Supportive Care to Improve Results in Colorectal Cancer Care

In the inaugural event of the Global Cancer Movement, initiated by OncoDaily, Matti Aapro, a renowned medical oncologist, highlights the vital role of supportive care in colorectal cancer management. The virtual event, held from December 6-8, 2024, brought together leading experts to discuss comprehensive strategies aimed at improving patient outcomes and quality of life.

I’m Matti Aapro, I’m a medical oncologist, I’m based in Genolier in Switzerland. I do have a few functions in different associations and I was joining this initiative after discussion with Gabor, thank you very much Gabor for getting me on, with the idea that we need to, in view of all the fantastic discussions that are going to happen in the next three days, not forget that everything we do, we do it for a patient and the patients besides the fact that he or she needs the best possible treatment and before that of course early detection and after the treatment and the right support, during the treatment the patient is going to need a lot of help and this help I call it supportive care. So let me move now to slide number three, if I have control here.

You guys have control, so can you move me to slide number three? These are my conflicts of interest, they have to be shown and now we have shown them, thank you very much. Next one is the one on my comment on the asthma and ASCO involvement in colorectal cancer supportive care.

Next slide please, just below the screen, there we go. I looked at asthma GI in 2024. In 2023 I was invited to the asthma GI and I gave a talk on control of some side effects of treatment and in 2024 they probably believed that that was enough and no one was invited to talk about supportive care.

At ASCO GI there was a specific session called supportive care in colorectal cancer, next slide please, but this session, if you look at it, it’s a one-hour session with four speakers each having 10 minutes to speak about topics that should certainly need at least half an hour if not more for each and it’s not only about supportive care, it’s also some other important issues like fertility and sexual health after a diagnosis of colorectal cancer, a major issue for many of our patients and don’t think only for the younger patients, also for the older patients and there’s a lot that needs to be discussed, but at least complements to ASCO GI for having this important session in the program this year, next slide please.

Supportive care has been put forward by MASSC, the Multinational Association of Supportive Care in Cancer, MASSC, makes excellent cancer care possible and this is the picture that I was allowed to use of Dorothy Keith, the past MASSC president, who probably was the one who really pushed this motto of MASSC forward, next slide please.

What does MASCC say about supportive care? Well, of course, alleviate symptoms and complication, reduce and prevent toxicities, improve communications and a very important point, it’s so often forgotten, was already highlighted earlier by the speakers, communication with the patients and bottom line, which I’m not going to be able to talk about, to discuss about the emotional burden, the psychological issues, and the social issues alluded to, for example, by Andrei Labaoui just a few minutes ago in this plea for universal health coverage, which is a problem in so, so many countries, blocking access to care because patients cannot afford it, next slide please.

So, this was, I was highlighting to you, next slide, this I would like to have, I would have liked to show to you early palliative care and colorectal cancer survival. I didn’t find anything about that, maybe I missed it, maybe there’s something, apologies to the author of that paper if I missed that, but we do know and the prime example that everyone uses is the one of Jennifer Temple, published in New England Journal of Medicine 2010, so this is almost 15 years ago, on the study where she showed that indeed giving early, she called palliative care, I call it supportive care to patients, made a difference.

If you look at the curve here on the difference, it’s quite impressive, we say how, this is immunotherapy, no it’s not, it’s supportive care, next slide. I just said supportive care, palliative care, questions of terminology at the European Society of Medical Oncology, we discuss it at length and there’s a paper by Karen Jordan in Amnesty Oncology 2017 to stop this discussion.

Whatever you say, the important point is that we are trying to help a patient at one or another point of the patient’s journey, so call it supportive at the beginning, palliative at the end, or palliative somewhere, doesn’t matter, the important is to help patients, this is what this is all about, next slide please.

Then we talked today about open access, OncoDaily is here with open access, and then I went to prepare this talk to look at various items that I could find in this cloud, in the internet, and I hit excellent material from the Canadian Cancer Society, and once again, and it’s my frustration, I hit the fact on the right hand side of the slide, you see, well actually you shouldn’t be accessing this site because you are not in Canada, oh come on, we are in 2024, what are you protecting?

What’s wrong if someone from, oh god, Switzerland wants to see what does the Canadian Cancer Society say? So sorry, but really I have to say this, this is something we have to correct in the future, because it’s not only about me as a professional, it’s about patients, patients that want to see what do the Canadians say, would like to see what the Canadians say, and they are blocked, for what reason in the world?

Next slide please, next slide, can you move forward, thank you, oops, don’t come back, okay, nutrition, nutrition, nutrition, nutrition, one of the items that is still today neglected in so many areas in the world, fortunately not by many surgeons, surgeons nowadays start to pay attention to nutrition, next slide please, and we do have excellent guidelines that take into account also the issues of colorectal cancer, especially by ASPEN, as you can see there are two major guidelines that we have in the European scenario, of course there are fantastic guidelines elsewhere in the world, those are the ESMO guidelines, the ASPEN guidelines on nutrition, and the importance of rehabilitation for surgical colorectal cancer, which is so important, of course if the patient has a major issue and needs immediate surgery, as unfortunately we know, as Andrei Labaoui said, sometimes they present in emergency cases

But even in emergency, there are data to say that you can do without surgery, you can prepare the patient, you can use colonoscopy to open the area where there’s the blockade, and then prepare the patient for surgery rather than doing it immediately, this is something we need to discuss, and in the meanwhile start nutrition of often undernourished patients that present to you, next slide please, and continue this during the treatment, whichever it is, next slide, one of the iron, one of the issues with our colorectal cancer patients is, as you all know, that anemia is a common issue in these patients

And sometimes they are really deeply anemic, and this can have profound effects on tolerability of chemotherapy, on the efficacy of radiation therapy, because of the oxygen transportation of red blood cells, which is need the oxygen effect in radiation oncology, and certainly patients that are anemic and are under an operation, and that stress, I’m not going to do better than those that are not anemic, so of course in the acute settings, blood transfusion is to be used, please be careful, it’s not as safe as one believes, even today with all the teams, and then when needed, please follow guidelines

I’m putting of course forward the European guidelines on the use of iron in this setting, on the use of erythropoietins in this setting, the guidelines are there, don’t neglect them, I see too often patients who are anemic, because they were anemic, so who cares, and then lo and behold, for example, they have with chemotherapy, much higher toxicity than that should happen, next slide please.

Another issue with chemotherapy, and some associations with the new drugs, is febrile neutropenia, for this, once again, we do have the evidence that allows us, next slide, to use correctly, depending on the impact of the treatment on the white blood cell lineage, the growth factors, and this is nothing new, there were guidelines from URTC and from ASCO in 2010, since then, updated and re-updated, and the latest ones have to be updated again, because there are a couple of new agents coming forward, but which are not widely available yet, next slide please.

And this is a picture that was given by Professor Jean-Jacques Baudy, a long time ago, an expert of the bone metabolism, also in cancer patients, and we have to mention this point in supportive care, next slide, often neglected issue, and again, I have seen patients having fractures, when they were cured from the colorectal cancer, no one had thought, oh, this person who has a certain age might have osteoporosis, especially when it’s a male patient, you never think of osteoporosis in a male patient, do you? Well, male patients can have osteoporosis, there’s no doubt about that, so please screen for that, please look at this, it’s easy to do, it’s simple, and there are, again, guidelines on what to do, ASMO is going to update these guidelines very soon, there’s going to be a couple of changes, but we are not going to be really that fundamental compared to the ones which are available today, next slide.

The wording that you have on the slide about the importance of vitamin D, the importance of doing something about osteoporosis, when there is osteoporosis, comes from a fantastic paper which was published recently by Barzi and colleagues, and I have the reference here, and this is freely downloadable for you, if you have time to delve into this, or then you rely on your friends and colleagues who are experts of osteopenia and osteoporosis, next slide, please.

An issue that everyone talks about is, of course, nausea and vomiting, I’m not going to discuss about the nausea and vomiting related to the obstruction, this is actually discussed in the MASCC-ASMO guidelines, we do have some guidelines on how to treat the patients who are in an obstructive state, and what to do there, so you can give a look at that in these guidelines, but for chemotherapy, next slide, we do have now updated guidelines.

An important point for those that treat colorectal cancer is that we do have evidence today, it’s level one evidence that oxaliplatin in female patients beyond the age of 50, that’s the study which says that there is a need for triple association of anti-emetic agents, because these women suffer from a high risk of nausea and vomiting, this is not true in other settings, don’t abuse about anti-emetics, but please follow the guidelines, there are other excellent guidelines also from ASCO, and maybe also from several countries, but usually have taken into account the ASCO or the MASCC-ASMO guidelines, next slide, this is about acute, this is about the delayed phase

I’m not going to insist on this, but just to tell you that we do have guidelines, apply guidelines, we have evidence, there have been several studies that have shown that non-application of guidelines leads to more than 10% decrease of the complete response, so 10% of patients have nausea and vomiting because people don’t follow guidelines, whereas they could have been avoided if they followed the guidelines, next slide, please.

Diarrhea is a frequent problem, as you know, in the setting colorectal cancer, already the alternation between constipation and diarrhea is a signal that we should never forget, unfortunately forgotten quite often, then diarrhea for many reasons can happen with GI tract cancer surgeries, there’s a lot discussed in this fantastic guideline of ASMO, once again, guidelines are there to help you with supportive care, next slide, please.

After the treatment, we need to help and support patients, there are many issues, for example, with ostomies with these patients, there was a very nice review published very recently by Angela Jew and colleagues, which unfortunately comes to the bottom line that you can see on the slide, the data, the quality of the data on what to do for these patients is not very high, there are lots of ideas, but the final good way to approach these patients, it seems not to be out there, so we need more work for these patients for the quality of life after the treatments that we give them, next slide, please.

Lots of guidelines, those of MASCC-ASMO and of ASMO, next slide, for those that speak French, we do have guidelines in French from AFSOS, but we also have fantastic guidelines from the Chinese Anti-Cancer Association in Chinese, we have them in German, we have them in Spanish, in Italian, in so many languages, as long as they are evidence-based, that is important, that’s crucial, next slide, please.

But yes, there is a problem, sorry for this little typo, if our patients go to the web, to the cloud, use the internet, whichever search engine they use, they are going to hit lots of interesting suggestions, potentially dangerous, we have to understand this, this is part of supportive care, to tell patients, please talk to me if you need help, please, I will listen to you, next slide, please. I’m ready to discuss with you all kinds of other treatments, but please talk to them about me, because they might not be the ones that are really going to help you.

So, let’s take our time, I know how difficult it is in many countries where you are overburdened with the patient load, and you have so little time, but please guide our patients for a better treatment, and not to follow those that have interesting ideas, which have no proof, and some of them are really dangerous, next slide, please, is to tell that there is a fantastic chapter of the ASCO Educational Book of 2003 around this topic, next slide, is to invite everyone to the MASCC, Multitasking Association Supportive Care and Cancer Meeting in Seattle in 2025, and finally, thank you very much.