both mother and baby.
- After a Cancer Diagnosis: Follow These Recommendations, If You Can. Check with your health professional about what is right for you.
To learn more about each recommendation and how to implement them, use the link below to access individual articles for each.
- Coronavirus Outbreak: Daily Updates (Jun.30/20)
Indoor Summer Activities
More time spent indoors to escape summer’s heat may increase risk of COVID-19, according to Edward Nardell, a professor of medicine and global health and social medicine at Harvard Medical School in Massachusetts. “The states that, in June, are already using a lot of air conditioning because of high temperatures are also the places where there’s been greater increases in spread of COVID-19, suggesting more time indoors as temperatures rise,” Nardell told the Harvard Gazette. As people go indoors in hot weather and the re-breathed air fraction goes up, the risk of infection is quite dramatic.
WHO Says Pandemic is ‘Speeding Up’
Tedros Ghebreyesus, PhD, MSc, the director-general of the World Health Organization (WHO), cautioned at a briefing, “Although many countries have made some progress, globally the pandemic is actually speeding up.” While many countries have used “unprecedented measures” to contain the virus, those measures have only slowed the spread, but did not stopped it. Ghebreyesus concluded that “the hard reality is: this is not even close to being over.”
For continued daily updates please follow the link below.
- Convalescent Plasma Found Safe for Diverse Patients with COVID-19 (Jun.18/20)
Mayo Clinic researchers have found investigational convalescent plasma to be safe following transfusion in a diverse group of 20,000 patients. This safety study assessed the seven days following transfusion for hospitalized patients between April 3 and June 11 who were deemed at risk of progressing to a severe or life-threatening condition. About 40% of the patients were women; 20% African Americans; nearly 35% Hispanic and 5% Asian. Seven-day mortality rates declined to 8.6 % compared to 12% in a previous study of the first 5,000 transfused patients.
This expanded report reveals a decline in mortality while there is a more rapid availability of plasma for use. The authors caution that this alone does not provide any evidence on effectiveness of convalescent plasma for treating COVID-19. At this time, convalescent plasma therapy is the only antibody-based therapy for COVID-19.
The researchers say that while the mortality rate has decreased, the patients in the latter part of this study were less critically ill. They also say the decrease may be in part due to improved medical care based on increased knowledge during the pandemic and that more of the patients received the plasma earlier in their hospital treatment. There was no system in place for delivering convalescent plasma in March and now there is sufficient donation to meet most of the demand. Also, as donors came forward more rapidly, it was more likely their plasma contained neutralizing antibodies.
- French SARS-CoV-2 Guidelines for Cancer Patients (Jun.20/20)
According to findings from Memorial Sloan Kettering Cancer Center in New York City, cancer patients receiving immunotherapy were at increased risk for severe outcomes from COVID-19. Among over 400 cancer patients with symptomatic COVID-19, those treated with immune checkpoint inhibitors saw a nearly threefold risk of hospitalization and severe respiratory illness in a multivariate analysis.
In the 35 patients with lung cancer, higher rates of hospital admission and severe respiratory illness were seen for those on immunotherapy compared to those not treated with these agents. To a lesser degree, this pattern was seen among patients with other solid cancers receiving immune checkpoint inhibitors as well. However, treatment decisions regarding these anticancer agents in patients with symptomatic COVID-19 should not be altered without further evidence, and recommended increased testing to ward of potential infections in this population.
Earlier reports showed no increased risk of worse outcomes among patients undergoing chemotherapy within 30 days of their COVID-19 diagnosis, and major surgery and metastatic disease did not predict worse outcomes. On multivariate analysis, patients with hematologic malignancies had an increased risk of hospitalization and potentially severe respiratory illness, in line with a previous report showing higher mortality in this group. Non-white race and chronic lymphopenia or corticosteroid use were also significantly associated with an increased risk of hospitalization. This disease is not fully understood, and this is just one of many studies that need to be done on the connections between cancer and COVID-19. Thus, people should not stop or postpone cancer treatment.
In this study, 423 cancer patients diagnosed with COVID-19 were examined at Memorial Sloan Kettering from March 10 to April 7. Majority of the patients were 60 and older (56%), and older age was tied to worse outcomes. Overall, a fifth of patients developed severe respiratory illness, 9% required mechanical ventilation, and 12% died. Hospitalization was required in 40% of patients, and 20% were admitted to the ICU. Among these hospitalized and ICU patients, respectively, 24% and 35% died. About three-fourths of patients in the cohort had solid tumors. Breast cancer was the most common tumor type (20%), followed by lymphoma (11%), colorectal cancer (9%), lung cancer and leukemia (8% each), prostate cancer (6%), and myeloma (5%).
- New Study Details the Best Types of COVID-19 Face Masks (Jun.30/20)
Since the start of the COVID-19 pandemic, health agencies have recommended face mask usage to limit the spread of the novel coronavirus. Since there isn’t enough medical-grade personal protective equipment to go around, many have sewn their own fabric masks or simply used a bandana. While it’s understood that some level of protection is better than none, there hasn’t been much information on the effectiveness of these homemade masks. A new study, published in the scientific journal Physics of Fluids, sheds new light on how the materials and construction of a face mask can impact its effectiveness.
- The most effective homemade face masks are those made with tightly woven fabric and providing a good seal along the edges.
- Bandanas / handkerchiefs were not found to be effective.
- N95 masks need to be properly fitted and should be reserved for those who need them.
- Surgical face masks are another effective option in areas where they’re readily available.
Physical Distancing: Still Crucial
Even the most effective face masks are not the be-all and end-all in terms of avoiding transmission. Face coverings are not 100% effective in blocking respiratory pathogens, which is why it’s imperative that we use a combination of social distancing, face coverings, hand washing, and other recommendations from healthcare officials until an effective vaccine is released. Large-scale gatherings in an enclosed space and certain interactions have the potential to spread aerosol droplets farther than 6 feet.
- Physical and Mental Health Survey of Cancer Survivors During the COVID-19 Pandemic
The Exercise Oncology Lab (PI: Dr. Linda Trinh) is looking for cancer survivors to complete an online survey about their experiences with physical activity and mental health during the COVID-19 pandemic. By understanding this we may be able to develop tailored resources to address the needs of cancer survivors during this time. The survey will take about 45 minutes to complete, but anyone who participates will be eligible to enter into a drawing to win 1 of 6 $25 CAD gift cards to Amazon.
Please use the secure survey link here: https://redcap.utoronto.ca/surveys/?s=NWWARAMCK9
Note: Clicking on this link does not mean you are agreeing to participate in the study. This link will take you to the front page of the survey, which has more detailed information about the survey.
We are looking to reach cancer survivors globally so please feel free to disseminate this e-mail to other networks that you may have.
If you have any questions please feel free to reach out to our research team at the Exercise Oncology Lab at 416-946-5856 or at email@example.com.
- Protecting Cancer Patients From COVID-19: Clinical Trial Tests a Novel Immune-Boosting Strategy
Canadian researchers have launched an innovative clinical trial focused on strengthening the immune system for one of the most vulnerable populations – cancer patients. The trial involves IMM-101, a preparation of safe, heat-killed bacteria that stimulates the innate, or “first-response,” arm of the immune system. Researchers hope that boosting cancer patients’ immune systems with IMM-101 will protect them from developing severe COVID-19 and other dangerous lung infections.
“An effective vaccine that provides specific protection against COVID-19 could take another year or more to develop, test, and implement,” says Dr. Rebecca Auer, study lead, surgical oncologist and Director of Cancer Research at The Ottawa Hospital and associate professor at the University of Ottawa. In the meantime, it is urgent that people with cancer are protected from severe COVID-19 infection, which IMM-101 is intended to do. “The immune systems of cancer patients are compromised both by their disease and the treatments they receive placing them at much higher risk of severe complications from COVID-19.” says Dr. Chris O’Callaghan, CCTG Senior Investigator, who will be overseeing this national trial. It is also difficult for these patients to practice social isolation due to the need to regularly attend hospital to receive critically important cancer treatment.
The trial, called CCTG IC.8, has been approved by Health Canada and is expected to open at cancer centres across Canada this summer. People who are interested in participating should speak with their cancer specialist.
For additional information about the organizations and groups involved in this trial, visit the link below.
- Impact of COVID-19 on Cancer Care (Jun.27.20)
COVID-19 May Result in 10,000 Excess Deaths From Breast and Colorectal Cancer (CRC)
With the up-rise of the COVID-19 pandemic, cancer patients and individuals attempting to maintain recommended screening and early detection programs were often unable to access appropriate care. According to the National Cancer Institute the COVID-19 pandemic will result in nearly 10,000 additional deaths due to breast cancer and CRC over the next decade.
A report released at the American Association for Cancer Research Virtual Annual Meeting assumed only a moderate disruption in screening and care that completely resolves after 6 months. However, if the pandemic disrupts routine care to a greater degree or for a longer period, the effect on cancer mortality could be even worse.
Common Cancer Treatments Don’t Worsen COVID-19 Infection
According to a study from Memorial Sloan Kettering, patients in active cancer treatment who develop COVID-19 infection don’t fare any worse than other hospitalized patients. Metastatic cancer, recent chemotherapy, or major surgery within the previous 30 days did not show a significant association with either hospitalization or severe respiratory illness due to COVID-19. This suggests that no one should delay cancer treatment because of concerns about the virus.
The study evaluated 423 patients diagnosed with COVID-19 between March 10 and April 7 at Memorial Sloan Kettering Cancer Center. Overall, 40% were hospitalized for COVID-19, and 20% developed severe respiratory illness. The most frequent cancer types included solid tumors such as breast, colorectal, and lung cancer. Researchers found that age, race, cardiac disease, hypertension, and chronic kidney disease correlated with severe outcomes. The investigators found that patients taking immunotherapy drugs called immune checkpoint inhibitors were more likely to develop severe disease and require hospitalization. However, other cancer treatments, including chemotherapy and surgery, did not contribute to worse outcomes.
COVID-19 infections are still not fully understood and additional research and experience will better define the impact of an infection on cancer care but individuals impacted by a cancer diagnosis should definitely not stop or postpone their cancer treatment.
- Cancer Patients & COVID-19: What You Need to Know (Jun.26/20)
Cancer patients, their families, and caregivers are disproportionally impacted by the COVID pandemic. Cancer patients are twice as likely to become infected than the general population and significantly more likely to die from COVID-19 once infected. Individuals impacted by a cancer diagnosis should consider two different strategies to reduce their risk during the pandemic. The first is to ensure they take appropriate precautions to avoid unnecessary exposure to the virus. The second is to consider whether changes to their treatment strategy could be implemented to reduce their risk of infection.
Symptoms of Coronavirus Infection in Cancer Patients
The symptoms of COVID-19 are the same in cancer patients as the general population. Patients being treated with steroids can suppress the development of fever.
Common symptoms include:
- Coughing – typically dry non-productive cough
- Myalgia (muscle aches)
- Head Ache
- Shortness of breath
- Some patients report GI symptoms (nausea, diarrhea)
Take Preventive Measures
For now patients should undergo the same preventive measures they would for other common illnesses like the common cold and influenza. Most importantly, wash your hands frequently, make sure you cover your cough and your sneezes, stay away from other individuals with respiratory symptoms, and avoid travel to places where there are documented cases of COVID. Avoid crowds and situations where you’re likely to be less than six feet from others (droplets released by the virus can travel three feet). Researchers are still working to develop a vaccine so it is important to take the preventive measures stated above.
What should I do if I have symptoms of COVID-19?
Call your treatment centre or physician first to report your symptoms. This allows your doctor to determine what evaluation is necessary and where that evaluation should take place.
Are all patients with cancer at equal risk for infection?
Patients with a weakened immune system may be at greater risk of infection because their defences against infection are lowered. Blood-related cancers such as leukaemia, lymphoma, or multiple myeloma, those undergoing chemotherapy, individuals with more advanced disease, and those with cancer involving the lungs are most vulnerable. Patients over the age of 70 are more likely to develop severe cases of COVID-19, as are those who also have cardiovascular disease, diabetes, or high blood pressure, or are active tobacco smokers.
Treatment for COVID-19
Treatment mainly consists of supportive measures to reduce symptoms and respiratory complications similar to the Flu. Researchers are rapidly evaluating medicines in order to determine if any available medications might be helpful in eradicating the disease and new medications designed to target COVID-19 are being developed.
What are Clinics and Cancer Centres Doing?
In order to protect cancer patient’s cancer centers and clinics are already adopting measures designed to improve patient safety by decreasing the risk of exposure to the virus. They are:
- Delaying or deferring non-essential clinic visits.
- Using phone consultation or telemedicine appointments when possible.
- If clinic or hospital visits are necessary;
- Wear a mask or facial covering.
- Practice physical distancing.
- Clinics are screening for exposures either at clinic entrance or by phone one day prior to visit by checking for fever, cough, and other symptoms.
- Minimizing visitors (1 visitor + patient).
- Increasing the interval between visits when possible
Does the benefit of adjuvant therapy justify the risk?
The answer for most patients will be yes but some patients with early stage breast, colon or other cancers elect to receive post-operative adjuvant therapy to reduce the risk of cancer recurrence that is of marginal benefit. For example, if chemotherapy increases your chance of cure from 80% to 85% is that benefit enough given the risks of COVID-19? Are there tests that can help better define the benefit of chemotherapy so it can be avoided in individuals that don’t benefit? Measurement of cell free ctDNA can help determine who should receiv-e chemotherapy for colon cancer, and the OncotypeDX test helps determine which patients with early stage breast cancer might avoid chemotherapy.
What is the benefit of radiation therapy and can it be administered over a shorter duration of time?
In certain situations, including some patients with early stage breast cancer radiation may be delivered over a shorter period of time and therefore reduce the number of visits and exposures to others during treatment. Accelerated partial breast irradiation (APBI) is radiation delivered at a more concentrated and higher dose over a shorter period of time, (typically over a one week period).
Can oral chemotherapy medications be used instead of infusions to decrease clinic/infusion centre visits?
Switching to an equivalent oral therapy can help avoid prolonged clinic visits and oral chemotherapy is available for many cancer types. Certain patients with MPN’s require frequent clinic visits to undergo phlebotomy as part of their treatment –phlebotomy can also be replaced by using an oral chemotherapy to control their cancer.
How useful is imaging: are follow up CT/MRI scans really necessary?
Evaluation of a cancers response to treatment is performed at intervals during and following treatment. These tests can provide physicians and patients information about how an individual cancer is responding to treatment. During the COVID-19 era it may be prudent for patients to reduce the frequency of scans especially when the result won’t immediately change their treatment. Blood biomarker tests are also increasingly available that can detect recurrence and patients should inquire whether a simple blood test can be performed instead of several scans.
Preparing Your Home in the COVID-10 Era
Individuals caring for someone who is at a higher risk for serious illness from COVID-19 should consider the following.
- Contact the patient’s health care provider to ask about possibly obtaining extra, necessary medications. If this is not possible, see if you can have the medications mailed to you instead of picking them up in person.
- Be sure to have over-the-counter medical supplies on hand that can be used to treat fever and other symptoms.
- Have enough household items and groceries available so that you limit the time you need to be outside or at the store.
- Be sure to clean and disinfect your home to remove germs. A good practice is to routinely scrub often-touched surfaces, such as tables, doorknobs, and light switches. When cleaning these items, use detergent or soap and water prior to disinfecting.
As a caregiver, it is important to have your own support, too. So, it is essential to take some time for yourself (and having support around you can help). Try to delegate responsibilities. If you are feeling overwhelmed or need to take a step back, it is very helpful to talk with someone about your feelings and needs. Make sure you also practice good personal wellbeing, healthy eating, and hygiene. Try to find an outlet to address the additional stress and anxiety you may be experiencing
What if I was Considering Elective Surgery?
Following a careful review of the current situation, the following is recommend:
- Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs.
- Immediately minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators. There are many asymptomatic patients who are, nevertheless, shedding virus and are unwittingly exposing other inpatients, outpatients, and health care providers to the risk of contracting COVID-19.
- Reschedule elective surgeries as necessary.
- Shift elective urgent inpatient diagnostic and surgical procedures to outpatient settings, when feasible.
- Limit visitors to COVID-19 patients.
- Plan for a surge of critically ill patients and identify additional space to care for these patients. Include options for:
- Using alternate and separate spaces in the ER, ICUs, and other patient care areas to manage known or suspected COVID-19 patients.
- Separating known or suspected COVID-19 patients from other patients (“cohorting”).
- Identifying dedicated staff to care for COVID-19 patients.
Products from China?
The production of many medical products, medications and household items of course occurs in China. Currently there is no reason to suspect that packages from China can contain active COVID-19 and medications and other products appear safe. Currently, it’s only known that the spread of the disease outside of China happens between person to person although there is an active investigation of an individual with COVID-19 in Sacramento and no known contact with an infected individual.
- Frequently Asked Questions for COVID-19
Q: What is COVID-19 (or novel Coronavirus Disease – 19)?
A: Coronaviruses are a large family of viruses that can cause illnesses in humans and animals. Coronaviruses can cause illnesses that range in severity from the common cold, to more severe diseases such as Severe Acute Respiratory Syndrome (SARS) and most recently, COVID-19. COVID-19 or novel coronavirus originated from an outbreak in Wuhan, China in December 2019. The most common symptoms associated with COVID-19 can include fever, fatigue, and a dry cough. Though additional symptoms have now been linked with the disease, which may include aches and pains, nasal congestion, runny nose, sore throat, diarrhea, skin rash and vomiting. It is also possible to become infected with COVID-19 and not experience any symptoms or feeling ill. The spread of COVID-19 is mainly through the transmission of droplets from the nose or mouth when a person coughs, exhales or sneezes. These droplets land on surfaces around a nearby person. COVID-19 can be transmitted to that nearby person who may end up touching the surface contaminated with COVID-19 and then end up touching their nose, mouth, or eyes. A person can also contract COVID-19 through inhaling these droplets from someone with COVID-19. Although research is still ongoing, it is important to note that older populations (over the age of 65), those with a compromised immune system and those with pre-existing conditions including heart disease, high blood pressure, lung disease, diabetes or cancer may be at a higher risk of severe illness due to COVID-19.
Q: What can I do to avoid getting Coronavirus?
A: There are various ways in which we can reduce our risk of contracting COVID-19. Below are some measures suggested by the World Health Organization
- Keep at least 2 metres (or 6 feet) between yourself and other people. This will reduce the risk of inhaling droplets from those infected with COVID-19.
- Regularly clean your hands for at least 20 seconds with warm water and soap, or an alcohol-based hand rub. This will kill any viruses on your hands.
- Avoid touching your eyes, nose and mouth. If the virus is on your hands, it can enter the body through these areas.
- Follow good respiratory hygiene by covering your mouth and nose with a tissue or elbow when you cough and sneeze. This prevents the droplets from settling on surfaces or being released into the air around you.
- Stay home as much as possible, especially if you are feeling unwell. If you think you may have the Coronavirus, please see “What should I do if I think I have Coronavirus?” section.
- Please wear a face covering or mask in public when physical distancing is not possible.
Q: Are there any treatments available for Coronavirus?
A: People with cancer are at a higher risk of severe illness due to COVID-19 as cancer is considered a pre-existing health issue. Some cancer treatments including chemotherapy, radiation and surgery can weaken the immune system, making it harder for the body to fight infections and viruses, such as Coronavirus. It is important to diligently follow the World Health Organization’s recommendations above to reduce the risk of contracting COVID-19. If you have any concerns about your risk, it is best to contact your doctor or healthcare team.
There are currently no treatments available for COVID-19 but trials are underway to determine how to best treat and manage those afflicted with the virus. Vaccine candidates are being vigorously tested in a number of countries around the world, Canada included. The US government is funding 3 major phase 3 trials on potential COVID-19 vaccines and all 3 trials are being conducted by 3 different pharmaceutical companies looking at different vaccine candidates. The hope is to have a vaccine by the end of the year!
Q: Are there special precautions that people with cancer can take?
A: People with cancer (and other chronic ailments such as heart disease, diabetes, high blood pressure and lung disease) are at a higher risk of severe illness due to COVID-19 as cancer is considered a pre-existing health issue. Some cancer treatments including chemotherapy, radiation and surgery can weaken the immune system, making it harder for the body to fight infections and viruses, such as Coronavirus. It is important to diligently follow the World Health Organization’s recommendations above to reduce the risk of contracting COVID-19. If you have any concerns about your risk, it is best to contact your doctor or healthcare team.
Will anything change with regards to my cancer related medical visits? As each patient and treatment plan is unique, it is always best to contact your health care provider for updated information about your treatment plan. In some cases, it is safe to delay cancer treatment until after the pandemic risk has decreased. In other cases, it may be safe to attend a clinic that is separate from where COVID-19 patients are being treated. Oral treatment options could be prescribed by your care provider virtually, without the need to attend the clinic. Finally, some follow-up appointments or discussions could be held virtually (via skype or zoom for example) or over the phone to minimize your risk. As we know, conditions and protocols are changing daily due to the nature of the COVID-19 outbreak, and vary based on location, therefore, the best first step is to reach out to your care provider for guidance.
Should you wish to contact your local public health agency, please see below.
COVID-19 info for Albertans
Social media: Instagram @albertahealthservices, Facebook @albertahealthservices, Twitter @GoAHealth
Phone number: 811
British Columbia COVID-19
Social media: Facebook @ImmunizeBC, Twitter @CDCofBC
Phone number: 811
Social media: Facebook @manitobagovernment, Twitter @mbgov
Phone number: 1-888-315-9257
New Brunswick Coronavirus
Social media: Facebook @GovNB, Twitter @Gov_NB, Instagram @gnbca
Phone number: 811
Newfoundland and Labrador
Newfoundland and Labrador COVID-19 information
Social media: Facebook @GovNL, Twitter @GovNL, Instagram @govnlsocial
Phone number: 811 or 1-888-709-2929
Northwest Territories coronavirus disease (COVID-19)
Social media: Facebook @NTHSSA
Phone number: 811
Nova Scotia novel coronavirus (COVID-19)
Social media: Facebook @NovaScotiaHealthAuthority , Twitter @healthns, Instagram @novascotiahealthauthority
Phone number: 811
Nunavut COVID-19 (novel coronavirus)
Social media: Facebook @GovofNunavut , Twitter @GovofNunavut, Instagram @governmentofnunavut
Phone number: 1-888-975-8601
Ontario: The 2019 Novel Coronavirus (COVID-19)
Social media: Facebook @ONThealth, Twitter @ONThealth , Instagram @ongov
Phone number: 1-866-797-0000
Prince Edward Island
Prince Edward Island COVID-19
Social media: Facebook @GovPe, Twitter @InfoPEI,
Coronavirus disease (COVID-19) in Québec
Social media: Facebook @GouvQc, Twitter @sante_qc
Phone number: 1-877-644-4545
Social media: Facebook @SKGov, Twitter @SKGov
Phone number: 811
Yukon: Find information about coronavirus (COVID-19)
Social media: Facebook @yukonhss, Twitter @hssyukon
Phone number: 811