Understanding Refractory CRC

John L. Marshall, MD: We’ve made a lot of progress in colorectal cancer over the last decade or so, and so now we are talking about this as being more of a chronic disease. There are a lot of new medicines that have extended survival, but we have to keep taking the medicines. And, while we still haven’t found a cure for metastatic colon cancer that can’t be removed surgically, we are having patients live longer and longer. And so, we’re at this point of what we call refractory disease. You’ll see that out there in our literature. I think of that as patients who’ve had the two main kinds of chemotherapy: the oxaliplatin-based chemotherapy and the other drug called irinotecan, or Camptosar. And so often, they have been on those medicines. Patients have been on those medicines for a couple of years; sometimes longer, sometimes shorter. But, now we have patients who’ve really exhausted those and they’re in the refractory setting. Any special things about patients at this setting, and what are we thinking about for the next steps?

Mohamed E. Salem, MD: I also learned across the way that some of the terminology we use as medical professionals actually have a negative impact on patients. When I use the word ‘refractory’ for my patients, they actually get very sensitive to that word because of maybe the implication that means. So, I try to stay away from those terms, and I explain it exactly as you say it: it’s a chronic disease. An analogy I usually use is it’s like diabetes or high blood pressure. It’s something you have; you can’t get rid of it. You just have to know to live with it and take medicine for it. If the medicine stops working, we should move to the next one and it will hopefully work. Now, in that advanced stage or if patient progressed on those drugs, we have two options which came relatively recently: Lonsurf, which got approved a few months ago, and Stivarga, or regorafenib, which was approved a couple years ago. Mostly, it’s the same indication; both are extra options for our patients that we can use to beat their diabetes and such.

John L. Marshall, MD: A lot of our patients are used to coming in every couple of weeks for IV treatments and now these medicines are more pills. Do you see some reaction from patients in this setting that that’s different, that that’s a change?

Monica Chacha, RN: Yes, absolutely. I think people are feeling nervous that they’re going to be taking this pill at home. They don’t have the infusion nurse right there with them saying, “Is that going to be okay?” And then, it is a matter of they’re not going to be monitored as closely when they’re on it, because they’re going to be at home. However, I also tell people there’s a lot more freedom that comes with pills, like they can travel.

John L. Marshall, MD: Yes. And so, we do tell them we’re going to monitor them and we are going to follow them closely, but they’re free to not come and get IVs. So, refractory disease is a success, not a negative, and we have more tools to extend patients’ survival longer and longer with metastatic disease.

Monica Chacha, RN: Something I always tell my patients is that I would rather them overcommunicate than undercommunicate. Sometimes, people tell me they didn’t want to tell me something. They thought it was insignificant. But, that’s why I’m here. That’s why I have this role. So, even if you think it’s nothing, I tell my patients at least shoot me an e-mail, give me a call. Let me and the physician decide if it’s nothing or if it might be something that can turn into something bigger later, and we can stop it before it becomes a problem.