REVIEW ONCOLOGY

Targeting driver mutations in non-small-cell lung cancer, beyond the usual suspects (EGFR and ALK)

In the last decade, systemic treatment for non-small-cell lung cancer has undergone an unprecedented change because of new targeted therapies and the introduction of immunotherapy. Advances in the understanding of lung cancer biology have led to the discovery of several oncogenic driver genes and the development of drugs that target driver mutations, according to the strategy of ‘personalised therapy’. The bestknown alterations are epidermal growth factor mutations and anaplastic lymphoma kinase rearrangements, but the improvement in genomic technologies and the continuous research in this area have led to the identification of new druggable targets. This is a comprehensive overview focused on the development of targeted therapies and their mechanisms of action.

(BELG J MED ONCOL 2018;12(5):223–232)

Brain metastases: Systemic treatment approach in 2017

This review proposes to go through reasonable systemic therapy options in brain metastases, notably immune checkpoint inhibitors and oncogen-driven targeted therapies. We deliberately focus on drugs currently available in Belgium in clinical practice. In the large majority of cases, clinical trials – in particular registration trials – exclude patients with brain metastases. Therefore we have to deal with small size non-randomised phase II trials or retrospective analysis with the known caveats of highly selected patients and numerous biases.

(BELG J MED ONCOL 2018:12(3):96–102)

Brain metastases: The evolving role of whole-brain radiotherapy

Over the last decade the use of whole-brain radiotherapy has decreased due to therapeutic advances, as well as in systemic treatment as in radiotherapy, but also due to a growing concern about neurocognitive failure in long-term survivors.

In patients with good prognostic factors (defined by recursive partitioning analysis or disease specific-graded prognostic assessment) and with limited brain metastases (excluding histologies s.a. SCLC, germ cell tumours, lymphomas and leukaemias), there is a trend to defer WBRT and only perform localised treatment (surgery, radiosurgery, stereotactic fractionated radiotherapy) with close follow up.

WBRT is still an option in better prognostic patients with higher intracranial tumour burden. When patients have a poor performance status, best supportive care is an equally valid option.

(BELG J MED ONCOL 2018:12(3):103–109)

The role of chemoradiotherapy in elderly patients with locoregionally advanced head and neck cancer

Paralleled by rising cancer burden, recent global demographic changes have been marked by a constantly growing number of people aged 65 or more. In the United States, presently 54% of malignant head and neck cancer cases occur in the geriatric population, and by 2030, this proportion is expected to attain 66%. Despite the obvious importance of addressing specific needs of elderly patients, these individuals have often been undertreated and refrained from geriatric assessment in clinical practices and underrepresented in prospective trials. Unfortunately, many health care professionals still believe that older patients cannot tolerate intensified treatment regimens. In this paper, we focused on concurrent chemoradiation as definitive or post-operative treatment in locoregionally advanced squamous cell carcinoma of the head and neck. Although confirmatory data from large randomised phase III trials conducted in the elderly are lacking, available evidence from meta-analyses of prospective trials and retrospective reviews of population-based cross-sectional registries indirectly support this approach, primarily in the definitive treatment setting. However, irrespective of calendar age, distinction between fit and frail senior patients is of paramount priority. In this respect, several geriatric screening tools have been developed for use by practicing physicians to help select which patients need a comprehensive geriatric assessment, who requires a specific examination only (e.g. focused on certain comorbid conditions, cognition, nutritional status, social support, or psychological state), and where no further testing is warranted.

(BELG J MED ONCOL 2018;12(3):110–117)

Optimal management of pancreatic cancer: current standards and challenges for improving care and research

Summary

Pancreatic cancer is one of the most lethal cancers and will become the second leading cause of cancer-death; despite some progress in management, median survival remains around 24 months in resected disease, fifteen months in locally advanced non resectable disease and twelve months in metastatic setting. Two backbone regimens, folfirinox and gemcitabine-abraxane are nowadays used in routine practice, mainly in metastatic disease but are now investigated in both adjuvant and neo-adjuvant therapy. Neoadjuvant therapy, although requiring robust proof of definite efficacy, is more frequently used for borderline resectable tumours with promising results; moreover, it offers a unique window to integrate care and research by assessing new drugs in translational platforms. Molecular biology (multiomics) and imaging (radionomics) will also permit and promote a more comprehensive use of new drugs, including immune-oncological ones and strategies and select the best patients for precision medicine, the ultimate goal being to improve this poor outcome. This review covers the current standard and best practice in the different sub-entities of pancreatic cancer and opens perspectives in new therapeutic challenges.

(BELG J MED ONCOL 2018;12(2):39–45)

Fertility preservation in breast cancer patients

Summary

Fertility issues are a major concern for young patients diagnosed with breast cancer. This review focuses on the importance of taking treatment-related ovarian function and fertility decline into consideration by offering appropriate pre-treatment counselling. Fertility preservation options, including oocyte or embryo vitrification, cryopreservation of ovarian tissue, and administration of gonadotropin-releasing hormone analogues should be discussed before starting chemotherapy. We outline the advantages and disadvantages of each technique and review recent data on their efficacy and safety.

(BELG J MED ONCOL 2018;12(1):4–8)

Breast cancer and pregnancy-related issues

Summary

Breast cancer and pregnancy-related issues are important areas of concern for young women. Prior pregnancies and breastfeeding may impact the risk of developing breast cancer and its biologic features. Nowadays, thanks to major advances in oncology practice, breast cancer patients have excellent survival outcomes; hence, survivorship issues including the possibility to constitute a family after treatment are of crucial importance. Furthermore, considering the current trend of delaying childbearing, an increased awareness should be paid towards the possibility of breast cancer diagnosis during pregnancy. Despite increased amounts of data available and consensus guidelines having been published on these topics, it should be noted that current recommendations rely on limited evidence. Hence, further research efforts are needed to obtain more conclusive considerations in this regard.

This review article focuses on the link between reproductive behaviour, infertility treatments and the risk of developing breast cancer, the management of patients diagnosed with breast tumour during pregnancy, as well as the concerns of a pregnancy in survivors with prior history of breast malignancy.

(BELG J MED ONCOL 2018;12(1):9–14)