Medical Sound · Medical Road ｜ Standardized diagnosis and treatment, the only way for advanced colorectal cancer

*For medical professionals for reading reference

"Each tumor has the best treatment opportunity for each tumor." Standardized diagnosis and treatment becomes the mainstay of the late CRC.

In 2020, colorectal cancer (CRC) has become the third in the world with the third and second mortality rate of mortality. Among them, 1,931,590 new cases and 935,173 deaths of deaths accounted for 10%and 9.4%of the total of global cancer. [1]. The disease is seriously threatening the health of global residents. In the face of these shocking numbers, it is urgent to implement a standardized diagnosis and treatment plan to reduce the mortality of the disease and prolong patients' survival time.

In this context, the medical community specially planned a series of medical sounds and medical roads, and invited Professor Jin Yongdong from Sichuan Cancer Hospital and Professor Li Rongrong from Hunan Cancer Hospital to jointly interpret the significance of the advanced CRC standardized diagnosis and treatment.

The first time ——

The first diagnosis of standardized therapy is essential for the benefit of the survival of patients

Regarding the first diagnosis of malignant tumors, Professor Jin Yongdong said: As a special major disease, the first treatment choice is essential. The first treatment should be selected for surgery, chemotherapy, or radiological treatment, which is a very critical choice point. Malignant tumors have certain particularity, which is different from common and multiple chronic diseases such as hypertension and diabetes. It is recommended that the first diagnosis and treatment of malignant tumors is preferentially selected in the oncology department of comprehensive hospitals in third -level tumor hospitals or third -level A comprehensive hospitals. The first diagnosis and treatment plan should also be decided under the discussion of the multidisciplinary diagnosis and treatment team (MDT), because the decision -making of the first diagnosis and treatment plan will have a profound and huge effect on the effect of later treatment, and will play a decisive role in the entire total survival period (OS).

For the importance of the first diagnosis, Professor Li Rongrong also believes that the preliminary diagnosis gives patients the correct staging, diagnosis and professional treatment plan for patients, which almost determines the patient's OS. On the one hand, the first diagnosis treatment plan is scientific and reasonable. Patients have accepted the best treatment plan. Many patients in early, middle and late stages also have the opportunity to get healing. On the other hand, even if some patients in the middle and late stages have lost the opportunity to cure, they can extend the OS through early system and professional treatment solutions to maximize the prognosis. The treatment of tumors does not turn back. The first diagnosis and first treatment, follow the guide and evidence, and give patients a standardized and professional treatment plan. It is like creating the foundation of the building. If the foundation is a bubble project, it may collapse in the process of building a building.

Coordinate and take into account ——

"Standardization" and "homogeneity" diagnosis and treatment covers different regions and different medical institutions

For the "standardization" and "homogeneity" of malignant tumors, Professor Kim Yongdong believes that "standardization" is not uniform, not all patients apply the same treatment plan, but follow the guide The ESMO guide, based on the standardized treatment plan and evidence recommended by the guide, gives patients with sufficient and sufficient treatment for patients. "Homogeneity" considers that the economic foundation and medical level of different regions are uneven. On the basis of the same examination or diagnosis and treatment schemes in various regions, they can give as much as possible to the most high -quality diagnosis and treatment plan as much as possible. Diagnosis and treatment gap between regions and different medical institutions.

Professor Li Rongrong's interpretation of "standardization" and "homogeneity" is the same as Professor Kim Yongdong's views. She said that there is still a big gap between the current diagnosis and treatment technology of grass -roots hospitals and large -scale three -level hospitals. "Quality", that is, the gap between the diagnosis and treatment between different levels of hospitals, to the greatest extent enables patients at grassroots hospitals to obtain safe and secure medical services, and ultimately implement patients' survival benefits.

Benefit -seeking excellence-

The era of "individualization" and "precision" tumor treatment has been fully opened

Combined with the current "individualization" diagnosis and treatment trend of tumors, Professor Jin Yongdong said: "Individualization" treatment decisions need to be based on the patient's personal tolerance, including the age, physical score, basic diseases, etc. Considering comprehensive factors such as foundation and personal treatment. It should be emphasized that "individualization" and "standardization" do not conflict. It is complementary. All individualized treatment plans need to rely on guidelines and evidence as blueprints. Individualization is not equal to randomization.

In today's rapid development of genetic testing and targeting, immune, immune, tumor treatment has also entered the era of "precision" treatment. Professor Li Rongrong carried out the current CRC's "precision" treatment: CRC's precise treatment needs to start with the results of genetic testing. Different genetic mutations are very different in the prognosis and choice of drug treatment plan. In actual work, the diagnosis and treatment plan should be used as a factor for independent evaluation. At the same time, according to the different genetic test results, the patient can develop a more reasonable and effective individualized diagnosis and treatment plan, so that the patient can benefit the greatest extent.

RAS gene wild CRC patients can prevent the signal conduction pathways of tumor cells from the new targeting drugs of anti -EGFR through anti -EGFR new targeting drugs, inhibit the proliferation, invasion and metastasis of tumor cells, thereby achieving the effect of anti -tumor. At present, the molecular targets of colon cancer that have been discovered include epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), human epidermal growth factor receptor 2 (HER2), V-raf mouse sarcoma virus cancer gene is the same Source B1 (BRAF), mouse sarcoma virus cancer gene (K-RAS), programmatic death receptor 1 (PD-1) and other antibodies. At the same time, many retrospective studies also show that the prognosis of intestinal cancer (spleen to rectal) and intestinal cancer (cecum to horizontal colon) intestinal cancer is significantly different. The treatment plan is different. Professor Li Rongrong conducted the following summary of the treatment of left, right half CRC and some targets based on the results of the current guidelines and multiple data research [2-3]: Siciecci Mipide has better effect on the left half of CRC patients. Essence NCCN guidelines pointed out that Sicien Mipida combined with chemotherapy is suitable for KRAS/NRAS/Braf gene wild left half CRC patients. For the right half CRC patients, the use of Bevarzumab has more benefits compared to Sicium Mipida.

Because the prognosis of the right half CRC itself is poor and the effect of conventional chemotherapy is not good, the proportion of MSI-H is higher, and it benefits greater benefits from immunotherapy. For patients with MSI-H/DMMR, the NCCN guidelines recommend Paborzab and Nawuli Ulipipioscopy.

In response to the BRAF mutation, the NCCN guide proposed that the Bevarzab combined chemotherapy is currently the first -line treatment mode of Braf mutant MCRC.

For the current anti -HER2 targeted therapy related to HER2 amplification CRC, the NCCN guideline recommends Twozhu Mippochemical+Puffyzumab+Lapatinini in the advanced CRC three -line treatment of HER2.

Army arrays -back -line treatment still cannot be discarded

At present, tumor treatment is still a process of management, and the treatment of each line is indispensable. Regarding how the overall therapy is carried out and how to manage back -line treatment, Professor Kim Yongdong pointed out: Many patients after receiving first and second -line standard treatment are still common in the progress of the disease, and it is urgent to effectively require effective third -line and subsequent treatment. Decision and choice of back -line treatment plan are also the focus and difficulty of clinical diagnosis and treatment of advanced CRC. Combined with the precise treatment of "standardized and individualized" mentioned earlier, the third -line treatment is first based on the standard treatment plan recommended by the guide. The goal aims to extend the survival period and ensure the quality of life of patients. Among them, for patients who cannot continue tolerated chemotherapy after first -line and second -line treatment, tyrosine kinase inhibitors (TKI) can be selected. Based on FRESCOII Research Data [4], oginib has become one of the three -line standard treatment plan.

In the choice of TKI drugs for three -line therapy, Professor Kim Yongdong interpreted in combination with relevant research: currently the head opposite with other TKI drugs is not compared, but in the FRESCO Hybrid research design, 呋喹itinib therapy was received in FRESCO studies in research on FRESCO research Criminal data to compare the treatment data of other TKI in the real world. The research results show that the PFS (no progressive survival time) of the 呋喹inib group is significantly longer than other TKI groups (3.71 months vs2.49 months). Studies have shown that in the back -line therapy of Chinese MCRC patients, olinib benefits more than other TKI PFS [5].

线 三nib has increased the choice of third -line therapy drugs. Professor Li Rongrong combined with relevant research saying that clinically, patients with CRC accompanied liver metastasis, she is more inclined to use 呋喹ntinib: from the Fresco Research Asian group analysis data released by CSCO in 2018 In terms of safety in terms of safety, there are no significant differences between the hepatic toxicity of the pyrinib group in patients with liver metastasis in CRC [6]. Regardless of whether the liver metastasis occurs, the liver toxicity of the pupinib is basically the same as the placebo group. Therefore, in the clinical application, the third -tier treatment of the liver metastase patients is recommended to be recommended.

At present, back -line treatment plans are still being explored, and antibrokers' combined immunotherapy has also made certain progress in CRC backline therapy. A Phase IB Research Data of the Phase IB IB of the ASCO Conference in 2021 shows that the anti -vascular generation combined immunotherapy has good efficacy and safety in MCRC backline. [7] Professor Kim Yongdong added: In clinical practice, some patients who have been cured have benefited PFS for more than one year in the anti -vascular generating combined immunotherapy plan, but there are also some patients with poor effects. In the future, the selection of anti -vascular generation combined immunotherapy beneficiaries also needs to be explored.

True knowledge- ——

Adverse reaction of controlling medication throughout the process

During the clinical backline practice diagnosis and treatment, while paying attention to the efficacy of patients, the quality of life has also become the focus of doctors' attention in back -line treatment. Therefore, the adverse reactions of drugs are important criteria for judging the quality of life of patients. Professor Kim Yongdong combined with the adverse drug reactions of his actual diagnosis process: TAS-102 as the main adverse reaction of chemotherapy drugs in bone marrow suppression. The choice of three lines tends to TKI -like drugs. In the process of clinical practical diagnosis and treatment, the adverse reactions of the vasiniin are relatively milder than other TKI drugs, and the overall tolerance is good. The common clinical adverse reactions of chimotinib are hypertension, proteinuria and hand and foot syndrome, but the reaction is mostly mild. The control of adverse reactions requires monitoring, symptomatic treatment and adjustment of the dosage during treatment. For example, in the process of home medication, patients need to be regularly monitored. For the treatment of hypertension and proteinuria, vascular tensioning antagonists (ARB) or vascular tensionase conversion enzyme inhibitors (ACEI) category reduced voltage pressure reduction Medicine, reduce these two adverse reactions as much as possible. In addition, in addition to symptomatic treatment, doctors will make individualized dose adjustments based on the actual clinical situation of the patient, so that patients have better tolerance and safety. Regarding the relevant adverse reactions of cycitinib, Professor Li Rongrong said: As a small molecular blood vessel generating inhibitor, the incidence of severe hypertension and proteinuria is relatively rare in the clinical. Mild hypertension and proteinuria occur in 的inibigo, which can be well controlled after symptomatic treatment. In addition, for the treatment of hand and foot syndrome, clinically apply urea cream or vitamin E cream, soften the keratin, and tell patients to reduce hand and foot friction daily; Avoid infection; if the hand -foot syndrome above level 3 occurs, the drug dose will also be adjusted clinically according to the actual situation of the patient. Basically, the patient's adverse reactions can be effectively controlled after the symptomatic treatment. In terms of drug liver toxicity, the data from FRESCO studied the data analyzed by the Asian group [6] is still safer. Both can be restored. Generally speaking, the tolerance and safety of Setinib are relatively good. The occurrence of adverse reactions needs to be monitored and follow -up, and symptomatic treatment can be effectively guaranteed to effectively ensure the safety of patients' medication and improve the quality of life of patients.

Summarize

Patients with malignant tumors have the best treatment opportunities, standardize the clinical application of anti -tumor drugs, carry out the full management of CRC standardized diagnosis and treatment, enhance the consciousness of standardized diagnosis and treatment of medical institutions and staff at all levels, and jointly commit to implementing more standardized bowel cancer diagnosis and treatment The plan, with the goal of achieving a healthy China 2030 at an early date, benefits the broader CRC patients.

Expert Introduction

Professor Kim Yongdong

Cancer Hospital of the School of Medicine of the University of Electronic Science and Technology

Director of the Cancer Hospital of Sichuan Cancer Hospital

PhD chief physician/researcher graduate mentor

Canadian McGill University visiting scholar

Candidates for the Sichuan Provincial Health and Health Commission's academic and technical leader

Chairman of the Sichuan Anti -Cancer Association Tumor Support and Full Management Committee

Deputy Chairman of the Popularization Committee of the Sichuan Provincial Medical Association

Member of the Chinese Anti -Cancer Association A targeted treatment committee and a member of the Liver Diseases Committee

Standing Committee Member of the China Anti -Cancer Association Tumor Sickness Discipline Special Committee

CSCO colorectal cancer committee member

Member of the China Pharmaceutical Education Association Colorectal Cancer Specialization Committee

Member of the Lighten Cancer Specialist Committee of the Beijing Cancer Prevention and Control Society

Member of the Sichuan Medical Association, Sichuan Medical Association Cancer Branch

Responsible for the topic of the "Thirteenth Five -Year Plan" Ministry of Science and Technology, one project of the national key R & D plan, presided over 2 projects of the Provincial Health and Family Planning Commission, and 1 project of Sichuan Cancer Hospital. He has published a number of SCI and national academic papers. One editor -in -chief of academic monographs and 1 deputy editor.

Expert Introduction

Professor Li Rongrong

A deputy chief physician of digestive urology

Secretary of the Hunan Anti -Cancer Association Tumor Treatment Professional Committee

Member of the Hunan Anti -Cancer Association Family Hereditary Cancer Professional Committee

Member of the Youth Committee of the Molecular A targeted Professional Committee of the Hunan Provincial Anti -Cancer Association

Host and participated in a number of provincial science and technology departments issues

The first author of the first author was selected as 2022 ASCO Annual Meeting Abstracts.

Published dozens of papers in the first author in SCI and core journals

references:

[1] .sng h, flace j, siegel rl, et al. Global Cancer Statistics 2020: GLOBOCAN ESTImates of 249.

[2]. Zhou Liming. The research progress of targeted therapy for colorectal cancer [J]. Yan'an University Journal (Medical Science Edition), 2022,20 (1): 1-9. Doi: 10.19893/J.CNKI.YDYXB. 2022-0042. [3]. Li Chunyi, Huang Xinen, Wang Ping. The research progress of the target and targeting therapy of colorectal cancer [J]. Shandong Pharmaceutical, 2021,61 (17): 108-112. Doi: 10.3969 /j.issn.1002-266x.2021.17.030.

[4].Li J, Qin S,Xu RH, Shen L, Xu J, et al. Effect of Fruquintinib vs Placebo onOverall Survival in Patients With Previously Treated Metastatic Colorectal Cancer: The FRESCO Randomized Clinical Trial. JAMA. 2018 Jun 26; 319 (24): 2486-2496.

[5].Jin Y, Li J, Shen L, et al. : A multi-center effectiveness comparison study of fruquintinib with constructed external control cohort of other TKIs using real-world data in 3+ line treatment of metastatic colorectal cancer. 2021 CSCO.

[6].Qin S, Xu RH, Shen L, et al. Subgroup Analysis by Liver Metastasis in the FRESCO Trial Comparing Fruquintinib versus Placebo Plus Best Supportive Care in Chinese Patients with Metastatic Colorectal Cancer.Onco Targets Ther. 2021;14:4439 -4450.

[7] .Ye Guo, Weijie ZHANG, Jieer Ying, et al. Preliminary Results of a Phase 1B Study of Fruquintinib Plus Sintilimab in Advanced Colorectal Cancer. 2021 ASCO ABSTRACT 2514.

*This article is only used to provide scientific information to medical people, and does not represent the viewpoint of this platform

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