Treatment updates: Patient perspective with Dr. Manju George (2020)

Manju George  0:02 
Hello, everyone, many thanks to OncoAlert and the sponsors of the first online OncolAlert colloquium for inviting me to share the patient perspective in this session. I’m Dr. Manju George, a Stage 3b rectal cancer survivor. I’m also the Scientific Director of Colontown. I’m a patient advocate at the NCI Rectal-Anal Taskforce and The Stand Up to Cancer CRC Dream Team. Colontown is an online international colorectal cancer patient and caregiver support and education community. We believe in patient empowerment through education. In Colontown we have over 140 different neighborhoods that cater to almost every aspect of the CRC patient and caregiver experience. This includes our Clinical Trial Groups, where information about promising clinical trials are posted on a regular basis. My talk is titled 2020– From a CRC Patient Point of View.

Manju George  0:58 
First, let us remind ourselves why we’re here. Colorectal cancer is the second leading cause of cancer-related mortality in men and women combined in the US. We expect 104,610 new CRC cases this year. Of which 17,930 will be rectal cancer. We expect 53,200 deaths from CRC, of which 3,640 are deaths in patients under the age of 50. One of them, Chadwick Boseman, recently brought the spotlight on the rising incidence of CRC in young people. So I want to take a moment in memory of all the lives we have lost. And also to thank the healthcare workers, oncologists, surgeons, radiation oncologists, GI doctors, nurses and all the support staff for everything that you’ve done, that you do on a regular basis, to save and extend the lives of people affected by colorectal cancer.

Manju George  2:08 
First thing on my on my list today is this, which is the lowering of the CRC screening age.

Manju George  2:14 
Recently, USPSTF issue draft guidelines to reduce the CRC screening age from 50 to 45. In my mind, this is the most or the single significant development from 2020 which when finalized has the potential to save a lot of lives from colorectal cancer.

Manju George 2:39 
The second one on my list, the second item on my list is the result of the IDEA CRC trial, which is, less is more for the duration of adjuvant chemotherapy.

Manju George 2:49 
The results from this trial was presented at ASCO earlier this year. And the take-home message is that for the vast majority of stage III colorectal cancer patients, three months of adjuvant chemo, about four cycles of CAPOX, is recommended. What does it mean for patients? It means that patients have a more proactive role and are part of the collaborative decision-making with their care team to find the duration of adjuvant chemotherapy that fits their tumor and needs. It also means that for patients with a shorter duration of adjuvant chemotherapy, there are lower chances of long-term neuropathy. What we also find among patient groups is an increased awareness and interest in tests that differentiate high risk versus low risk tumors. For example, immunoscore, ctDNA, liquid biopsy, etc.

Manju George  3:44 
The third item in my list is ctDNA tests for minimal residual disease.  Dr. John Marshall called ctDNA tumor trash in your bloodstream. It looks like in 2020, these ctDNA tests are becoming more mainstream.

Manju George  3:58 
Here I give an example of Signatera, which is a test for minimal residual disease. And they use a personalized and tumor-informed approach where the tumors are sequenced to identify a unique signature of tumor mutations. And then based on this, they design a custom assay for each patient and it targets up to 16 mutations found in the tumor. And using this personalized assay, they test the patient’s blood for the presence of circulating tumor DNA. There is a lot of interest among patients with respect to these tests, and my hope is that in the coming years MRD testing based on ctDNA becomes standard of care. There are a couple of ongoing trials and many plans to test the utility of ctDNA as a predictive biomarker.

Manju George  4:49 
The next item in my list is rectal cancer. The trend in 2020 is more towards total neoadjuvant therapy and non-operative management.

Manju George 4:59 
So, for locally advanced rectal cancer, it seems that now therapy has become more personalized. The three different modes of treatment that make up the treatment for rectal cancer are radiotherapy, systemic chemotherapy and we will being seeing more customizable and it seems to be able to be more personalized depending on the patient, the patient’s tumor and preferences where possible. So again, this means that there’s a lot of collaborative decision-making between the patient, the care team of radiation oncologists, oncologists, and surgeons, and it seems that the trend is more towards organ preservation. So there is a lot more focus on quality of life. What patients want now is, in order to be effective in collaborative decision-making, patients need to be informed and patient and caregiver support communities like Colontown can play a big role in educating patients. The other thing, with the increasing rates of rectal cancer, we need a lot more to be done towards side effect management. For example, the bowel, urinary,  and sexual dysfunction that can result because of treatment has major implications for quality of life.

Manju George  6:19 
The last item on my list is the availability of more treatment options. Through the fear, COVID has had a lot of ill effects on healthcare and biomedical research. With respect to colorectal cancer.

Manju George  6:32 
We have had some new and improved therapy options possible this year. For example, for MSI-high colorectal cancer, which is like about 4% of our metastatic MSI-high colorectal cancer which is about 4% of all stage IV CRC. Immunotherapy is now approved as first-line therapy. And then the BRAF V600E mutant colorectal cancer is about 10% of all CRC and at ESMO this year, new results were presented of a trial of targeted therapy plus immunotherapy which is being done at MGH. And this offers a lot of promise. Variations of this trial is now being run at MD Anderson and UCSF. The other trial that is garnering a lot of discussion in the patient community is the second line FOLFIRI plus Bevacizumab plus Onvansertib trial. This is for KRAS-mutated MSS CRC patients, but it seems too early to decide one way or another. Looking at all the discussion that is going on in the patient communities, it looks like people are pinning a lot of hope on this trial.

Manju George  7:50 
With that, thank you so much for listening and happy holidays.