Oncology
Oncology
Oncology
This section is dedicated to providing continuing education for oncologists, oncology specialist nurses, hospital doctors and other healthcare professionals, who can earn CPD while learning about various topics in oncology.
There are modules on immunotherapies and chemotherapies to treat cancers, managing patient expectations, HIV-related malignancies, radiotherapy techniques, the use of technologies such as ctDNA and liquid biopsy, reports covering recent conferences, and reflections on the most recent research and its implications in clinical practice.
Pneumonitis: how to assess the breathless patient
Module description
1 CPD hour
This module presents highlights of the Royal Marsden conference ‘A user guide to cancer immunotherapy’ held in London on 7 December, 2022. This conference focused on immunotherapy-related toxicities in a range of organs and organ systems and aimed to inform clinicians about why toxicities occur, how they can be identified and what treatment approaches to consider.
This report focuses on a talk on managing immune checkpoint inhibitor (ICI)-related pneumonitis by Dr Ricardo José.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Review the differential diagnoses of the breathless patient
● Learn how to identify ICI pneumonitis and how to approach treating it
● Appreciate the differential diagnoses of individuals displaying symptoms of ICI pneumonitis
● Know how ICI pneumonitis is graded and what treatments the different grades entail
Introduction
Dr Ricardo José started his conference presentation by highlighting the incidence of immune checkpoint inhibitor (ICI) pneumonitis among patients who have received ICI immunotherapy such as CTLA-4 inhibitors or PD-1/PD-L1 inhibitors for cancer.
He said that clinical trials among patients with lung cancer showed that the incidence of ICI pneumonitis is approximately 3-6%, but when monitored in the real world, the incidence can be higher. This can be as high as 33% in patients receiving sequential chemoradiation/immunotherapy.1
He stated that the incidence of ICI pneumonitis was up to 6% in patients with genitourinary cancers, up to 10% in patients with lymphomas and acute myeloid lymphoma (AML) and about 1% in patients with melanoma.
He reported that ICI pneumonitis can occur in 1% of patients on CTLA-54 inhibitors, 5% of patients on PD-1/PD-L1 inhibitors, and in 10% of patients on combination treatments.
Dr José noted that there appeared to be a higher incidence of ICI pneumonitis in anti-PD-1 therapy relative to anti-PD-L1 therapy, and in smoking-related lung cancers (20% of patients will experience some degree of ICI-related pneumonitis).2-5 Similar to the timeframe of cardiotoxicity onset, the median onset is typically 3-4 months after initiation of therapy, although this can be sooner or later, and, in some cases, it can even occur after the therapy has ceased.
Therefore, Dr José urged physicians to approach cases with a high index of suspicion.
In real-world studies, the incidence of ICI pneumonitis can be as high as 33% in patients receiving sequential therapy
(Image credit: Wanderluster/Getty Images)
References
1. Jung J, Kim HY, Kim DG, Park SY, Ko AR, Han JY, Kim HT, Lee JS, Lee Y. Sequential treatment with an immune checkpoint inhibitor followed by a small-molecule targeted agent increases drug-induced pneumonitis. Cancer Res Treat 2021; 53(1):77-86.
2. Nishino M, Giobbie-Hurder A, Hatabu H et al. Incidence of programmed cell death 1 inhibitor–related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncol 2016; 2(12): 1607-16.
3. Su Q, Zhu EC, Wu JB et al. Risk of pneumonitis and pneumonia associated with immune checkpoint inhibitors for solid tumors: a systematic review and meta-analysis. Front Immunol 2019; 10: 108.
4. Khunger M, Rakshit S, Pasupuleti V et al. Incidence of pneumonitis with use of programmed death 1 and programmed death-ligand 1 inhibitors in non-small cell lung cancer: a systematic review and meta-analysis of trials. Chest 2017; 152(2): 271-81.
5. Fukihara J, Sakamoto K, Koyama J et al. Prognostic impact and risk factors of immune-related pneumonitis in patients with non–small-cell lung cancer who received programmed death 1 inhibitors. Clin Lung Cancer 2019; 20(6): 442-50.
Risk factors
According to Dr José, ICI pneumonitis in NSCLC patients can increase by the presence of the following risk factors:
Interstitial lung disease
Interstitial lung disease
Pre-existing COPD
Pre-existing COPD
Chest radiation, or
Chest radiation, or
Treatment in combination with tyrosine kinase inhibitors2-5
Treatment in combination with tyrosine kinase inhibitors2-5
References
2. Nishino M, Giobbie-Hurder A, Hatabu H et al. Incidence of programmed cell death 1 inhibitor–related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncol 2016; 2(12): 1607-16.
3. Su Q, Zhu EC, Wu JB et al. Risk of pneumonitis and pneumonia associated with immune checkpoint inhibitors for solid tumors: a systematic review and meta-analysis. Front Immunol 2019; 10: 108.
4. Khunger M, Rakshit S, Pasupuleti V et al. Incidence of pneumonitis with use of programmed death 1 and programmed death-ligand 1 inhibitors in non-small cell lung cancer: a systematic review and meta-analysis of trials. Chest 2017; 152(2): 271-81.
5. Fukihara J, Sakamoto K, Koyama J et al. Prognostic impact and risk factors of immune-related pneumonitis in patients with non–small-cell lung cancer who received programmed death 1 inhibitors. Clin Lung Cancer 2019; 20(6): 442-50.
Pneumonitis: how to assess the breathless patient
This module reports on Dr Ricardo José’s talk on managing immune checkpoint inhibitor-related pneumonitis, presented at the Royal Marsden conference ‘A user guide to cancer immunotherapy’ held in December 2022.
Pneumonitis: how to assess the breathless patient
This module reports on Dr Ricardo José’s talk on managing immune checkpoint inhibitor-related pneumonitis, presented at the Royal Marsden conference ‘A user guide to cancer immunotherapy’ held in December 2022.
Modern radiotherapy techniques in oncology
Module description
1 CPD hour
In this learning module for oncology trainees, oncologists and healthcare clinicians interested in oncology, Dr Sophie Raby discusses advances in radiotherapy techniques. Key learning points include the indications for the use of each approach and their practical applicability within the context of the NHS.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Understand the usefulness and prevalence of radiotherapy in cancer management
● Learn about the types of stereotactic radiotherapy, challenges involved, and indications for these procedures
● Consider the clinical utility of high-energy proton radiotherapy and patient eligibility for this treatment
● Review the clinical utility of a magnetic resonance linear accelerator (MR LINAC) in planning radiotherapy treatment
● Read about how 4D imaging is used in the planning and delivery of radiotherapy
● Refer to the clinical practice of deep inspiration breath hold for patients receiving radiotherapy to minimise cardiac exposure to radiation magnetic resonance linear accelerator (MR LINAC) in planning radiotherapy treatment
History of radiotherapy
Radiotherapy treatment has rapidly evolved and expanded over the last 100 years since Wilhelm Roentgen discovered X-rays in 1895 and Marie Curie discovered radium in 1898. In 1907, Sabouraud introduced radiotherapy to treat ringworm, and this continued to be used as the standard technique for over 50 years until it was replaced with griseofulvin, which was introduced in 1957. Children who were treated with radiation were found to have an increased risk of subsequently developing meningiomas.1 Experimental treatment of cancers began in the early half of the 20th century, but the dangers of radiotherapy soon became apparent when the experimenters discovered that radiation could cause cancer as well as cure it.
Roentgen discovered X-rays in 1895, and for 50 years from 1907, radiation was used to treat ringworm
(Image credit: ZU_09/DigitalVision Vectors/Getty Images)
References
1. Pfeffer RM, Lawrence Y, Symon Z. Radiation epilation for tinea capitis: a historical review. Int J Radiat Oncol Biol Phys 2012; 84(3): S547.
Evolution of techniques
Radiotherapy plays a key role in the management of patients with cancer. Up to 40% of cancer patients receive radiotherapy as part of a curative radical management plan, and 50% of all patients with a cancer diagnosis will receive radiotherapy at some point during their treatment, either with a curative or palliative intent (for example, in the management of painful bone metastases, cord compression, gastrointestinal bleeding and brain metastases).2,3 Despite this, radiotherapy receives only 5% from the NHS cancer budget,4 which is a relatively small allocation from the budget when compared to the funding for systemic treatment.
Radiotherapy is evolving. Scroll below to find out more.
CRT
The last few decades have seen the evolution of conformal external beam radiotherapy (CRT), which uses computed tomographic (CT) images to precisely delineate a target, with X-ray beams from different directions targeting a tumour. Prior to this, radiotherapy beams were delivered using minimal image guidance as simple square or rectangular fields.
Conformal radiation therapy (CRT)
(Image credit: JazzIRT/Getty Images)
IMRT
Intensity-modulated radiotherapy (IMRT) is an extension of CRT, in which individual beams can be modified to produce doses of varying intensity, sculpting and shaping the beam to produce a concave shape. This reduces the dose and, consequently, the toxicity, to nearby normal tissues.
Intensity-modulated radiotherapy (IMRT)
(Image credit: Mark Kostich/Getty Images)
VMAT
Unlike IMRT, which uses multiple different beams of different intensities to produce an inhomogeneous dose distribution, volumetric modulated arc therapy (VMAT) can deliver dose continuously as the gantry of the linear accelerator (LINAC) rotates around the patient, hence reducing treatment time and minimising the overall dose. It is being increasingly used for everyday radiotherapy treatment and is especially useful when a tumour is next to a critical organ at risk.
Volumetric modulated arc therapy (VMAT)
(Image credit: Mark Kostich/Getty Images)
References
2. Parker T. Radiotherapy services in England 2012. DH 2012.
3. Atun R, Jaffray DA, Barton MB et al. Expanding global access to radiotherapy. Lancet Oncol 2015; 16(10): 1153–86.
4. Norlund A. SBU Survey Group. Costs of radiotherapy. Acta Oncol 2003; 42: 411–5.
Stereotactic radiotherapy
Stereotactic radiotherapy is the precise delivery of a focused high dose per fraction irradiation to small targets using advanced image guidance, delivery apparatus and patient immobilisation systems.
It has seen a rapid increase in use among patients with a limited burden of metastatic disease (often referred to as oligo-metastatic disease). Thanks to the improvements in non-curative systemic therapies, there is a growing population of patients living with active metastatic malignancy.
Modern radiotherapy techniques in oncology
In this learning module for oncology trainees, oncologists and healthcare clinicians interested in oncology, Dr Sophie Raby discusses advances in radiotherapy techniques.
Modern radiotherapy techniques in oncology
In this learning module for oncology trainees, oncologists and healthcare clinicians interested in oncology, Dr Sophie Raby discusses advances in radiotherapy techniques.
Managing the oncology patient’s expectations
2 CPD hours
In this learning module for oncologists and other healthcare professionals, Drs Lucy Faulker, Harriet S Walter, Sam Khan, Anne L Thomas and Olubukola Ayodele discuss the evolution of cancer medicine and the accompanying challenges in managing the oncology patient’s expectations.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Consider the rapid advances in cancer diagnostics and treatment
● Appreciate the importance of communication with the patient and within the multidisciplinary team
● Understand what motivates patients to participate (or decline from participating) in clinical trials
Guidance update: pembrolizumab plus chemotherapy in locally advanced or metastatic triple negative breast cancer
0.25 CPD hours
In this guidance update, Dr Ailsa Oswald looks at NICE’s recommendations on pembrolizumab with paclitaxel or nab-paclitaxel for triple-negative, locally recurrent unresectable or metastatic breast cancer in adults who have not had chemotherapy for metastatic disease.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Understand the criteria for recommendation of treatment for locally advanced or metastatic triple negative breast cancer (TNBC)
● Review approvals currently in place for treating locally unresectable or metastatic TNBC
● Read about what the guidelines mean for patients with TNBC
Podcast: the changing picture of cancer
0.5 CPD hours
Good cancer care involves not only deploying the latest diagnostic tests and treatments, but also treating your patient as an individual. This special episode of the Clinical Update podcast features an interview with oncology physician Dr Robert Uzzo, president and CEO of the Fox Chase Cancer Centre in Philadelphia, USA.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Recall the scale of the cancer burden globally
● Reflect on current thinking about why cancer develops
● Understand how cancer screening and diagnosis are changing
● Consider how practice is changing in the light of new advances
HIV-associated malignancies
1 CPD hour
In this learning module, aimed at oncologists and healthcare professionals with an interest in oncology, Dr Alessia Dalla Pria and Professor Mark Bower describe malignancies that are associated with HIV.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Discuss the cancer risk in people living with HIV (PLWH)
● Learn about the effect of therapy on cancer survival outcomes in PLWH
● Be aware of the cancers that are considered to define AIDS when PLWH develop them
● Review the non-AIDS-defining malignancies and their treatment outcomes
Managing the oncology patient’s expectations
2 CPD hours
In this learning module for oncologists and other healthcare professionals, Drs Lucy Faulker, Harriet S Walter, Sam Khan, Anne L Thomas and Olubukola Ayodele discuss the evolution of cancer medicine and the accompanying challenges in managing the oncology patient’s expectations.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Consider the rapid advances in cancer diagnostics and treatment
● Appreciate the importance of communication with the patient and within the multidisciplinary team
● Understand what motivates patients to participate (or decline from participating) in clinical trials
Guidance update: pembrolizumab plus chemotherapy in locally advanced or metastatic triple negative breast cancer
0.25 CPD hours
In this guidance update, Dr Ailsa Oswald looks at NICE’s recommendations on pembrolizumab with paclitaxel or nab-paclitaxel for triple-negative, locally recurrent unresectable or metastatic breast cancer in adults who have not had chemotherapy for metastatic disease.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Understand the criteria for recommendation of treatment for locally advanced or metastatic triple negative breast cancer (TNBC)
● Review approvals currently in place for treating locally unresectable or metastatic TNBC
● Read about what the guidelines mean for patients with TNBC
Podcast: the changing picture of cancer
0.5 CPD hours
Good cancer care involves not only deploying the latest diagnostic tests and treatments, but also treating your patient as an individual. This special episode of the Clinical Update podcast features an interview with oncology physician Dr Robert Uzzo, president and CEO of the Fox Chase Cancer Centre in Philadelphia, USA.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Recall the scale of the cancer burden globally
● Reflect on current thinking about why cancer develops
● Understand how cancer screening and diagnosis are changing
● Consider how practice is changing in the light of new advances
HIV-associated malignancies
1 CPD hour
In this learning module, aimed at oncologists and healthcare professionals with an interest in oncology, Dr Alessia Dalla Pria and Professor Mark Bower describe malignancies that are associated with HIV.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Discuss the cancer risk in people living with HIV (PLWH)
● Learn about the effect of therapy on cancer survival outcomes in PLWH
● Be aware of the cancers that are considered to define AIDS when PLWH develop them
● Review the non-AIDS-defining malignancies and their treatment outcomes
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