Cancer patients receive a number of drugs — chemotherapy, supportive care, and medicines for conditions other than cancer. In a recent study, more than one in four patients on chemotherapy were taking medications that had a risk of drug interaction.    

Four hundred chemotherapy patients completed a questionnaire listing the medications they had taken in the past four weeks.  Nearly 300 potential drug interactions were identified, ten percent of them with the possibility of causing death, another 80 percent with the risk of serious health problems.

Most potential interactions — 87 percent — involved drugs that were not anti-cancer agents including warfarin, high blood pressure agents, cortisteroids, and anticonvulsants.  However, 13 percent involved cancer treatments.  Eight percent were actually duplicate prescriptions.

Despite identifying potential risky drug interactions, the study did not go on to find out if the interactions led to serious problems.

Writing in the Journal of the National Cancer Institute, Rachel P. Riechelmann and her colleagues concluded:

Potential drug interactions were common among cancer patients and most often involved medications to treat comorbid conditions. Duplicate medications were infrequent.

SOURCE:  Riechelmann et. al., Journal of the National Cancer Institute,Volume 99, Number8, pp:592-600, April 2007.     

Deciding which patients with liver metastases from colon or rectal cancer will benefit from surgery to remove them can be difficult.  Surgery is usually not helpful if cancer has also spread outside the liver or if liver tumors are extensive.

Traditionally CT scans have helped surgeons and patients make decisions about appropriate surgery.  PET scanning with fluorodeoxyglucose (FDG) uses a different technique to identify cancer both in and outside the liver.  Adding a radioactive tracer to glucose lights up areas in the body where cancer absorbs more of the glucose.

But does adding FDG-PET scanning provide better information to decide on surgery?

Surgeons in the Netherlands compared two groups of patients who had surgery to remove colorectal liver metastases.  The first group (A) was chosen on the basis of traditional CT-scanning.  The second group (B) had FDG-PET scans added to the decision-making process.

During surgery, doctors found that liver resection was not possible in about 30% of the Group A patients and 20% of group B.  It was more common to find that cancer had spread outside the liver in the CT-only group A.  Ten percent of those surgeries were not completed because of extra-hepatic mets compared to only 2% of those who had the additional PET study before surgery.  In the rest of the unresectable cases, the liver spread itself was too widespread to remove.

Despite being able to find extra-hepatic cancer spread, using FDG-PET scanning added little to either survival or disease-free survival.   Three years after surgery 57 percent of Group A survived and 60 percent of Group B, with PET scanning, were also alive.  Cancer-free survival for group A was 23 percent compared to 30 percent in Group B, which was not significant.

B. Wiering and colleagues concluded:

In patients with colorectal liver metastases, FDG-PET may reduce the number of negative laparotomies. However, the effect size on the selection of these patients seems not sufficient enough to affect the overall and disease-free survival after treatment.

SOURCE:  Wiering et. al., Annals of Surgical Oncology, Volume 14, Number 2, pages 771-779, February 2007.

WHAT THIS MEANS FOR PATIENTS

Surgery to remove liver mets can lead to cures for advanced colorectal cancer in carefully selected patients.  Choosing which patients are likely to benefit depends on imaging before surgery.  If tumors in the liver are too extensive to permit the liver to function after surgery, an operation may have to be abandoned once begun.

In addition, cancer that has spread outside the liver and cannot be removed may make liver surgery futile.

Surgery has risks, including pain and complications.  Recovery reduces the possibility of chemotherapy that may increase survival time.  So selecting who can benefit and who will not is very important.

In this study, researchers found that FDG-PET did identify more cancer outside the liver, but knowing this information didn’t seem to change either survival at three years or cancer-free survival.

CT-scanning alone may be sufficient in making a decision about having liver resection surgery.

Despite national guidelines for screening men and women for colorectal cancer, actual screening rates remain below 15% in the Canadian province of Alberta.

A recent telephone study found that only 14.3 percent of average risk Alberta adults were up-to-date on screenings.  More women than men reported having had a recent fecal occult blood test (FOBT) — 14 percent versus 9.8 percent.  Men were more likely to have had endoscopy in the past five years — 4.3 percent versus 1.6 percent of women.

Recommendation from a doctor to have colorectal screening was an important factor for patients who actually got tested.  Men were five times more likely to be tested when a doctor suggested it, women almost four times so. 

S. Elizabeth McGregor and her team concluded:

Three years after the release of national guidelines, rates of screening among average risk adults aged 50–74 yr were very low. Public education programs and primary care interventions to specifically invite average risk adults for screening may be required to increase CRC screening rates.

SOURCE:  McGregor et.al.,American Journal of Gastroenterology, early online articles, 2007.

PROTOCOL # 06-C-0164: A Phase II Study of BAY 43-9006 (Sorafenib) in Combination with Cetuximab (Erbitux®) in EGFR Expressing Metastatic Colorectal Cancer

Researchers at the National Cancer Institute want to know if they can improve the number of patients who respond to Erbitux® (cetuximab) by adding a second agent to it. 

Patients with metastatic colorectal cancer who have already had at least one type of chemotherapy are being sought for a phase II clinical trial combining oral sorafenib (BAY 43-9006 or Nexavar®) with intravenous cetuximab.   Nexavar® targets and blocks proteins that are important in the  growth and multiplication of cancer cells.  It is already approved by the FDA to treat kidney cancer.

Eligible patients include those who

• have metastatic colorectal cancer
• have had at least one previous chemotherapy and cancer progression
• have not been treated with either Erbitux or sorafenib
• have at least one measurable tumor
• do not have brain metastases
• are not eligible for surgical removal of their metastatic tumor
• can swallow pills

Patients on the clinical trial will be treated at the NIH Clinical Center in Bethesda, MD.  There is no cost for treatment at the Clinical Center and funds are available to help with transportation and lodging during outpatient visits.

Patients will spend the first 2-3 days in the hospital to get treatment underway.  After that, treatment will be part of weekly outpatient clinic visits.  There is a possibility that local oncologists can administer cetuximab after the first cycle, reducing some travel to Bethesda.

More information about enrolling in the trial is available from:

Laura D. Otten, R.N., B.S.N., O.C.N.
Medical Oncology Referral Coordinator
Phone: 301-451-1228
1-866-611-6310 (Toll Free)
ottenl@mail.nih.gov

or

Janelle Bingham, R.N.
Research Nurse
Phone: 301-435-2715
jbingham@mail.nih.gov

Dr. Shivaani Kummar is the physician-scientist responsible for the trial.

To contact her:

Shivaani Kummar, M.D.
Principal Investigator
Phone: 301-435-5402
kummars@mail.nih.gov

It is very common for colorectal cancer to spread to the liver — metastasize.  Sometimes liver mets are discovered at the same time as the primary tumor in the colon or rectum, synchronous liver metastasis. At other times, the liver met follows the primary tumor after a period of time, metachronous.

Surgeons in Taiwan wanted to know if whether liver mets were synchronous or metachronous made a difference in how long patients remained cancer-free after surgery to remove the liver tumors.  They reviewed 155 cases of liver resection surgery done between 1995 and 2004.

They discovered that synchronous liver tumors tended to occur in younger patients, have a greater number of mets, and be located in both lobes of the liver.  About 40% of patients with synchronous mets were alive 5 years after their surgery, but cancer had returned in all but 16% of them.

Risk factors for poorer cancer-free survival included:

• synchronous metastases
• advanced stage of the original colorectal tumor
• mets in both lobes of the liver
• more than three metastases
• original tumor in the colon rather than the rectum

When all risks were considered together, synchronous tumors found at an advanced stage led to the poorest disease-free survival.  These patients may need closer follow-up and aggressive chemotherapy after liver surgery.

Writing in the Annals of Surgical Oncology, Ming-Shian Tsai and colleagues concluded:

The synchronous presence of primary colon cancer and liver metastasis may indicate a more disseminated disease status and is associated with a shorter disease-free survival than metachronous metastasis. These patients may need more careful monitoring and aggressive chemotherapy following curative resection.

SOURCE: Ming-Shian Tsai et.al., Annals of Surgical Oncology, Volume 14, Number 2, February 2007, pages 786-794.