The Patient Experience With Community-Based Care for Metastatic Colorectal Cancer

JOLEEN HUBBARD, MD
Deputy Director, Clinical
Research, Allina Health
Cancer Institute
Minneapolis, MN

AJMC®: How would you describe the differences in patient experience between receiving metastatic colorectal cancer (mCRC) care in a community setting versus requiring a referral to a tertiary center?

HUBBARD: The patient experience in mCRC care differs between community settings and tertiary centers, mainly due to the need for multidisciplinary care. Referral to tertiary centers is common when specialist involvement, like thoracic or liver surgeons, is necessary for resectable or potentially resectable disease. Chemotherapy protocols remain consistent across settings. Patients often undergo multidisciplinary evaluations at tertiary centers and then continue chemotherapy in the community setting, either before or after surgery. Referral to tertiary centers may also occur for access to clinical trials, especially phase 1 or 2 trials, which might not be available locally, depending on the trial and patient context.

AJMC: What are the main advantages of continuing mCRC care in a community oncology setting compared with a tertiary center?

HUBBARD: In community oncology settings, the smaller scale often fosters a more personal patient experience due to fewer staff members. Parking tends to be more accessible compared with tertiary care centers located in metropolitan areas. This convenience is significant, especially considering the frequent appointments spanning months to years for treatment. For many patients, the ability to park easily and receive treatment without extensive commuting is crucial for their quality of life.

Moreover, with a growing number of younger patients with CRC who are often juggling treatment with work and family commitments, staying in their community allows them to maintain engagement in their daily lives, whether it’s attending events or being with family. Minimizing the time spent on treatment-related activities such as appointments, getting [laboratory testing], and waiting for results enables patients to prioritize their time with loved ones and in their communities. These factors underscore the importance of accessible care close to home for [patients with mCRC].

AJMC: How does access to clinical trials impact the treatment options available to patients with progressed mCRC in community oncology settings?

HUBBARD: In community oncology settings, access to clinical trials for patients with progressed mCRC varies based on trial availability. Typically, community centers participate in larger phase 3 trials conducted nationwide as part of a consortium. However, as patients exhaust standard therapies, particularly in later lines of treatment, they may seek earlier phase trials like phase 1 or phase 2, which are more commonly available in tertiary care centers or major metropolitan areas. Thus, tertiary centers offer more opportunities for patients to access these early-phase trials, expanding their treatment options beyond standard therapies.

AJMC: In community practices, how do patient preferences influence the choice between regorafenib, fruquintinib, and trifluridine/tipiracil (FTD/TPI) with bevacizumab for progressed mCRC?

HUBBARD: In community practices, when choosing between regorafenib, fruquintinib, and FTD/TPI with bevacizumab for progressed mCRC, patient preferences play a significant role. While patients often inquire about the most effective option, it’s important to note that these agents haven’t been directly compared. Overall survival outcomes suggest a potential advantage with FTD/TPI plus bevacizumab, but certainty is lacking. Some patients prefer treatments that don’t require frequent visits to infusion centers, making fruquintinib or regorafenib favorable options for them initially, knowing that FTD/TPI plus bevacizumab will remain an option in the future. Additionally, considerations extend beyond efficacy to include quality of life and potential [adverse] effects. [Study outcomes] indicate that FTD/TPI plus bevacizumab can maintain quality of life without compromising it, a crucial factor for patients facing advanced stages of cancer. Therefore, alongside efficacy, patient comfort and quality of life heavily influence treatment decisions in community settings.

AJMC: What real-world experiences can you share regarding the use of combination therapy involving FTD/TPI with bevacizumab in treating patients with progressed mCRC?

HUBBARD: In my experience with patients receiving combination therapy [involving] FTD/TPI with bevacizumab for progressed mCRC, fatigue emerges as a significant challenge. While we can manage nausea effectively, fatigue remains a prevalent issue, impacting patients’ quality of life. Additionally, cytopenias, particularly neutropenia, require monitoring due to the risk of infections. Despite these challenges, overall tolerance is reasonable, and patients can maintain a decent quality of life. Encouraging physical activity and collaborating closely with palliative care can help alleviate fatigue. While neutropenia typically doesn’t lead to severe infections, careful monitoring and [dose adjustments] may be necessary. Thus, fatigue and neutropenia stand out as the primary concerns in real-world experiences with this combination therapy.

AJMC: What challenges do you face in ensuring treatment adherence among patients with mCRC receiving these therapies in the community?

HUBBARD: Ensuring treatment adherence among [patients with mCRC] in the community poses challenges, particularly with oral chemotherapies [with which] adherence risk increases. Extensive education, often led by clinical pharmacists, is crucial, especially for medications like FTD/TPI, which has a complex dosing schedule. We implement early toxicity checks, typically within the first week, followed by regular follow-ups to monitor progress and address any emerging issues. Patient adherence is often motivated by the desire for additional survival benefits, especially in advanced treatment stages. While challenges exist, diligent education and proactive follow-up strategies significantly support adherence in community settings.

AJMC: What patient support programs are available to community oncology practices to help patients better understand treatment options and seek financial support?

HUBBARD: Each pharmaceutical company offers support programs that include nursing assistance and patient support programs. These programs often include patient assistance initiatives, sometimes income-dependent, to facilitate medication access. Fortunately, access to drugs has not been a significant issue thanks to the proactive support from pharmaceutical companies. Typically, these companies assign dedicated points of contact known to our pharmacy staff, who assist with accessing available programs to ensure patients receive their prescribed medications without difficulty.

AJMC: From your perspective, what are some of the unmet needs in mCRC care within community oncology settings?

HUBBARD: The unmet needs in mCRC care are consistent across both community and tertiary care settings. Patients require more effective and better-tolerated treatments, especially concerning issues like oxaliplatin-induced peripheral neuropathy. As we progress to third-line treatments and beyond, options are limited, often adding only a few months to survival, which falls short of patients’ needs. The call for drug developers is clear—we need KRAS inhibitors and trials accessible in the community. The pace of drug development and regulatory approval processes needs acceleration to meet the urgent needs of our patients with limited time.

AJMC: What advancements or innovations in mCRC treatment do you foresee impacting community oncology practices in the near future?

HUBBARD: I’m particularly enthusiastic about the development of KRAS inhibitors, considering that about 50% to 55% of mCRC cases involve a RAS mutation, which has been challenging to target effectively. While KRAS G12C inhibitors show promise, they only benefit a small percentage of patients. Thus, the advancement of KRAS or RAS inhibitors is crucial for improving outcomes. Additionally, combining immunotherapy with targeted treatments to activate immune responses in cold tumors holds promise, although progress in this area has been slow. Exciting prospects include bispecifics and cellular therapy, which leverage the patient’s immune system. Expediting the availability of these treatments, particularly KRAS inhibitors, is imperative for enhancing mCRC care in community oncology practices.

AJMC: What final thoughts would you like to share regarding the management of mCRC in the third-line setting?

HUBBARD: It’s crucial for every oncologist, whether in a community or tertiary care setting, to actively enroll patients in existing clinical trials to advance scientific knowledge. Educating patients about the reality of clinical trials is equally vital [for] dispelling myths and misconceptions. Regarding third-line management, while the ideal sequence remains unclear, exposing patients to all available treatments is essential for prolonging survival. Additionally, comprehensive next-generation sequencing is a valuable tool that community oncologists have been utilizing effectively. Continuously incorporating this approach can not only identify treatment options but also potential trial opportunities in the future.