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Managing Patients After Adjuvant Therapy

Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Cathy Eng, MD, FACP, The University of Texas MD Anderson Cancer Center; John L. Marshall, MD, The Ruesch Center for the Cure of GI Cancers ; Michael A. Morse, MD, Duke Cancer Institute; Dale R. Shepard, MD, PhD, FACP, Taussig Cancer Institute, Cleveland Clinic
Published: Monday, Mar 05, 2018



Transcript: 

John L. Marshall, MD: They have had their therapy. I tend to bring patients back for a follow-up visit—a “Now what,” visit. What kind of advice, Dale, are you giving a patient? They finished their adjuvant therapy. How do you follow up with those patients?

Dale R. Shepard, MD, PhD, FACP: There are a few things. I really focus on lifestyle modification, as best as I can. It’s sort of a teachable moment. They’ve had cancer. There are studies that have come out recently that suggest that 40% of cancers are due to preventable causes. If we can use that cancer as a trigger to get them to watch their weight and exercise more…
Then the other thing is that there are family and friends that are often at risk. So, I promote screening. I use this as an opportunity to get people to think about screening.

John L. Marshall, MD: What are some other tips? Michael, what do you tell patients?

Michael A. Morse, MD: I think we all agree that aspirin has a role. The challenge is, when I’ve talked to some of my internal medicine colleagues, aspirin does have risks—as much as we think of it as the cure-all for everything. There are going to be people with serious bleeds from taking aspirin. Nonetheless, I usually discuss it with people. I have to admit that we don’t do additional testing to see if they have the PI3-kinase mutations. We just recommend it, in general. Calcium and vitamin D has been another area of discussion. The National Comprehensive Cancer Network guidelines don’t necessarily recommend vitamin D, yet. But I think it’s very clear that people with low vitamin D levels have a worse outcome. So, to me, it’s an easy intervention for people. It’s crazy, but I’ve been telling my patients to go have lunch outside and not wear sunscreen.

Cathy Eng, MD, FACP: How long is this lunch?

John L. Marshall, MD: It’s just for a little bit. We’ve made ourselves vitamin D deficient by avoiding the sun.

Cathy Eng, MD, FACP: I was going to tell you that there’s another trial though. Don’t forget that there’s the PACES trial, the SWOG S0820 trial, that’s specifically for colorectal carcinomas—stage 0 through 3—after adjuvant chemotherapy.

John L. Marshall, MD: You have to enroll within about a year, I think, of the completion?

Cathy Eng, MD, FACP: Yes

John L. Marshall, MD: That’s an interesting study.

Cathy Eng, MD, FACP: People always ask, “What can I do besides exercise, watch my diet, etc?” I do tell them about this trial.

John L. Marshall, MD: The guidelines say that I can have an annual CAT scan and I can get a carcinoembryonic antigen (CEA) test every 3 months. I don’t like that guideline. What do you do?

Johanna C. Bendell, MD: I don’t really like that guideline either, especially in colon cancer where, if you catch a metastasis early, you can potentially resect that metastasis. I tend to be a 3-monther for the first couple of years. Then I go to 6 months, then a year, and then check the CEAs. I know there’s this data, back and forth, about what is good enough. But, yes, I don’t like it.

Cathy Eng, MD, FACP: I do bi-annual scans on high-risk patients.

John L. Marshall, MD: What does that mean? One node positive? 10 nodes positive?

Cathy Eng, MD, FACP: Usually, 4 or more. Or those who presented with perforation or poorly differentiated that is not MSI–high.

John L. Marshall, MD: Yes, and looking for that metastasectomy opportunity. Dale, do you do anything different?

Dale R. Shepard, MD, PhD, FACP: I tend to do 6 months on scans. I always struggle with CEAs. If they’re elevated. How elevated is elevated? But I scan at 6 months.

John L. Marshall, MD: Colonoscopies, when do you do that?

Michael A. Morse, MD: Within the first year or earlier if the person didn’t have a complete colonoscopy. And after that, we really base it on the gastroenterologist’s recommendation, to tell you the truth.

John L. Marshall, MD: Sometimes, they’ll come back in 3 to 5 years.

Michael A. Morse, MD: Correct.

John L. Marshall, MD: Our patients are nervous about that 3-year recommendation.

Cathy Eng, MD, FACP: I think that it depends on the type of polyp that they find or if they find additional polyps, too. So, you have to take that into account.

Johanna C. Bendell, MD: Mike made a very important point. Sometimes, you don’t get told, by the gastroenterologist, whether or not the patient had a complete colonoscopy. So, you always have to make sure that they got all the way around. If they didn’t, you’ve got to go back in again.

Cathy Eng, MD, FACP: Or else they just did a flexible sigmoidoscopy.

Johanna C. Bendell, MD: Yes.

John L. Marshall, MD: That’s very common. Usually, the gastrointestinal person has noted and has wanted them back. But it gets lost in the whole cancer discussion. So, getting those patients to stage 4, no evidence of disease. Now what? I have no idea what to do with a patient who has now been rendered as stage 4 with no evidence of disease. What do you do?

Dale R. Shepard, MD, PhD, FACP: Somebody who had adjuvant therapy prior to that?

John L. Marshall, MD: Yes, they’ve had some chemotherapy.

Dale R. Shepard, MD, PhD, FACP: It’s a tough call. I don’t know what to do with that either. They’ve already had adjuvant chemotherapy.

John L. Marshall, MD: Do you give them a round of FOLFIRI for the heck of it?

Dale R. Shepard, MD, PhD, FACP: I don’t think there are good data for that.

John L. Marshall, MD: No?

Johanna C. Bendell, MD: No.

Dale R. Shepard, MD, PhD, FACP: I would not do that.

John L. Marshall, MD: OK.

Dale R. Shepard, MD, PhD, FACP: You know, if it’s been a really long interval since they had their adjuvant therapy, I might give them a little bit more FOLFOX. But I think observation is probably the right call.

John L. Marshall, MD: Yes. It’s hard to do though, isn’t it?

Dale R. Shepard, MD, PhD, FACP: It is hard.

Michael A. Morse, MD: Well, you know, for some of these people, if we’re sort of following how the EPOC study was done….

Cathy Eng, MD, FACP: Do you want to mention what the EPOC study was?

Michael A. Morse, MD: This was a study for people with resectable liver metastasis who were randomized to receive FOLFOX, surgery, FOLFOX afterwards or surgery alone. There was a better relapse-free survival. But so far, there’s no overall survival difference between the 2 arms. For those patients that I mentioned earlier, where surgeons are asking us to give them some preoperative therapy, to me it makes sense to give them postoperative therapy, if we’re sort of following what was done in that study.

John L. Marshall, MD: And the idea of there being curative intent, which goes back to maybe why, for me, irinotecan is out. It’s never worked in the adjuvant setting.

Cathy Eng, MD, FACP: That study was given only in the adjuvant setting. It wasn’t given in the neoadjuvant setting, followed by surgery, followed by adjuvant.

John L. Marshall, MD: So, you think it might work in this setting?

Johanna C. Bendell, MD: Do you think just shifting it? It was actually metastatic liver resections, negative for FOLFIRI adjuvant.

Cathy Eng, MD, FACP: I understand that. But then, you have a patient that you’ve given neoadjuvant FOLFIRI to because they just, let’s say, failed FOLFOX recently. They had adjuvant chemotherapy. You look at the tumor viability. If there’s a significant reduction in tumor viability, that sometimes suggests that there was benefit. And if it’s a young patient, sometimes you want to obviously give them the best chance possible.

Johanna C. Bendell, MD: But that’s sort of a case-by-case scenario.

Cathy Eng, MD, FACP: Of course. Everything that we’re talking about is case-by-case.

John L. Marshall, MD: But I do think that’s really important. I think the guidelines say to consider more chemotherapy or something like that. It’s, “Where’s your evidence? What are you doing?” We don’t want to just beat patients up for the heck of it to make us feel better.

Johanna C. Bendell, MD: Right.

John L. Marshall, MD: It’s important. So, no one has the answer? I was hoping that one of you did.

Michael A. Morse, MD: Thank you for mentioning this.

Transcript Edited for Clarity

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Transcript: 

John L. Marshall, MD: They have had their therapy. I tend to bring patients back for a follow-up visit—a “Now what,” visit. What kind of advice, Dale, are you giving a patient? They finished their adjuvant therapy. How do you follow up with those patients?

Dale R. Shepard, MD, PhD, FACP: There are a few things. I really focus on lifestyle modification, as best as I can. It’s sort of a teachable moment. They’ve had cancer. There are studies that have come out recently that suggest that 40% of cancers are due to preventable causes. If we can use that cancer as a trigger to get them to watch their weight and exercise more…
Then the other thing is that there are family and friends that are often at risk. So, I promote screening. I use this as an opportunity to get people to think about screening.

John L. Marshall, MD: What are some other tips? Michael, what do you tell patients?

Michael A. Morse, MD: I think we all agree that aspirin has a role. The challenge is, when I’ve talked to some of my internal medicine colleagues, aspirin does have risks—as much as we think of it as the cure-all for everything. There are going to be people with serious bleeds from taking aspirin. Nonetheless, I usually discuss it with people. I have to admit that we don’t do additional testing to see if they have the PI3-kinase mutations. We just recommend it, in general. Calcium and vitamin D has been another area of discussion. The National Comprehensive Cancer Network guidelines don’t necessarily recommend vitamin D, yet. But I think it’s very clear that people with low vitamin D levels have a worse outcome. So, to me, it’s an easy intervention for people. It’s crazy, but I’ve been telling my patients to go have lunch outside and not wear sunscreen.

Cathy Eng, MD, FACP: How long is this lunch?

John L. Marshall, MD: It’s just for a little bit. We’ve made ourselves vitamin D deficient by avoiding the sun.

Cathy Eng, MD, FACP: I was going to tell you that there’s another trial though. Don’t forget that there’s the PACES trial, the SWOG S0820 trial, that’s specifically for colorectal carcinomas—stage 0 through 3—after adjuvant chemotherapy.

John L. Marshall, MD: You have to enroll within about a year, I think, of the completion?

Cathy Eng, MD, FACP: Yes

John L. Marshall, MD: That’s an interesting study.

Cathy Eng, MD, FACP: People always ask, “What can I do besides exercise, watch my diet, etc?” I do tell them about this trial.

John L. Marshall, MD: The guidelines say that I can have an annual CAT scan and I can get a carcinoembryonic antigen (CEA) test every 3 months. I don’t like that guideline. What do you do?

Johanna C. Bendell, MD: I don’t really like that guideline either, especially in colon cancer where, if you catch a metastasis early, you can potentially resect that metastasis. I tend to be a 3-monther for the first couple of years. Then I go to 6 months, then a year, and then check the CEAs. I know there’s this data, back and forth, about what is good enough. But, yes, I don’t like it.

Cathy Eng, MD, FACP: I do bi-annual scans on high-risk patients.

John L. Marshall, MD: What does that mean? One node positive? 10 nodes positive?

Cathy Eng, MD, FACP: Usually, 4 or more. Or those who presented with perforation or poorly differentiated that is not MSI–high.

John L. Marshall, MD: Yes, and looking for that metastasectomy opportunity. Dale, do you do anything different?

Dale R. Shepard, MD, PhD, FACP: I tend to do 6 months on scans. I always struggle with CEAs. If they’re elevated. How elevated is elevated? But I scan at 6 months.

John L. Marshall, MD: Colonoscopies, when do you do that?

Michael A. Morse, MD: Within the first year or earlier if the person didn’t have a complete colonoscopy. And after that, we really base it on the gastroenterologist’s recommendation, to tell you the truth.

John L. Marshall, MD: Sometimes, they’ll come back in 3 to 5 years.

Michael A. Morse, MD: Correct.

John L. Marshall, MD: Our patients are nervous about that 3-year recommendation.

Cathy Eng, MD, FACP: I think that it depends on the type of polyp that they find or if they find additional polyps, too. So, you have to take that into account.

Johanna C. Bendell, MD: Mike made a very important point. Sometimes, you don’t get told, by the gastroenterologist, whether or not the patient had a complete colonoscopy. So, you always have to make sure that they got all the way around. If they didn’t, you’ve got to go back in again.

Cathy Eng, MD, FACP: Or else they just did a flexible sigmoidoscopy.

Johanna C. Bendell, MD: Yes.

John L. Marshall, MD: That’s very common. Usually, the gastrointestinal person has noted and has wanted them back. But it gets lost in the whole cancer discussion. So, getting those patients to stage 4, no evidence of disease. Now what? I have no idea what to do with a patient who has now been rendered as stage 4 with no evidence of disease. What do you do?

Dale R. Shepard, MD, PhD, FACP: Somebody who had adjuvant therapy prior to that?

John L. Marshall, MD: Yes, they’ve had some chemotherapy.

Dale R. Shepard, MD, PhD, FACP: It’s a tough call. I don’t know what to do with that either. They’ve already had adjuvant chemotherapy.

John L. Marshall, MD: Do you give them a round of FOLFIRI for the heck of it?

Dale R. Shepard, MD, PhD, FACP: I don’t think there are good data for that.

John L. Marshall, MD: No?

Johanna C. Bendell, MD: No.

Dale R. Shepard, MD, PhD, FACP: I would not do that.

John L. Marshall, MD: OK.

Dale R. Shepard, MD, PhD, FACP: You know, if it’s been a really long interval since they had their adjuvant therapy, I might give them a little bit more FOLFOX. But I think observation is probably the right call.

John L. Marshall, MD: Yes. It’s hard to do though, isn’t it?

Dale R. Shepard, MD, PhD, FACP: It is hard.

Michael A. Morse, MD: Well, you know, for some of these people, if we’re sort of following how the EPOC study was done….

Cathy Eng, MD, FACP: Do you want to mention what the EPOC study was?

Michael A. Morse, MD: This was a study for people with resectable liver metastasis who were randomized to receive FOLFOX, surgery, FOLFOX afterwards or surgery alone. There was a better relapse-free survival. But so far, there’s no overall survival difference between the 2 arms. For those patients that I mentioned earlier, where surgeons are asking us to give them some preoperative therapy, to me it makes sense to give them postoperative therapy, if we’re sort of following what was done in that study.

John L. Marshall, MD: And the idea of there being curative intent, which goes back to maybe why, for me, irinotecan is out. It’s never worked in the adjuvant setting.

Cathy Eng, MD, FACP: That study was given only in the adjuvant setting. It wasn’t given in the neoadjuvant setting, followed by surgery, followed by adjuvant.

John L. Marshall, MD: So, you think it might work in this setting?

Johanna C. Bendell, MD: Do you think just shifting it? It was actually metastatic liver resections, negative for FOLFIRI adjuvant.

Cathy Eng, MD, FACP: I understand that. But then, you have a patient that you’ve given neoadjuvant FOLFIRI to because they just, let’s say, failed FOLFOX recently. They had adjuvant chemotherapy. You look at the tumor viability. If there’s a significant reduction in tumor viability, that sometimes suggests that there was benefit. And if it’s a young patient, sometimes you want to obviously give them the best chance possible.

Johanna C. Bendell, MD: But that’s sort of a case-by-case scenario.

Cathy Eng, MD, FACP: Of course. Everything that we’re talking about is case-by-case.

John L. Marshall, MD: But I do think that’s really important. I think the guidelines say to consider more chemotherapy or something like that. It’s, “Where’s your evidence? What are you doing?” We don’t want to just beat patients up for the heck of it to make us feel better.

Johanna C. Bendell, MD: Right.

John L. Marshall, MD: It’s important. So, no one has the answer? I was hoping that one of you did.

Michael A. Morse, MD: Thank you for mentioning this.

Transcript Edited for Clarity
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