PRACTICE GUIDELINES

Screening for dihydropyrimidine dehydrogenase deficiency to prevent severe fluoropyrimidine-associated toxicity

Fluoropyrimidines are the cornerstones of all currently applied regimens for the treatment of patients with cancers of the gastrointestinal tract, breast, head and neck. Dihydropyrimidine dehydrogenase plays a pivotal role in the metabolism of 5-fluorouracil and, as such, a deficiency of dihydropyrimidine dehydrogenase has been recognised as an important risk factor, predisposing patients to develop severe 5-fluorouracil associated toxicity. Screening for dihydropyrimidine dehydrogenase deficiency would not only decrease fluoropyrimidine morbidity and enhance patient quality of life but also potentially reduce costs by avoiding toxicity-related hospitalisations. Genotype and phenotype-based dosing recommendations of fluoropyrimidines propose a dose of 50% of the starting dose followed by an increase in dose in patients experiencing no or clinically tolerable toxicity, to ensure efficacy and a dose decrease in patients who do not tolerate the starting dose, to minimize toxicity.

(BELG J MED ONCOL 2015;9(3):95–8)

Therapy-orienting testing of BRCA1 and BRCA2 germline mutations in women with ovarian cancer

With the aim to optimally position poly-(adenosine diphosphate-ribose) polymerase inhibitors in the treatment of ovarian cancer, a panel of Belgian Experts came to a national multidisciplinary consensus: (i) germline BRCA1/2 testing should be indicated for all women with high-grade serous epithelial ovarian cancer, who are in good general condition (i.e. eligible for systemic treatment with low toxicity); BRCA1/2 mutation detection ratios being about 15–20% in this group; (ii) as the finding of a BRCA1/2 germline mutation has therapeutic implications in ovarian cancer patients, the request for therapy-orienting testing should be made as soon as possible during the course of first-line treatment. Pre-test genetic counselling is important because positive testing has implications for both the patients and their relatives, and the nature of the discussions depends on whether they take place in a therapeutic or familial context. The organisation of consultations should be coordinated in a collaborative effort between clinical geneticists, and gynaecological and medical oncologists, keeping in mind that ‘fast-track’ pre-test genetic counselling and short turnaround times are required for patients for whom the test results will have a therapeutic impact. Offering germline BRCA1/2 testing to all patients with high-grade serous epithelial ovarian cancer who are eligible for systemic treatment with low toxicity will lead to a limited increase in the number of patients eligible for this test in Belgium.

(BELG J MED ONCOL 2015;9(2):65–70)

Management and systemic treatment of clear cell metastatic renal cell carcinoma: BSMO expert panel recommendations

Almost 30% of patients with renal cell cancer present initially with advanced stage IV disease. In the past decade, the management of the metastatic renal cell cancer has been revolutionised by the knowledge of its molecular biology and development of targets against vascular endothelial growth factor and mammalian target of rapamycin pathways. In this paper we present recommendations based on a thorough review of available guidelines and data from the phase III randomised controlled trials that evaluated new agents in patients with advanced metastatic renal cancer.
(BELG J MED ONCOL 2015;9(1):16–24)

Penile cancer practice guidelines

We present a condensed version of the ESMO clinical practice guidelines on penile cancer.¹

Penile cancer is an uncommon but ominous disease. In the last few years there has been a shift towards penile-preserving techniques, because besides local control, an important aim of surgery is to preserve the functionality and sexual function of the penis. This has an important impact on the patient’s self-esteem, quality of life and general mental health. Despite the rarity of the disease we gradually achieve more insight in the proper staging and treatment of this malignancy.

(BELG J MED ONCOL 2014;8(5):213–6)

Update of the Belgian guidelines for HER2 testing in breast cancer

This update of the Belgian guidelines for HER2 testing is based on the updated recommendations recently published by the American Society of Clinical Oncology and the College of American Pathologists.^1–3

(BELG J MED ONCOL 2014;8(4):109–15)

New medical treatments in thyroid cancer

Thyroid cancers are rare diseases and include types that range from indolent localised differentiated carcinomas to fulminant and lethal anaplastic disease. Until recently, treatment options for advanced or metastatic radio-iodine refractory thyroid cancer were limited. Recently kinase inhibitors targeting angiogenesis and other pathways have shown promising activity.

(BELG J MED ONCOL 2014;8(3):81–6)

How to sequence systemic therapies and radiotherapy in early breast cancer?

Breast cancer is the most common malignancy in women in the Western world. Over the last decades, the use of postoperative systemic therapies (chemotherapy, hormonal therapy, trastuzumab) and radiotherapy led to significant survival benefits for patients with early breast cancer. Although these modalities have been extensively studied and used, a major question is how these systemic therapies are optimally sequenced with radiotherapy in the adjuvant setting. This article reviews available data on how to combine systemic therapies with radiotherapy in women with early stage breast cancer, and provides recommendations that unfortunately do not reach level I evidence due to insufficient quality of available clinical data.

BELG J MED ONCOL 2014;8(3):72–80