REVIEW ONCOLOGY

Highlights in oncology 2016

SUMMARY

Every year brings new knowledge and insights that help to direct research that ultimately leads to improved care for patients with cancer. This report, which is based on the clinical cancer advances 2017 article published by the American Society of Clinical Oncology, reviews the most important advances made in the different fields of oncology that are most likely to impact daily clinical practice.¹ Over the last few years, immunotherapy has become a new treatment option for patients with a growing number of cancer types. Building on the initial successes with immunotherapy, a key next step is to understand why currently fewer than half of patients benefit from immunotherapy and why the benefit, if it occurs, may be short lived. In 2016, several reports revealed early insights into patient and cancer characteristics that might predict whether immunotherapy could work well in an individual patient. Many studies also assess whether combining immunotherapy with other cancer treatments might extend the potential of this new group of therapies.

A second part of this report focuses on targeted therapies. The research into cancer biology is propelling rapid development of novel treatments targeting the key molecules that allow cancers to grow and spread. In 2016, this strategy resulted in new targeted therapies for patients with advanced lung, breast, and kidney cancer, as well as several hard-to-treat forms of blood cancer. In addition to this, new molecular technologies are emerging that can quickly pinpoint molecular changes in the tumour or free-floating cancer DNA in the blood.

(BELG J MED ONCOL 2017; 11(2):37–45)

Premedication strategy for paclitaxel, still an unsolved question after 30 years

SUMMARY

Background: For paclitaxel administered 3-weekly, the Food and Drug Administration recommends the use of premedication with dexamethasone 20 mg orally twelve and six hours prior to paclitaxel, histamine–1 and –2 antagonists 30–60 minutes prior to paclitaxel, to prevent hypersensitivity reactions. There are no guidelines for the use of premedication when paclitaxel is given weekly.

Material and methods: MEDLINE was searched using the keywords premedication, dexamethasone, paclitaxel and hypersensitivity in November 2016. Articles were surveyed for additional citations.

Results: We retrieved 28 papers, of which sixteen on prospective trials (four on weekly, nine on 3-weekly paclitaxel). Using a dexamethasone tapering regimen in patients without hypersensitivity reactions after the first weekly paclitaxel administration, hypersensitivity reactions were reported in 1.0%, 2.3% and 5.7% of patients. In five single arm studies, intravenous dexamethasone 20 mg was administered prior to 3-weekly paclitaxel. Hypersensitivity reaction rates varied between 0–15%. Hypersensitivity reaction rates in sequential cohorts, in a single centre, with an intravenous or oral dexamethasone regimen were 14.5% and 5.4%, respectively (p=0.07). In a randomised trial there was no significant difference between an intravenous and oral dexamethasone regimen prior to 3-weekly paclitaxel administration.

Conclusions: Tapering of dexamethasone or no premedication at all seems to be safe in patients without hypersensitivity reactions after the first weekly administration of paclitaxel. Substitution of oral dexamethasone by a single intravenous administration immediately prior to 3-weekly paclitaxel was associated with a higher risk of hypersensitivity reactions, until 17,9%.

(BELG J MED ONCOL 2017;11(2):46–55)

Robot-assisted radical prostatectomy, an update of the current evidence

SUMMARY

Robot-assisted radical prostatectomy has become standard-of-care in most centres of excellence in the treatment of prostate cancer. Recent literature shows a reduced complication risk, reduced transfusion need, shorter hospitalisation and functional and oncological benefit in comparison with open radical prostatectomy. Long term follow-up data and large randomised clinical trails are currently lacking.

(BELG J MED ONCOL 2017;11(1):4–6)

Should tumour infiltrating lymphocytes and PIK3Ca mutation be added as markers to the histology report for breast cancer?

SUMMARY

Tumour infiltrating lymphocytes are a sign of immune mediated reaction of the host against the tumour. They are considered as a positive prognostic marker and may also have a predictive role for the use of certain therapies. The challenge remains to convert tumours with low tumour infiltrating lymphocytes into tumours with high tumour infiltrating lymphocytes in order to enhance the immune mediated effect of therapies.

PIK3Ca mutation is one of the most frequent mutations encountered in breast cancer, particularly in hormone receptor positive cancer in which it can confer resistance to hormonal therapy. Therefore, a lot of effort has been made to target the PI3K-pathway with drugs, and to find a way to predict their efficacy: some results have been achieved; in particular with the detection of PIK3Ca in circulating DNA, but many questions still remain. This article provides an overview concerning these two biomarkers, and attempts to determine whether they could be used in clinical practice today.

(BELG J MED ONCOL 2017;11(1):7–11)

Gastric cancer: the role of VEGFR2, MET and HER2

Summary

Gastric cancer is one of the leading causes of cancer deaths worldwide. A new molecular classification based on comprehensive genomic analysis is currently replacing the old, clinically pointless classification. This classification based on targetable genomic abnormalities and pathway amplifications may open avenues for clinical research based on targeted medications and strategies. We review three important potential targets in advanced gastric cancer.

(BELG J MED ONCOL 2016;10(7):243–248)

Interest of physical activity in lung cancer care: a systematic review

Summary

Cancers can benefit from physical activity. Most evidences concern breast, prostate and colorectal cancers. Literature about lung cancer and exercise is scarce. However lung cancer is frequent all around the world. The aim of this review was to summarise the knowledge on effects of exercise in lung cancer patients. The benefit of physical activity as a preventive strategy was also analysed.
We systematically searched for studies published between 2008 and 2013. Used key words were lung cancer, physical activity, quality of life, fatigue, functional performance, exercise, rehabilitation, treatment, prevention, complication. The following databases were reviewed: PubMed, ScienceDirect, Chest, Cochrane, SportDiscus and WHO. Eligibility criteria were availability of full texts in English or in French. Studies were classified in four categories: exercises as prevention, in preoperative period, during treatment and after treatment.
Positive effects of exercise were globally demonstrated on physical and psychological outcomes in the four categories. Benefits of exercise were particularly observed for supervised program. Home exercise program benefits were less convincing.
Even if physical activity and exercise programs can be beneficial in prevention, during and after the treatment of lung cancer, the heterogeneity of the literature is too large to reach a conclusion about their place in the treatment.

(BELG J MED ONCOL 2016;10(6):199–206)

State of the art: gene expression profiles in early breast cancer

Summary

Gene expression profiles provide strong prognostic information and can predict breast cancer outcome mainly in women with lymph node-negative, oestrogen receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. They are primarily designed to enable a more precise assessment on whether or not a patient needs adjuvant chemotherapy. However, the optimal use in clinical practice is still not established. The first set of data published from the TAILORx study and the results from the MINDACT study provide strong evidence for the clinical utility of gene expression profiles. Full disclosure of the results of prospective studies such as MINDACT and TAILORx on this topic is awaited in order to define their exact place in clinical decision-making. However, in several countries, these tests are already used in daily clinical practice, and are reimbursed. In addition, the use of gene expression profiles as a potential ancillary tool for treatment decisions is supported in several international treatment guidelines. Multiple studies have shown that there is a change in treatment decision based on gene expression profiles. In addition, different assays may provide different risk stratification at short-, middle- and long-term, so thoughtful use of these tests is recommended. Patients should be well informed about the benefits, risks, costs and uncertainties associated with these tests. Clinicians should also be educated on these matters. Furthermore, as gene expression profiles are expensive and not reimbursed in many countries, these tests are not accessible to all breast cancer patients. Patients’ preferences are important when making risk assessments and treatment decisions in those cases where there is doubt on the benefit of giving adjuvant chemotherapy. Taken together, gene expression profiles provide information that may be complementary to that provided by standard clinicopathological assessment in guiding decision of therapy in the adjuvant setting. These assays represent a step forward towards personalised medicine. We strongly propose to allow reimbursement of gene expression profiles in Belgium, but pragmatic and clear criteria for reimbursement should be developed with all stakeholders to avoid overconsumption.

(BELG J MED ONCOL 2016;10(4):114–122)