John L. Marshall, MD: Your physician has just recommended to you, Lonsurf, or TAS-102, as we call it. This is an oral medicine and it is a new kind of chemotherapy. It’s kind of a cousin of the 5-FU, or Xeloda/capecitabine, that you had before, but it is different. It’s oral, which is nice. It frees you up from having to come to the infusion unit, although you’ll miss all the team down there. You’ll get a break from all of that and coming back week in, week out. You take it in an unusual schedule. You take it for 5 days in a row and take 2 days off, and then another 5 days in a row and then another 2 days off. And then, we give you 2 weeks off for good behavior. Now, you’ll feel pretty well. Most patients do while they take this medicine. A few people will get some nausea and some GI (gastrointestinal) upset, so don’t be surprised if you get a little of that, but most people can control that with our good anti-nausea medicines.
So, most folks feel pretty well, but the problem with this medicine is it drops your blood counts. Maybe up to this point you haven’t really had a super-low blood count or had to come into the hospital because of fever and worrying about a low blood count. This does this with this medicine. Your counts can go below where it’s safe and you can’t fight off an infection. Be real sensitive, not hyper, not crazy about your temperature. If you feel sick, if you feel your temperature go up—always in the afternoon, by the way—take your temperature. If it’s over 100.5, call us, whoever your team is, and tell them. They’ll probably have you come to the emergency room to have that checked to make sure that you have enough white cells to fight this off. Now, most folks don’t have that temperature, but you might come back to begin the second round of the treatment and find that your counts are too low to start. Don’t be surprised if you have to delay an extra week. Or sometimes physicians like to give growth factor shots that boost your immune system and your white cells, so that they don’t go down quite so low or stay down so low.
This medicine controls the growth of cancer in a high proportion of patients. It has a fairly low side effect profile, except for this mild nausea and the low blood counts. And your physician’s recommended it to you in the hopes of extending your survival and having your quality of life remain high, so you can make it to that next important 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 come to the next decision. We’ve got two agents in refractory setting. We have TAS-102 and we have regorafenib. How do you go about picking a 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 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, you’re about to start the medication called Lonsurf, and this might be something totally new and different for you. You’re used to going to the infusion center. The nurse gives you your medication, you go home. But, now you’re at home, you have these pills. It’s all in your hands, and this medication is a little bit hard with the dosing. You take it 5 days on, 2 days off, 5 days on, 2 days off, and then 2 weeks off. So, I want you to make sure that you write down the days when you’re supposed to take the medication and at what time. You’re going to take tablets in the morning and at night, so make sure that you remember the dosing. Another important thing is sometimes it’s hard to remember. If you don’t know if you took a dose, don’t take it again. That’s really important. You don’t want to double dose on the medication. Something else is that you might be experiencing some side effects: a little bit of nausea, some vomiting. If you have any of that, those are side effects, but it’s important to communicate those to your care team. The really, really important thing that I want you to remember with this medication is if you have a fever—and I tell my patients 100.4 or greater—I either need you to call us right away or just go right to the emergency room. Because if your white cells are low, you might be at risk for infection and you might need some IV antibiotics.