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Colorectal cancer is the second most common cancer in Poland. Despite very experienced surgical centers, the group of patients in whom the 3-line treatment has not worked, has no chance of a cure. We are talking about it with Prof. Piotr Wysocki, President of the Polish Society of Clinical Oncology.
Joanna Lewandowska: How often do Poles suffer from colorectal cancer? What are its symptoms?
Prof. dr hab. n. med. Piotr Wysocki: The most recent data from the National Cancer Registry, which we have at our disposal, from 2013, indicate that colorectal cancer was diagnosed in 9500 men and 7900 women. At the same time, in the same year there were 6200 deaths among men and 5000 deaths among women due to this cancer.
When summed up, it gives a huge number – less than 17 thousand. cases and 11 thousand. deaths, which, from the point of view of epidemiology, ranks colorectal cancer in second place after lung cancer.
The symptoms of colon cancer are closely related to where the cancer is located. If it is located more near the end of the large intestine, i.e. the left half of the colon, sigmoid colon or rectum, the symptoms appear relatively early and may be related to defecation disorders (recurrent constipation, diarrhea), the presence of fresh blood in the stool. On the other hand, the lesions located in the right part of the intestine give less characteristic symptoms, most often pain, anemia or lack of appetite. Unfortunately, the symptoms most often appear when the disease is already advanced, because at an early stage, colorectal cancer causes virtually no discomfort. That is why screening tests such as colonoscopy are so important.
What can be done to reduce the risk of colon cancer?
Colonoscopy, or endoscopic examination of the large intestine, is an examination that allows the detection and removal of changes (polyps) that may become malignant in the next few years and give rise to colorectal cancer. It is currently known that such measures contribute to the reduction of the risk of colorectal cancer. According to the current guidelines, colonoscopy should be performed in all people over 50 years of age, and in the case of people whose relatives have had colorectal cancer, much earlier.
What is the prognosis depending on the stage of the disease?
The prognosis is strictly dependent on the stage of the neoplastic process. Is it located only in the intestinal wall, are the cancer cells already in the lymph nodes outside the intestine, or are there distant metastases (cancerous tumors in other locations – e.g. liver, lungs, bones)? In the case of patients whose tumor is confined to the intestine – 5-80% of patients survive 100 years, in the case of lymph node involvement – 30-60%, in the case of distant metastases – only every 5th patient has a chance to survive for 20 years.
What are the treatment options for patients with colorectal cancer in Poland?
The basic form of treatment is surgery to remove a fragment of the intestine with the tumor and surrounding tissues. Sometimes, in the case of rectal cancer, surgery is preceded by radiation therapy. After surgery, depending on the tumor advancement determined on the basis of microscopic examination, adjuvant chemotherapy is usually administered for six months to reduce the risk of disease recurrence. In patients with distant metastases (in other organs), chemotherapy is the primary treatment. In some patients with liver metastases, there is a chance of radical surgical treatment, often in conjunction with preoperative chemotherapy, which reduces the metastases and allows the surgeon to completely remove them. In this case, the patient has a potential for complete recovery despite the presence of distant metastases.
In the case of patients with a generalized neoplastic process (multiple metastases in different locations), apart from the possibilities of radical surgical treatment, palliative chemotherapy is the only treatment option. Palliative chemotherapy is aimed at maximizing the patient’s life and maintaining an optimal quality of life. Therefore, this treatment is chronic and is based on the successive use of various chemotherapy regimens (combinations of oncological drugs). The progress in the treatment options for patients with generalized colorectal cancer is based primarily on new drugs that have been introduced into clinical practice over the last 10 years. Compared to Western European countries, not all modern drugs are reimbursed in Poland, and in some cases reimbursement significantly reduces the possibility of their use. For example – the so-called targeted drugs (monoclonal antibodies), which for some patients should be used (in accordance with European recommendations) in the first stage of palliative chemotherapy, are only available in Poland at the 2nd or 3rd stage of treatment. Unfortunately, such restrictions mean that some patients with very aggressive colorectal cancer will not receive these drugs at all, and others who could potentially be completely cured (surgical removal of metastases from the liver after aggressive preoperative chemotherapy) will not get such a chance. .
Is there a therapeutic option for patients who have exhausted all available treatment options in Poland?
In Poland, in the vast majority of chemotherapy centers for patients with generalized colorectal cancer, the treatment of metastatic disease ends with 3 lines of systemic treatment.
Experienced centers try to use different, less standard chemotherapy regimens in subsequent lines of treatment, but such treatment is usually not effective. Some patients in Poland sometimes have the opportunity to participate in clinical trials evaluating new, promising drugs, which may become the standard of care for colorectal cancer in the future, but we are talking about it only in 2-3% of patients.
At the moment, two drugs are registered in Europe that can be used as part of the 4 and 5-line treatment, after the therapeutic options currently available in Poland are exhausted. In the case of regorafenib, a targeted anti-angiogenic drug, registered over 3 years ago, the Agency for Health Technology Assessment and Tariffication (AOTMiT), after taking into account pharmacoeconomic aspects, issued a negative recommendation regarding the legitimacy of its reimbursement. In April this year. In Europe, a new chemotherapeutic drug has been registered, consisting of a combination of two chemotherapeutic drugs, trifluridine and tipiracil, used in tablet form, which appears to be a drug with a relatively higher activity than regorafenib – its use is associated with a 32% reduction in the risk of death (23% for regorafenib) . We are currently waiting for the evaluation of this new preparation by AOTMiT.
Undoubtedly, access to new chemotherapeutic drugs would significantly improve the treatment options for patients with generalized colorectal cancer who have exhausted all standard forms of chemotherapy available in Poland. Thanks to better and better methods of supportive treatment, optimal therapy and nutrition, chemotherapy does not deteriorate the patients’ quality of life and their condition. Therefore, patients who have used standard methods of oncological treatment are often people in a very good condition, who want to live and fight the disease. For them, the awareness of the lack of reimbursement of effective oncological drugs is a huge tragedy and is like a sentence. As oncologists, we try to constantly improve the effectiveness and safety of our treatment, including by optimizing and making better use of standard forms of treatment and increasing the availability of clinical trials, but knowing how much the lack of reimbursement for new drugs makes it difficult for us to effectively and long-term treatment of our patients is very frustrating.
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