Multidisciplinary Team Essential to Management of Patients With mCRC

Drawing on providers in other specialties at one’s clinic is a must when caring for patients with metastatic colorectal cancer in the third and later lines of therapy, explained Emily Shelby, MSN, FNP-C.

After moderating a Case-Based Roundtable, Shelby emphasized in an interview with Oncology Nursing News that because adverse effects (AEs) can become obstacles to treatment for this patient population, referrals to specialties like cardiology, dermatology, and nutrition can help patients stay on treatment.

Standard treatments recommended by NCCN Guidelines for this setting include fruquintinib (Fruzaqla), regorafenib (Stivarga), and trifluridine with tipiracil (together, TAS-102; Lonsurf) with or without bevacizumab (Avastin). These treatments can be accompanied by an onslaught of symptoms such as diarrhea, fatigue, dermatitis, and hypertension.

In many cases, it may be unclear whether the patient’s advanced disease or their treatment regimen is the cause of the symptom. For this reason, Shelby explained, it is imperative to take advantage of whatever resources a clinic has to better understand the patient’s symptoms.

Participants largely indicated that AEs were prohibitive to optimized treatment in the third and later lines of therapy. How can APPs better care for patients with colorectal cancer struggling with AEs in later lines of therapy?

It is challenging in this setting. We’re seeing patients who are heavily pretreated to this point. Is the patient experiencing AEs because of the treatment, or is it symptoms of the cancer itself and deconditioning to this point? Resources are a huge plus. One of the participants…has a specific onco-dermatology clinic. For patients who have rash as an AE that is very inhibitive of their progress on a treatment regimen, reaching out to the resources available and finding out how they would treat it and how they would manage [is helpful]. Diarrhea and fatigue are also hard to manage because [we don’t know if] it comes from the cancer treatment or from the cancer itself. Again, we heavily rely on our resources and our GI specialist friends to help guide what the actual cause is and be able to fine-tune our treatment plan.

How should patients with advanced colorectal cancer be managed and monitored when receiving TAS-102?

We screen for myelosuppression at the beginning of every cycle across the board. If indicated or if we have concerns, we’ll bring patients back sooner and do a mid-cycle check. But my approach is: what cytopenia are they experiencing? If it’s multifactorial, if they have more than 1 line, what degree is it? Looking at the CTCAE [Common Terminology Criteria for Adverse Events] grading, is it 1, 2, or 3? Do I need to delay treatment, or do I need to dose reduce? Can I continue? Typically, my approach would be, if it’s a grade 2 single cytopenia, then dose reduce and proceed. If they’re pancytopenic, then we’re going to hold treatment, delay it for a week or 2, and then bring them back, recheck their counts, and talk about modifying the dose at that point.

What AEs should be expected in patients with mCRC receiving fruquintinib?

With fruquintinib, the biggest AE that I’ve seen in real-world practice is hypertension, which, across the board, is the general consensus: hypertension and fatigue. You have to get patients on a good regimen of anti-hypertensives. It comes down to resources, resources, resources. We heavily involve our cardio-oncology team to help us manage hypertension, especially on patients who already have a list of comorbidities or a list of medications they’re taking, to help maximize their treatment so that we can continue on a very constant regimen. With fruquintinib, we see a lot of dose reductions due to fatigue.

When should providers refer to cardiology for patients receiving fruquintinib?

We involve them as soon as patients have that first complaint. We’re much more likely to refer patients at onset than to try to manage it ourselves and bring cardiology in after onset. That could change between the severity of the complaint. Are we going to do an e-consult and reach out to our cardio-oncology colleagues to get advice, or do a formal referral where they can take over the management of that specific concern?

What are the key AEs providers see with patients receiving regorafenib?

With regorafenib, the number 1 complaint is fatigue…. It’s essential that they’re doing the most they can to keep their nutrition up, trying to stay as active as they can within reason. Here, again, dose modifications or even treatment schedule modifications may help them tolerate that a little bit easier.

Is it appropriate in this setting to refer patients to nutritionists?

Yes, we again go back to our resources. …We have a wonderful supportive care team here that we involve the beginning with our patients with metastatic disease. As the cancer progresses, it’s a very common theme to see the nutrition status of an individual drop, so the nutritionist is already involved, and it’s just a matter of them calling them to help walk through what they could do differently or foods that might be a little bit more palatable while undergoing treatment.

This transcript has been edited for clarity and conciseness.