PHARMACOTHERAPY

Neoadjuvant therapy for resectable and borderline resectable pancreatic cancer: Is radiotherapy worthwhile?

SUMMARY

For resectable pancreatic cancer, (RPC) or borderline resectable pancreatic cancer (BRPC) the standard treatment is surgery followed by adjuvant chemotherapy. There is a worldwide ongoing discussion on the benefit of neoadjuvant treatment instead of adjuvant treatment for these patients. Interpretation and comparison of studies is hard because of a difference in patient selection between studies about these two strategies. Reporting by intention to treat and randomised clinical trials are essential.

In the first decade of the 21^st century, many studies and reviews suggested superiority of the neoadjuvant approach in RPC and BRPC for patients with resected pancreatic cancer. Several reviews also suggested an advantage by intention to treat. The first two randomised trials failed due to lack of accrual, and the third discontinued because of changed standard regimens. Since 2018, two randomised trials were published and one presented. A meta-analysis of these six RCTs, four of which with neoadjuvant chemoradiotherapy, and all with gemcitabine based regimens, revealed that with neoadjuvant treatment overall survival improved compared to upfront surgery for both RPC and BRPC. Since local control and pathological factors such as pN classification and R0 resection rate are invariably better after neoadjuvant treatment, radiotherapy probably plays an important role.

Currently, more effective treatments are available, in particular FOLFIRINOX and gemcitabine + nab-paclitaxel are considered the best available chemotherapeutic schedules and stereotactic body radiotherapy (SBRT) is superior to conventional radiotherapy. Future studies should investigate the role of FOLFIRINOX or gemcitabine plus nab-paclitaxel combined with SBRT.

BELG J MED ONCOL 2021;15(3):117-22

Reactivations of prior infections in cancer patients treated with immunosuppressive/immunomodulatory treatments

SUMMARY

Prior infections may reactivate in cancer patients receiving immunosuppressive/immunomodulatory treatments. Depending on the severity of the immune suppression, chemoprophylaxis may be necessary and is recommended in Herpes simplex virus- and Herpes zoster virus-seropositive patients undergoing allogenous hematologic stem cell transplantation and in solid cancer patients with Hepatitis B surface antigen or hepatitis B core antibody seropositivity.

For other infections, a low threshold for performing diagnostic testing of potential viral or tuberculosis infections should be used should be used in daily clinical practice in order to prevent severe morbidity or mortality.

(BELG J MED ONCOL 2021;15(2):75-8)

Neoadjuvant treatment considerations in HER2-positive breast cancer patients

SUMMARY

HER2-positive breast cancer was considered an aggressive subtype with a worse prognosis, but the development of anti-HER2 agents changed this paradigm. In the last years, the treatment of early HER2 breast cancer patients faced several improvements. Different anti-HER2 targeted drugs, like trastuzumab, pertuzumab, lapatinib, and TDM-1 used in advanced disease started to be included in multimodal curative strategies. Further, the presence of complete pathological response to neoadjuvant treatments started to be used as a surrogate outcome and led to the development of post-neoadjuvant strategies. Here, we summarise the neoadjuvant and post-neoadjuvant treatments of HER2-positive breast cancer according to the best evidence, reviewing the pharmacological aspects of HER2 targeted agents.

(BELG J MED ONCOL 2021;15(1):4-10)

BELFIGO – A retrospective observational study to evaluate the treatment patterns of mCRPC patients in Belgium treated with radium-223

SUMMARY

BELFIGO is a national retrospective chart review that aimed to assess the sequencing and application of radium-223 (Ra-223) within routine clinical practice, and evaluate the use of Ra-223 in monotherapy. The collection of data was primarily used to describe the proportion of Belgian metastatic Castration Resistant Prostate Cancer patients receiving one-four versus five-six Ra-223 injections, and the potentially associated patient characteristics. In total, 164 patients from eleven centres in Belgium were included and analysed in this study. Hundred-thirteen patients (69%) completed five-six injections of Ra-223. There was a trend that patients with a lower Eastern Cooperative Oncology Group Performance Status score, lower extent of disease on bone scan, alkaline phosphatase at baseline < 140 U/L and lactate dehydrogenase at baseline <250 U/L showed a higher chance of completing the six cycles of Ra-223. Median overall survival was estimated at 6.9 months for the patients having received one-four injections and 23.8 months for patients who completed five-six injections of Ra-223. More than 70% of patients received at least one treatment line after Ra-223, mainly enzalutamide, docetaxel or abiraterone acetate. These results show that the life-prolonging targeted alpha-therapy Ra-223 does not preclude the start of subsequent lines of treatment and that its use in an earlier line results, in a higher probability of reaching five-six doses. Patients with less advanced disease are more likely to complete five-six injections and tend to have a higher median overall survival.

(BELG J MED ONCOL 2020;14(7):347-54)

Optimal systemic treatment for advanced hepatocellular carcinoma: current clinical evidence and new insights based on tumour immunobiology

SUMMARY

Advanced hepatocellular carcinoma, known for its dismal prognosis, is a disease that is challenging to treat. For almost a decade, sorafenib was the only available treatment. However, the last two to three years have witnessed a true revolution in systemic treatment options for this lethal disease. Several targeted therapies with mostly anti-angiogenic properties have been developed and immunotherapy has made its entrance into the field. Furthermore, a growing understanding of the molecular pathways involved in hepatocarcinogenesis and new insights in tumour-immunobiology have led to the development of rational combination therapies, showing very promising results in a myriad of ongoing clinical trials. Here we review the latest developments and discuss the main consequences for clinical practice.

(BELG J MED ONCOL 2020;14(7):339-46)

Biosimilars in Oncology – Part II: Considerations about the clinical use of oncology biosimilars

SUMMARY

Biosimilars are equally safe and effective treatment options compared to their biological reference products, and can lower treatment costs and increase patient access to necessary medicines. Biosimilars in oncology have been integrated in cancer care, with the availability of supportive care biosimilars (epoetin and filgrastim) for over a decade. With the arrival of monoclonal antibody (mAb) biosimilars (trastuzumab, rituximab and bevacizumab), this article provides an up to date overview of the biosimilars available in oncology, while explaining clinical considerations important for prescribers, highlighting the need for in-depth understanding among oncologists about biosimilars and discussing the experience with oncology biosimilars in Europe and Belgium.

(BELG J MED ONCOL 2020;14(6):286-92)

Biosimilars in oncology – Part I: The principles of biosimilars

SUMMARY

Equally safe and effective alternatives to biological reference products, biosimilars, can lead to lowered treatment costs and higher patient access. With the arrival of biosimilars in the treatment of cancer (i.e., trastuzumab, rituximab, bevacizumab), it is important that oncologists gain confidence to adopt biosimilars in clinical practice. This article, the first in a series of two, emphasizes the need for biosimilars to create a competitive and sustainable biologicals market, highlights key concepts of the regulatory approval pathway of biosimilars, explains what key challenges biosimilars are facing, and what actions have been undertaken in Belgium to increase their use. We conclude with some recommendations.

(BELG J MED ONCOL 2020;14(6):280-5)