PRACTICE GUIDELINES

Opportunities and challenges in oncology and molecular testing: the Belgian strategy

Summary

Molecular diagnostics in cancer aiming at improving diagnosis, prognosis and treatment are constantly exposed to new opportunities and challenges. The Belgian Commission of Personalised Medicine (ComPer-Med) has been created to advise the Federal Government on all matters related to personalised medicine in oncology, including the reimbursement of molecular tests. Here, we propose the Belgian strategy for molecular testing within a scientific based framework and its implementation in the Belgian healthcare system. For each tested biomarker a clinical test level is attached, which is key to establish the relevance of the test and to define the reimbursement.

(BELG J MED ONCOL 2018;12(2):46–50)

Prevention of chemotherapy-induced nausea and vomiting: Belgian antiemetic treatment options anno 2018

Summary

Chemotherapy-induced nausea and vomiting remains an important adverse effect of treatment in daily clinical practice. Recently, new data on combinations of antiemetic agents became available for the prevention of acute and delayed nausea/vomiting in patients receiving highly and moderately emetogenic chemotherapy. As a result, the leading international cancer societies updated their antiemesis guidelines. This text aims at providing guidance regarding these new regimens in the prophylaxis of chemotherapy-induced nausea and vomiting, with a particular focus on highly emetogenic chemotherapy.

(BELG J MED ONCOL 2018;12(2):51–60)

Second-line treatment of non-small cell lung cancer adenocarcinoma patients not harbouring an oncogene driver mutation anno 2017–2018: A consensus group meeting

Summary

The treatment landscape for patients with advanced non-small cell lung cancer, who do not harbour an oncogenic driver abnormality, has changed dramatically over the last years. Second-generation antiangiogenic agents, such as nintedanib and ramucirumab, and particularly PD-1/PD-L1 inhibitors, such as nivolumab, pembrolizumab and atezolizumab have shown to prolong survival in pretreated non-small cell lung cancer patients. Immune checkpoint inhibition in the treatment of advanced non-small cell lung cancer comes with the promise of durable responses in responding patients. Nevertheless, one must appreciate that the average response rate seen with these PD-1/PD-L1 targeting agents is only about 20%. While PD-L1 testing may be used as an enrichment biomarker, a substantial proportion of patients still do not benefit from these agents. They could benefit from alternative therapeutic options, including novel anti-angiogenic agents. In this paper, a treatment algorithm is proposed that aims to optimise the second-line treatment choice for patients with lung adenocarcinoma, based on the available clinical data.

(BELG J MED ONCOL 2018;12(2):61–66)

Systemic chemotherapy regimens in early breast cancer patients: updated recommendations from the BSMO breast cancer task force

SUMMARY

Since the publication from the Belgian Society of Medical Oncology breast cancer task force in 2014 in the Belgian Journal of Medical Oncology, new information has become available on optimal chemotherapy regimens for early breast cancer patients. On February 24^th, 2017, 37 medical oncologists involved in breast cancer management reviewed the most important scientific data on this topic. The authors of this paper summarised the findings, and sent a questionnaire to the members asking for their input. This paper summarises the consensus of this exercise.

(BELG J MED ONCOL 2017;11(8):375–379)

The ION-Ghent guidelines for the management of immune related adverse events (irAE’s)

SUMMARY

Checkpoint inhibitors targeting CTLA4, PD1 and PD-L1 have become a part of the daily clinical practice in the management of stage IV melanoma, renal cell carcinoma (RCC), non-small cell lung cancer (NSCLC) and Hodgkin-lymphoma patients. While these agents can elicit strong anti-tumour immune responses, they can also generate immune related adverse events, which can become life threatening if not detected and managed promptly. At the University Hospital Ghent, we created a working group of organ specialists with specific experience in dealing with immune related adverse events. This initiative is part of ION (Immuno-Oncology-Network) Ghent. In this paper we would like to share our institutional guidelines for the clinical care of patients treated with checkpoint-inhibitors with the Belgian Oncology Community.

(BELG J MED ONCOL 2017;11(6):265–276)

Therapy-orienting testing of EGFR inhibitor-resistant non-small cell lung cancer

SUMMARY

Somatic sensitising mutations in the tyrosine kinase domain of the epidermal growth factor receptor (EGFR) are detected in approximately 10% of patients with advanced non-squamous non-small cell lung cancer (NSCLC). EGFR tyrosine kinase inhibitors (EGFR-TKIs) are the first-line treatment option for patients with an actionable EGFR mutation. Despite initial responses, the majority of patients progress within one to two years after EGFR-TKIs treatment initiation.

The most common mechanism of resistance is the development of an additional EGFR-T790M mutation in exon 20, found in 50–60% of EGFR-mutant NSCLC patients who were rebiopsied on EGFR-TKI treatment. Phase II and III trials with osimertinib, a third-generation EGFR-TKI, demonstrated an objective response rate (ORR) of 60–70% and median progression-free survival (mPFS) of 10–11 months in EGFR-T790M-positive tumours.

A tissue biopsy of a progressing lesion for confirmation of histology and molecular characterisation is a critical consideration. However, a repeat tissue biopsy is not possible for every patient. Therefore, a liquid biopsy can be considered for EGFR-T790M mutation testing. Indeed, clinical trials testing osimertinib have shown similar clinical outcomes (ORR and mPFS on osimertinib) in patients with T790M-positive plasma versus T790M-positive tumour tissue.

Osimertinib clearly expands relapse treatment options for advanced stage EGFR-mutant NSCLC. Testing for EGFR-T790M at acquired resistance should become a standard component of patient care in EGFR-mutant tumours. In this manuscript, we propose and discuss two possible clinical diagnostic algorithms that could be used for the therapy-orienting testing of EGFR-TKI-resistant NSCLC patients. Tissue and liquid biopsies involve challenges in terms of specific clinical role, safety, logistics, and cost.

(BELG J MED ONCOL 2017;11(5):226–233)

Radium-223, patient selection is of utmost importance

SUMMARY

In this practice guideline, the use of clinical indicators to increase the chance of completing six cycles of radium-223 in patients with metastatic castration-resistant prostate cancer is discussed.

(BELG J MED ONCOL 2017;11(3):107–109)