John L. Marshall, MD; Mohamed E. Salem, MD; and Monica Chacha, RN, describe the role and use of Stivarga (regorafenib) as a treatment option for patients with colorectal cancer.
PUBLISHED September 22, 2016
John L. Marshall, MD: So, your physician has now recommended Stivarga, or regorafenib, for the treatment of metastatic colon cancer—for your disease—and it’s a little different. It works as a targeted drug. Cancers have broken genes and it’s like somebody has gone into the fuse box and mucked with the switches. Well, what this medicine does is go in and tries to restore those switches so the cells behave more normally; so-called targeted therapy. But, just because it’s oral and just because it’s fancy targeted therapy doesn’t mean it doesn’t have side effects. This medicine does have some side effects on the hands and on the feet, and there can be some fatigue. We’re all debating about what the exact right dose is. You’ll have a discussion with your physician about the standard dose, and maybe some different doses to try and reduce some of these side effects.
Now, most of the time, patients are really focused on their CEA (carcinoembryonic antigen) levels and the size of their cancer. They want to see it get smaller. They want a reduction. They want the CEA to fall. But, the reality is after that initial chemotherapy, we often don’t see much reduction and our real goal becomes one of stabilization. And that’s what this medicine can do. It can stabilize the cancer, keep it from growing in about 40% to 50% of patients, and about 1 in 5 of you will have stabilization of your cancer for a half a year or more. So, we are seeking to control the cancer, keep it from growing, keep your quality of life high by appropriately dosing this and, of course, extending your survival so you can make it to that next event in your life.
We know this patient a lot. You’ve talked to them a thousand times, right? You know their families, kids, all of that. We have a sense of their social support. So, now we have come to the next decision. We’ve got two agents in the refractory setting. We have TAS-102 and we have regorafenib. How do you go about picking the patient, who’s the right one for what drug?
Mohamed E. Salem, MD: As you mentioned, after a while, patients become part of your own family and you become part of their own family. And you know them very well. You even start to know their life, their kids, their wife, and vice versa. One of the important benefits of that is that you can tell what’s important for them even without them saying that. As a clinician, one thing you want to make sure, aside from ‘Yes, your drug will work,’ is to make sure the side effects fits their lifestyle profile, especially in that kind of stage. They’re refractory, so they already received a rough treatment, as you mentioned. For example, if I have somebody who likes to play guitar, I might choose not to give him Stivarga because of the hand-foot syndrome that affects his lifestyle. I had a patient who actually was going to play in a concert, and that was a determining factor. If somebody kept having infection one after the other and had a low white-cell count or platelet count, I might shy away from using Lonsurf, because of the count problem. So, you have to tailor your therapy to what fits really for that patient. In my opinion, I think colon cancer is a family name. I always think of every individual person as like a son and daughter, we share the same family. But, it’s different in its own character.
John L. Marshall, MD: I know, Monica, you have a lot of experience with both these drugs, managing it from the nursing side. Are there issues that distinguish where one patient you think might be better on Lonsurf, or one patient might be better with Stivarga?
Monica Chacha, RN: I think it’s like Dr. Salem said, a lot of times it comes down to side effects.
So, for many of you, this might be the first time that you are taking an oral drug. You’re about to start Stivarga, or regorafenib. You might be used to coming in to the infusion center every week. The nurse is there, she gives you your medication, and you go home. This is going to be different, because now it’s on your terms. You’re at home. Are you remembering to take your pills? It’s all in your court now. So, there are a couple of key tips that are really important to remember. Try to take the medication at the same time every day. Some people might take it in the morning with a low-fat breakfast. Sometimes doctors might even recommend that you take it after dinner, and that’s okay, too. Another thing is that there might be some side effects of medications. It might be something different than you’ve had before. You might be experiencing some nausea, some vomiting. You might also start to notice that your hands have some redness, some dryness, or some soreness. Those are common side effects of the medication, but just because those are common side effects, we still want you to be telling us. I tell my patients every time as soon as they start this medication, I want them to over-communicate rather than under-communicate. Even if they think it’s something small and insignificant, I want them at least to shoot me an e-mail and tell me about it. That way I can tell them, don’t worry about it, it’s fine. Because sometimes it’s the small things that if we stop them early, then it can prevent complications later on.