John L. Marshall, MD: So, your physician has just recommended to you, Stivarga, or regorafenib, for the treatment of metastatic colon cancer. And I want to just share with you how we handle that here at Georgetown’s Lombardi Comprehensive Cancer Center. Dr. Salem, when you make this recommendation, what do you tell a patient when they’re just setting out on this treatment?
Mohamed E. Salem, MD: The first thing we ask them is, “Okay, how many pills you should take?”, and it depends on the dose, whether we decided on two, three, or even four pills. If that was the decision, we tell them take it after food. But, I also go over the side effects a little bit in detail to warn them or inform them of hypertension, hand-foot syndrome, diarrhea, and fatigue.
John L. Marshall, MD: What’s hand-foot syndrome?
Mohamed E. Salem, MD: We describe it as more soreness of the hand and foot. Sometimes it is like calluses, if you will.
John L. Marshall, MD: They get tender. They have trouble opening bottles, things like that.
Mohamed E. Salem, MD: I hope it doesn’t get to that point. But, really what I tell patients is it is your job not to figure out what is going on or what’s causing it. Your job is to report to me and my team how you feel. We’ll take it from there, and hopefully find out the reason and solution. And I always encourage them to call us any time, any moment if you feel anything wrong with them.
John L. Marshall, MD: So, to be very clear, the standard dose is four pills a day, every day, but the doctor might recommend 3 or might even recommend 2 pills every day. And then, you’re going to see that patient back in 1 week and some blood tests will be drawn. The doctor will want to look at your hands and ask you how you’re doing. Keep a journal. Keep track of how you’re feeling.
Mohamed E. Salem, MD: I think that’s a good idea, because sometimes patients forget and doctor can also. Sometimes you need to see this information to make an adjustment.
John L. Marshall, MD: Monica, what are key things that a brand new patient needs to know when they’re starting out on Stivarga?
Monica Chacha, RN: I usually go over a couple of things. I like it a lot when there’s a family member or a friend in the room because this is going to be somebody that helps keep you on track. It’s a lot of information to remember at once. This can be your go-to person. So, we’re going to go over side effects more in depth, things to look for. If you’re having nausea, if your hands begin to be red, dry, cracked, anything like that, then they need to absolutely let me know as soon as that happens so we can stop it before it gets worse.
John L. Marshall, MD: So, don’t wait for that week appointment. Call you, e-mail you…
Monica Chacha, RN: The day of.
John L. Marshall, MD: The day of, okay. Because we might hold the drug on that day.
Monica Chacha, RN: Right, right. And, then, another thing that I talk to them about is pharmacy. A lot of times these types of medications are going to come through a specialty pharmacy, so that’s going to be different. You’re not going to go across the street and pick it up. It’s going to come in the mail. And, then, another thing is maybe they’ve not been on these oral therapies before. Maybe they’re used to IV drugs, so this is going to be up to them to remember to take their medicine. There’s not going to be an infusion nurse there.
John L. Marshall, MD: Yes. So, that’s a really important point about the drugs may not come. We’re used to writing a prescription and going to get it that night. Unlikely, right? It’s going to be a few days. And, so, we as healthcare providers need to keep track of that as well. Any other key issues you want to add?
Mohamed E. Salem, MD: Yes. If you take a large medication, you sometimes forget if you did or did not take the medicine. And I always warn my patients, if you have that doubt, don’t take it, because you might double up on the dose. If you vomited or something, you also don’t take it again.
John L. Marshall, MD: This drug is very sensitive to light, so it comes in a special bottle. You only get about a 1-month supply at a time and a 1-week supply is in each bottle. I think that is the way it’s provided. Check the dose. Make sure you’re clear with your doctor. Check the schedule. You should have an appointment about 1 week after starting. It may take a little while for the drug to come. Watch for that first week around your hands, nausea, diarrhea, and rash. Report right away if something is going wrong. Don’t wait till that next visit. Good secret, good plan to make sure that Stivarga, or regorafenib, has the best chance of working for you.