在肝细胞癌的全球威胁方面取得进展：不断增长的武器库

StephenW

Making Progress on the Global Threat of Hepatocellular Carcinoma: A Growing Armamentarium
2019-12-28 19:00:00
PT Staff
Considered a worldwide epidemic, hepatocellular carcinoma (HCC) is the fifth leading cause of cancer diagnosis and third leading cause of cancer-related death globally. In the United States, approximately 42,000 Americans receive a diagnosis of this deadly cancer annually and approximately 32,000 die. Its incidence has tripled since 1980, and researchers documented a 3% increase in HCC between 2006 and 2015. This topic was presented by Jolynn K. Sessions, PharmD, BCOP, at the 2019 Directions in Oncology Pharmacy™ conference. Dr Sessions is an oncology clinical pharmacist specialist and oncology pharmacy manager at the Charles George VA Medical Center in Asheville, North Carolina.

Many audience members were aware of risk factors (hepatitis B, hepatitis C, alcohol consumption, nonalcoholic steatohepatitis, and aflatoxin exposure) and this cancer’s pathophysiology. Dr Sessions presented a concise treatment overview using a flowchart, separating patients by those who are potentially curable and those who probably will not be cured by current therapy. She also presented a timeline of FDA with sorafenib and have drastically expanded in the past 2 years, emphasizing that there has been significant progress made in both the number and type of available agents.

She went on to emphasize the novel targeted therapies that have proven efficacy in HCC, including agents targeting vascular endothelial growth factor (VEGF) and the programmed cell death protein 1 (PD-1) inhibitors. She reviewed the evidence behind first-line agents, sorafenib and lenvatinib, administration pearls for their use, and also emphasized monitoring considerations. For example, patients being treated with any of the VEGF inhibitors should avoid strong CYP3A4 inducers, and the oncology team should recommend holding administration of these agents if a patient needs a major surgical procedure. She also presented a list of conditions under which these agents need to be temporarily or permanently discontinued (cardiac ischemia, myocardial infarction, hemorrhage, persistent hypertension, gastrointestinal perforation, QTC prolongation, drug-induced liver injury).

Next, using a case-based presentation, she discussed second-line options for patients with advanced HCC. These options consist of oral and infusion therapies. In the former category are regorafenib, cabozantinib, and sorafenib (if the patient received lenvatinib as first-line treatment). In the latter category are the VEGF inhibitor ramucirumab and the PD-1 inhibitors nivolumab and pembrolizumab.

Here, too, she described the evidence behind each of these agents, and talked about some unique concerns. She shared specific considerations for selection of second-line options. For example, patients who are taking regorafenib need to consume low-fat meals, and she explained that this means that the meal needs to have fewer than 600 calories and less than 30% fat. She also stressed that the PD-1 inhibitors should not be used in patients who have had a liver transplant.
Dr Sessions provided an education checklist that walked audience participants through significant items that need to be covered. In addition to the drug-specific items and adherence and persistence planning that all pharmacists educate patients about, patients with cancer need to understand how to dispose of their medication, what their monitoring plan is, and have contact numbers so they can reach an oncology clinician at all times. She shared specific details on how to help patients receiving VEGF inhibitors manage hand-foot skin reaction, diarrhea, and hypertension.

Dr Sessions summed up the presentation by indicating that pharmacists who use systematic approaches can provide effective education and monitoring that improve medication adherence, effectiveness, and tolerance.

StephenW

在肝细胞癌的全球威胁方面取得进展：不断增长的武器库
2019-12-28 19:00:00
PT员工
肝细胞癌（HCC）被认为是全球流行病，是全球癌症诊断的第五大原因和癌症相关死亡的第三大原因。在美国，每年约有42,000名美国人被诊断出患有这种致命的癌症，约有32,000人死亡。自1980年以来，其发病率已增加了两倍，研究人员记录到2006年至2015年之间，肝癌的发生率增加了3％。该主题由Jolynn K. Sessions，PharmD，BCOP在2019年肿瘤学药学方向会议上发表。 Sessions博士是位于北卡罗来纳州阿什维尔的查尔斯·乔治·VA医疗中心的肿瘤学临床药剂师和肿瘤学药剂师。

许多听众意识到危险因素（乙型肝炎，丙型肝炎，饮酒，非酒精性脂肪性肝炎和黄曲霉毒素暴露）和该癌症的病理生理学。塞申斯博士使用流程图展示了简洁的治疗概述，将患者按可能治愈的患者和可能无法通过当前治疗治愈的患者分开。她还介绍了索拉非尼与FDA的时间表，并在过去两年中大幅度扩展，强调在可用药物的数量和类型上都取得了重大进展。

她继续强调已在HCC中证明有效的新型靶向疗法，包括靶向血管内皮生长因子（VEGF）和程序性细胞死亡蛋白1（PD-1）抑制剂的药物。她回顾了一线药物索拉非尼和lenvatinib的使用背后的证据，并称其为行政用珍珠，并强调了监测方面的考虑。例如，接受任何VEGF抑制剂治疗的患者应避免使用强效CYP3A4诱导剂，如果患者需要大手术，则肿瘤学团队应建议继续服用这些药物。她还列出了需要暂时或永久停用这些药物的条件清单（心脏缺血，心肌梗塞，出血，持续性高血压，胃肠道穿孔，QTC延长，药物引起的肝损伤）。

接下来，她使用基于案例的演讲讨论了晚期肝癌患者的二线治疗方案。这些选择包括口服和输注疗法。前者是雷戈非尼，卡波替尼和索拉非尼（如果患者接受来伐替尼作为一线治疗）。在后一类中是VEGF抑制剂雷莫昔单抗和PD-1抑制剂尼古鲁单抗和派姆单抗。

在这里，她还描述了每个代理人背后的证据，并谈到了一些独特的问题。她分享了选择二线方案的具体注意事项。例如，服用雷戈非尼的患者需要食用低脂餐，她解释说这意味着该餐所含热量必须少于600卡路里，脂肪必须少于30％。她还强调，PD-1抑制剂不宜用于肝移植患者。
塞申斯博士提供了一份教育核对清单，引导听众了解需要解决的重要事项。除了所有药剂师都对患者进行药物培训的特定药物项目以及依从性和持久性计划之外，癌症患者还需要了解如何处置药物，监测计划是什么以及联系电话，以便他们可以联系肿瘤临床医生。每时每刻。她分享了有关如何帮助接受VEGF抑制剂的患者处理手足皮肤反应，腹泻和高血压的具体细节。

塞申斯博士在总结演讲时指出，使用系统方法的药剂师可以提供有效的教育和监控，以提高药物的依从性，有效性和耐受性。