Medical Voice Medical Road | the post-epidemic era colorectal cancer patients to seek medical treatment, oral targeted drugs to escort the post-line treatment

*For medical professionals only

The "epidemic" road forward, overcome the difficulties of the times, and fruquintinib guarantees the home treatment of colorectal cancer patients in the post-epidemic era

Since the outbreak of the new coronavirus pneumonia (COVID-19) epidemic (hereinafter referred to as the new crown epidemic) in December 2019, it has brought unprecedented challenges to mankind, and although the epidemic has now stabilized, the situation is still grim
.

The epidemic has brought great difficulties and challenges to patients' medical treatment, and tumor patients, as a special group, have different diagnoses and treatment from other types of diseases, and need to complete the diagnosis and treatment and follow-up
of diseases in a scientific and standardized manner.

The latest statistics show that colorectal cancer (CRC) has become the second most common malignant tumor in China, with about 560,000 new onset cases each year ^[1].


In the face of such a large population of CRC patients, in the context of the normalization of the current epidemic situation, how to ensure the standardized medication of tumor patients is one of the key and difficult points in realizing standardized treatment and whole-process management of
tumors.

With the continuous innovation and breakthrough of targeted drugs in the treatment of CRC, the total survival (OS) of patients with advanced CRC has been gradually extended, which has also made them enter the "era of chronic disease"
.

Taking this opportunity, the medical community specially planned the series of medical voices and medical roads, inviting Professor Hang Qun from the First Affiliated Hospital of Bengbu Medical College in Anhui Province and Professor Chen Shengchi from the First Affiliated Hospital of Nanping Hospital of Fujian Medical University to tell the current diagnosis and treatment status of the backline treatment of CRC patients in China in combination with their clinical diagnosis
and treatment practice and experience.

Under the epidemic, it is difficult for patients to seek medical treatment

At present, medical treatment under the epidemic has brought many inconveniences
to both doctors and patients.

Professor Hang Qun said: CRC patients are mostly middle-aged and elderly patients, in the context of the epidemic, patients must prepare time-sensitive nucleic acid certificates and smart phone health codes in advance, and they need to show certificates in various buildings in and out of the hospital, and the consultation procedures are cumbersome
.

Localities will adjust the timeliness of nucleic acids in real time according to the epidemic prevention and control policies, for example, from 7 days to 72 hours or 48 hours
.

If the patient's nucleic acid certificate results are invalid or the health code is not used, the access to the hospital is obstructed and the patient cannot receive examination or treatment on time, which may aggravate the doctor-patient conflict and even cause medical disputes
.

Under the epidemic prevention and control policy, the accompanying party can basically only require one person to be admitted to the hospital to accompany the patient, and even in the outpatient clinic, the patient can only be treated by the patient alone, if the patient's knowledge and cultural level is low or other family members want to understand the condition, the doctor cannot explain or decide on the treatment plan with the patient and other family members at the same time, and sometimes it is necessary to explain and communicate with different family members, increase communication costs, and waste medical resources
.

At the same time, patients with advanced colorectal cancer need to be admitted to the hospital for chemotherapy every 2 to 3 weeks in the first- and second-line treatment, and some patients have cross-regional medical treatment, if the patient's area is blocked by the epidemic, it will cause patients to be unable to be admitted to the hospital on time to receive treatment, affecting the efficacy
.

For the dilemma caused by the current epidemic background, Professor Chen Shengchi believes that the epidemic has indeed brought a lot of impact on patients' medical treatment, and malignant tumors as special diseases, their diagnosis and treatment need to be standardized and fully managed
.

For patients with initial diagnosis, CRC generally has a relatively insidious onset, due to epidemic prevention and control or cumbersome diagnosis and treatment procedures and other related reasons, most patients may not choose to be admitted to the hospital in time for examination in the early stage of onset, which delays the early diagnosis and treatment of tumors, thus affecting the disease prognosis
.

Patients with advanced CRC in first-line and second-line treatment generally need to receive more intensive chemotherapy, and for patients with poor compliance, the more cumbersome procedures under epidemic prevention and control may increase the chance of patients not being admitted to the hospital on time, thereby affecting the treatment effect
.

For hospitals, hospitals need to notify patients through multiple channels in a timely manner according to the requirements of epidemic prevention and control, which consumes manpower and material resources; Due to the delay in patient admission caused by the problem of nucleic acid timeliness, the medical and nursing party needs to comply with the requirements of epidemic prevention and control, calm the patient's emotions or carry out relevant treatment, which increases the investment in communication time, and is invisibly a waste
of medical resources.

According to the conditions of the times, Internet medical care has helped the diagnosis and treatment of cancer patients in the post-epidemic era

In view of the problems faced by the current late CRC, hospitals, countries and society go hand in hand to overcome difficulties
.

Professor Hang Qun said that the diagnosis and treatment of CRC patients caused by the epidemic is inconvenient, and the hospital has opened up relevant green channels for emergency patients and tried to cure them as much as possible
.

Since the outbreak of the new crown epidemic, the advantages of Internet medical care have become more and more prominent, and the "Internet + medical" model has also continued to explore, playing an increasingly important role
in the field of tumor diagnosis and treatment.

Patients often have bone marrow suppression in first- and second-line chemotherapy therapy, such as delaying treatment by mistaking agranulocytic fever for ordinary fever, and as a result, the disease continues to progress, and may even lead to septic shock
.

The reason is that many patients lack the awareness of disease-related adverse reactions, do not understand the relevant risks after chemotherapy, cannot determine the seriousness of adverse reactions, do not conduct relevant consultations in time, or refuse to go to the hospital for relevant treatment due to the cumbersome diagnosis and treatment procedures brought about by the epidemic, which has led to the tragedy
.

Internet medical care can first conduct relevant consultations through real-time online diagnosis and treatment, so as to decide whether it is necessary to go to the nearest hospital for relevant treatment in time, or to wait for observation at home to reduce the occurrence
of serious adverse events outside the hospital.

Professor Chen Shengchi also agreed that the current Internet medical care has brought great convenience to patients in the context of the epidemic, which has improved the efficiency
of diagnosis and treatment.

At the same time, it is said that Internet medical care can allow cancer patients to be monitored and managed
in real time during the process of staying at home outside the hospital.

The tumor patients themselves have low immunity, and the convenience of online diagnosis and treatment can avoid patients from repeatedly visiting the hospital because of mild adverse reactions
.

At the same time, through the online implementation of diagnosis and treatment, it is possible to provide diagnosis and treatment services
for this part of the advanced CRC patients who take oral targeted drugs at home.

The integrated service of online registration, online medical treatment and delivery of drugs to the home provides great convenience
for this part of advanced CRC patients.

Third-line treatment, home treatment in the post-epidemic era has become the main theme of advanced CRC

Thanks to the continuous development of new drugs, the third-line standard treatment for advanced CRC currently mainly includes three oral drugs: fruquintinib, regofinib and TAS-102, while for CRC patients who cannot tolerate chemotherapy drugs in first- and second-line therapy or are insensitive to chemotherapy drugs, two small molecule anti-angiogenic drugs
are mainly selected, fruquintinib or regofinib.

In the selection of targeted drugs for third-line therapy, Professor Hang Qun shared relevant sharing based on his own practical diagnosis and treatment experience: the FRESCOIII.
phase study published in JAMA in 2018 reached all the study endpoints preset by the trial^[2], and also established the status
of fruquintinib as the preferred recommended treatment in third-line therapy.

Although fruquintinib was not studied head-to-head with other tyrosine kinase inhibitors (TKIs), data from people treated with fruquintinib were compared in the FRESCO Hybrid study to compare real-world treatment data using other TKIs, showing a significant increase in median overall survival (mOS) in the fruquintinib group (9.
3 months vs 6.
6 months), The progression-free survival time (PFS) was significantly longer in the fruquintinib group than in the other TKI groups (3.
71 vs.
2.
49 months)^[3].


The study also suggests that fruquintinib is more
beneficial than other TKIs in the posterior treatment of patients with advanced CRC in China.

Oral targeted drugs take into account the efficacy and safety of advanced CRC post-line therapy, and at the same time, in the context of the post-epidemic era, they also ensure the convenience of patient medication, providing a solid guarantee
for the home medication of patients with advanced CRC.

Professor Chen Shengchi also said that the current clinical advanced CRC third-line treatment, CSCO guidelines recommend to the clinical actual diagnosis and treatment plan to guide
.

In patients with poor tolerability to chemotherapy after first- and second-line therapy, the adverse effects of targeted therapy on the third line are mild, and TKI can be used as the preferred third-line
therapy.

Clinical practitioners will select
an individualized treatment plan based on a combination of factors such as the patient's economic situation, tolerance level, and genetic test results.

At present, TAS-102 has not yet entered the medical insurance, and the domestic original research drug fruquintinib has a price advantage over other imported TKI drugs, so in the choice of drugs, try to choose drugs
with less economic burden on patients.

At the same time, data from subgroup analyses of the FRESCO study showed that there was no significant difference in hepatotoxicity in the fruquintinib group compared to the placebo group in patients even with liver metastases^[4].


Patients with liver metastases are also the most common site of metastases for advanced ^{CRCs [5]}, and fruquintinib ensures the safety of administration in patients with CRC liver metastases
.

Taking into account the efficacy, safety, convenience and cost-effectiveness of the drug, fruquintinib provides a better choice
for patients with advanced CRC.

It should be cured, and the post-epidemic era should also implement the whole process of treatment and follow-up

Although the recurrence of the epidemic and the dynamic adjustment of epidemic prevention policies have brought difficulties and challenges to the diagnosis and treatment of patients to a certain extent, oral targeted drugs in the backline treatment have also avoided the medical impact
of the epidemic to a certain extent.

For the management of post-epidemic CRC patients in the post-epidemic era, Professor Hang Qun said that it is still necessary to carry out full-scale management, real-time monitoring and adjustment of medication plans, he mentioned: treatment needs to adhere to the efficacy of the mainstay, taking into account the patient's quality of
life.

In the mode of post-line home treatment, adverse drug reaction monitoring and disease health education also occupy an important position in the whole treatment management, oral fruquintinib has the characteristics of convenience, efficiency and speed, while safety and tolerability are good, which is convenient for doctors to follow up the management
of patients at home in the post-epidemic era.

For the whole process of treatment and follow-up, Professor Chen Shengchi believes that the treatment of malignant tumors, especially advanced CRC, has now entered the era of
chronic disease management.

In the post-line treatment, home oral medication does highlight its unique advantages
in the context of the epidemic.

Management and adverse reaction monitoring of patients with home medication are also indispensable
.

As far as patients are concerned, they need to monitor and report their discomfort symptoms at home, contact the doctor in charge by phone or WeChat if there is an abnormal situation, and if they need to deal with it, they can go to the nearest hospital for relevant treatment, so as to avoid repeated admissions or waiting in the outpatient clinic for a long time; For doctors, according to the patient's feedback of symptoms, corresponding guidance or related adjustments to the dose of the drug are made
.

While ensuring the efficacy of patients in the process of home medication, it also ensures the quality of life of patients, increases the good experience of patients in actual medication, improves patient satisfaction, and truly realizes the whole process of chronic disease management for patients with advanced CRC, and effectively increases the benefits
of patients.

The future can be expected, so that patients can truly "cure" dependent

The treatment of advanced CRC is still under continuous exploration, and Professor Hang Qun has also made relevant prospects in the current treatment exploration of advanced CRC: in combination therapy, at present, in advanced CRC treatment, anti-angiogenesis combined immunotherapy has shown certain efficacy, providing follow-up research direction
for exploring advanced CRC.

For targeted drug combination therapy, Professor Chen Shengchi also pointed out that combination therapy may be the trend of advanced CRC treatment in the future, and the efficacy of drugs alone may be weak
.

Anti-angiogenesis therapy combined with immunotherapy or combined chemotherapy, or even a combination of three drugs, all use different mechanisms to achieve anti-tumor effects, and it is expected to achieve better benefits for
patients in the future.

In short, in the late CRC treatment in the post-epidemic era, the two professors combined their own clinical practical diagnosis and treatment experience to bring us wonderful sharing
.

To ensure that the majority of patients with advanced CRC seek medical treatment and use drugs safely, they need to be controlled
from all aspects.

Patients themselves need to pay attention to the real-time epidemic prevention policies of countries and regions, and actively contact the doctor in charge during the process of home medication; At the same time, in the era of increasingly developed Internet technology, you can enjoy the convenience
brought by Internet medical treatment to the current medical treatment.

For hospitals and doctors, strengthen the construction of Internet hospitals, improve offline and online synchronous diagnosis and treatment services, and use Internet resources to provide integrated online medical services such as online appointment number sources, online diagnosis and treatment, and drug distribution, so as to make "more information run and patients run less errands"
.

For pharmaceutical companies, increase investment in drug innovation and research and development, assume the social responsibility of pharmaceutical companies, ensure the supply of drugs for cancer patients, and increase the accessibility
of drugs.

For the national level, strengthen the supervision of network information security, effectively control the medical quality of online consultation, so that doctors can practice with peace of mind and patients can be assured
of diagnosis and treatment.

With the help of many parties, we will ensure that CRC patients in the late post-epidemic era can still receive full-scale and standardized treatment, move forward on the "epidemic" road, overcome the difficulties together, and look forward to finally winning
in this war without smoke.

The First Affiliated Hospital of Bengbu Medical College

Master of Surgery, Associate Professor, Master Supervisor

Deputy Chief Physician of Gastrointestinal Surgery, First Affiliated Hospital of Bengbu Medical College

Member of the Standing Committee of the Rapid Rehabilitation Surgery Committee of Anhui Medical Doctor Association

He is a member of the expert database of Anhui Medical Malpractice Appraisal Committee

He is good at laparoscopic minimally invasive treatment, and has unique insights into the diagnosis and treatment of gastrointestinal tumors and other gastrointestinal tract tumors, and has in-depth research
on the diagnosis and treatment of multiple diseases and intractable diseases in general surgery, as well as unexplained chronic abdominal pain, intestinal obstruction and chronic constipation.

He has participated in and presided over a number of research projects such as the National Natural Science Foundation of China, the Department of Education of Anhui Province, and major scientific research projects of universities in Anhui Province, and has published 2 SCI papers as an independent first author, and published more than 10 professional papers and teaching papers in national and provincial journals
.

He is the chief editor of 2 professional works and 3 professional works

He participated in the third batch of China's national medical team to aid South Sudan and studied in Paracelsus Clinik, Germany

Director of the Department of Oncology, Nanping First Hospital Affiliated to Fujian Medical University

Standing Committee Member of Tumor Metastasis Committee of China Medical Education Association

Standing Director of Fujian Anti-Cancer Association

Standing Committee Member of Oncology Branch of Fujian Medical Association, Standing Committee Member of Medical Oncology Professional Committee
of Fujian Anti-Cancer Association

Standing Committee Member of Cancer Rehabilitation and Palliative Care Committee of Fujian Anti-Cancer Association

Member of the Lung Cancer Professional Committee of Fujian Anti-Cancer Association of
Fujian Chemotherapy Quality Control Center

Standing Committee Member of Medical Oncology Branch of Fujian Medical Doctor Association

Standing Committee Member of Breast Disease Branch of Fujian Medical Association

Director of Nanping Cancer Chemotherapy Quality Control Center

Chairman of Nanping Anti-Cancer Association

Director of the Oncology Branch of Nanping Medical Association

References:

[1].
Sung H, Ferlay J, Siegel RL, et al.
Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries.
CA Cancer J Clin.
2021 May; 71(3):209-249.

[2].
Li J, Qin S, Xu RH, et al.
Effect of Fruquintinib vs Placebo on Overall Survival in Patients With Previously Treated Metastatic Colorectal Cancer: The FRESCO Randomized Clinical Trial.
JAMA.
2018 Jun 26; 319(24):2486-2496.

[3].
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.

[4].
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.

Gastrointestinal Surgery Group, Surgery Branch of Chinese Medical Association, Colorectal Surgery Group of Surgery Branch of Chinese Medical Association, Colorectal Cancer Professional Committee of Chinese Anti-Cancer Association, et al.
Guidelines for the diagnosis and comprehensive treatment of liver metastases of colorectal cancer in China (2018 edition)[J].
Chinese Journal of Gastrointestinal Surgery,2018,17(6):527-539.