Iwona Schymalla's guest is Dr Piotr Kędzierawski, M.D., from the Świętokrzyskie Oncology Centre.
For a long time now, we have been hearing that we are being hit by a real tsunami when it comes to oncological diseases. Are there really more and more cancer patients? At what stage do they present themselves to doctors?
There is a steady increase in the incidence of malignant tumours in Poland, as well as worldwide. There are cancers that occur more frequently, such as lung cancer, breast cancer in women and colorectal cancer. The important thing is to diagnose the disease at the earliest possible stage. Treatment is then more effective, less toxic and we can achieve long-term survival in patients. Recently, we have been seeing patients presenting to us with advanced cancer, although we have not had a lockdown at our ŚCO related to the coronavirus pandemic. We have tried all the time to admit patients and carry out diagnostic and therapeutic activities. Unfortunately, the number of oncology specialists in Poland is not increasing, so we have to cope with the number of staff and equipment we have. Specialising in oncology requires young doctors to have character traits such as empathy and mental toughness, which is why very few medical school graduates undertake it. This means that the current staff have to deal with more patients presenting to oncology facilities.
How can certain treatment procedures used with patients be optimised when there are so many of them?
The diagnosis of cancer, the diagnostic and therapeutic process itself, should be very well planned. Because only then are we able to treat our patients rationally and responsibly. A very good example of optimising treatment planning is the creation of multidisciplinary teams for the complex diagnosis and treatment of breast cancer patients, i.e. breast cancer units. Cancer treatment planning involves us being able to tailor treatment in an optimised way for each patient. Optimisation of surgical treatment, for example, involves reducing the number of mastectomies, replacing them with sparing procedures, or reducing axillary linphadenectomies (removal of lymph nodes in the armpit), replacing them with sentinel node biopsy. For patients with aggressive forms of breast cancer, HER2+ cancer and triple-negative cancer, we plan treatment in such a way that we start with systemic treatment, with chemotherapy and anti-HER2 treatment, so that in almost half of the patients we are able to achieve a reduction in disease progression and even achieve complete pathological regression. Such a good example of treatment optimisation is also the replacement of intravenous forms of drugs with subcutaneous or oral drugs.
I understand that the optimisation of reducing the administration time of the drug by administering it subcutaneously is a very good way of addressing the problem we discussed at the beginning. In which other cancers can we also administer the drug subcutaneously?
Subcutaneous medication is also given to patients with prostate cancer. This is at the moment the most common malignancy in men that is treated with hormone therapies. And it is in these patients that hormone therapy is administered subcutaneously. It often lasts many years, is long-lasting and chronic, and is therefore a form that does not interfere in any way with the patient's functioning and results in fewer hospitalisations. In breast cancer, the situation is similar. Approximately 20 per cent of breast cancer patients are diagnosed with HER2+ cancer and therefore these patients also require chronic therapy.
How does the subcutaneous form of drug administration differ from intravenous infusion?
The subcutaneous form is considerably shorter. It has been shown that at the same time that an intravenous form of the drug is administered to a patient, we can administer the subcutaneous form to two other patients. The intravenous form of the drug requires in many cases the placement of a vascular access, known as a vascular port, which involves the involvement of an anaesthetist, anaesthesia nurse and the need for an operating theatre. Subcutaneous administration can be performed in an outpatient setting. In fact, chronic patients themselves, in their discussions with us, say that this is an accessible and optimal form of drug administration for them. It should be noted that patients with HER2+ cancer mostly have pre-operative chemotherapy and treatment with trastuzumab. The chemotherapy is administered intravenously. Therefore, the complementary administration of trastuzumab is associated with patients not being subjected to hospitalisation, separation from family and being in hospital for an extended period of time. Many patients simply return to work after aggressive treatment while receiving subcutaneous trastuzumab.
Patients often emphasise that the form of subcutaneous administration of the drug provides them with psychological comfort, that they feel better mentally and physically after such administration. Does the Doctor confirm this from his practice?
Yes. This is a good point, because every stay in hospital has a negative impact on the psyche of patients. Every visit to the doctor creates fear and anxiety. Therefore, the shorter the visit, the better for patients. Subcutaneous administration is also associated with profit. The patient is given an entire ampoule of the drug, whereas with intravenous administration we calculate the dose per the patient's body surface area and therefore in some cases we do not give the entire ampoule, the rest of it simply has to be destroyed. The patient's time in the cancer centre is extremely short. With subcutaneous administration, the nurses can also devote their time to other patients, another benefit.
Mr Doctor is already talking about systemic benefits, because we do not waste the drug when administered subcutaneously and there is also more time for other patients. Outpatient care instead of hospitalisation also has a systemic dimension.
Yes. When I talk to patients, qualifying them for oncological treatment, I encourage them to have treatment in an outpatient setting. It encourages the patient to endure treatment better, to be with loved ones at home and in their surroundings, and therefore the psychological side of this treatment is better for the patient.
We are preparing for another wave of coronavirus. Studies show that women who have received chemotherapy or undergone surgery in recent months have a higher risk of SARS-CoV-2 infection. Doesn't it seem that we should be using the subcutaneous form more and more, as it is an excellent method of minimising the patient's risk of infection?
Oncology hospitals in Poland are characterised by full corridors of patients waiting for medical procedures, which in the current situation may favour the spread of the virus. Although many patients are vaccinated, thus minimising the risk of infection or its consequences, nevertheless interest in vaccination is declining, which worries us, so the density of patients in waiting rooms means that transmission of the virus may be easier. We do not know what might happen in the autumn. Forecasts vary. Hopefully we will be able to see patients safely and treatment will not be interrupted.
We are talking about breast cancer, particularly its aggressive HER2+ form. What is still missing for the treatment of these patients to be most beneficial, for the treatment effect to be the best possible?
HER2+ cancer is indeed an aggressive form of breast cancer. About 20 per cent of patients develop this cancer. Treatment is chronic. With modern therapies, combining chemotherapy with treatment with HER2 receptor blockers, we are able to achieve complete pathological remission of the primary tumour and lymph nodes in almost half of the patients. This means that there is no cancer in the histopathological preparation that is examined after surgical treatment. Nevertheless, the other half of these patients do not achieve complete regression, which is also not evidence of poor treatment, it is just the biology of this cancer. And these patients should be treated further in some way. A randomised trial conducted on a large group of patients showed that the survival of patients with HER2+ cancer who were additionally given trastuzumab with a cytostat was significantly longer than that of women receiving trastuzumab alone (this is happening now). We are now minimising the extent of surgery and using modern conformal radiotherapy techniques. And the treatment especially of patients with aggressive forms of breast cancer (HER2+ and triple-negative) should also be optimised. In many patients, we already use two HER2 receptor blockers preoperatively at this point. And in follow-up treatment, we should also cause these patients to receive optimal therapy. It is therefore important that the diagnostic process is quick and that the treatment is planned accordingly, so that the patient knows when to report, at what time and to which specialist, so that this process of continuity is maintained, and that the treatment of breast cancer is tailored to the biological subtype. There is no uniform template for treating breast cancer patients because we have different biological subtypes of breast cancer. And we have to give special care to patients whose form of cancer is aggressive.
Source: medexpress.co.uk