Survival of patients with deficient mismatch repair metastatic colorectal cancer in the pre-immunotherapy era.

BACKGROUND: Metastatic colorectal cancer patients with deficient mismatch repair (dMMR mCRC) benefit from immunotherapy. Interpretation of the single-arm immunotherapy trials is complicated by insignificant survival data during systemic non-immunotherapy. We present survival data on a large, comprehensive cohort of dMMR mCRC patients, treated with or without systemic non-immunotherapy. METHODS: Two hundred and eighty-one dMMR mCRC patients (n = 54 from three prospective Phase 3 CAIRO trials; n = 227 from the Netherlands Cancer Registry). Overall survival was analysed from diagnosis of mCRC (OS), from initiation of first-line (OS1) and second-line (OS2) systemic treatment. Cox regression analysis examined prognostic factors. As comparison for OS 2746 MMR proficient mCRC patients were identified. RESULTS: Of 281 dMMR patients, 62% received first-line and 26% second-line treatment. Median OS was 16.0 months (13.8-19.6) with antitumour therapy and 2.5 months (1.8-3.5) in untreated patients. OS1 was 12.8 months (10.7-15.2) and OS2 6.2 months (5.4-8.9) in treated dMMR patients. Treated dMMR patients had a 7.6-month shorter median OS than pMMR patients. CONCLUSION: Available data from immunotherapy trials lack a control arm with standard systemic treatment. Given the poor outcome compared to the immunotherapy results, our data strongly suggest a survival benefit of immunotherapy in dMMR mCRC patients.

The use of in-hospital medical care for patients with metastasized colon, bronchus, or lung cancer.

PURPOSE: At the end of life, patients and their families tend to favor adequate pain and symptom management and attention to comfort measures over prolongation of life. However, it has been suggested that many cancer patients without curative options still receive aggressive treatment. We therefore aimed to describe the number of diagnostic procedures, hospitalization, and medication use among these patients as well as factors associated with receiving such care. METHODS: We conducted a cohort study on all patients with metastasized cancer from a primary colon or bronchus and lung (BL) neoplasm from the moment of first admittance (January-December 2017) to end of follow-up (November 2018) or death. RESULTS: A total of 408 patients with colon (36%) or BL (64%) cancer were included in this study, with a median survival time of 7.4 months. 93% of the patients were subjected to at least one diagnostic procedure, 49% received chemotherapy, and 56% received expensive medication including immunotherapy. Patients had a median of 4.6 hospital admissions and 2.3 emergency room (ER) visits. A quarter of all patients (n = 105) received specialized palliative care with a mean of 1.96 consultations and the first consultation after a median time of 4.1 months. Patients with BL neoplasms received significantly more diagnostic procedures, chemotherapy episodes, ER/ICU admissions, and more often received an end-of-life statement per person-year than patients with a primary colon neoplasm. Females received significantly less diagnostic procedures and visited the ER/ICU less frequently than males, and patients aged > 70 years received significantly less chemotherapy (episodes) and expensive medication than younger patients. No differences in care were found between different socioeconomic status groups. CONCLUSION: Patients with metastasized colon or BL cancer receive a large amount of in-hospital medical care. Specialized palliative care was initiated relatively late despite the incurable disease status of all patients. Factors associated with more procedures were BL neoplasms, age between 50 and 70, and male gender.

[Palliative sedation in the acute setting]. / Acute palliatieve sedatie.

If a patient receiving palliative care suffers from an acute complication of an underlying disease and death is expected within minutes to hours, acute sedation may be necessary to alleviate intolerable refractory symptoms. Current guidelines do not provide sufficient information regarding the management of acute palliative sedation. Here, we describe the cases of three patients to stress the importance of anticipation for palliative sedation in the acute setting, a stepwise treatment approach and intensive counselling. Key learning points include timely identification and counselling of patients at risk, involvement of close relatives and careful medical management of acute palliative sedation.