Accreditation/Credit Designation

Physicians' Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians' Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians’ Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669, for 1.5 Contact Hours.

Acknowledgment of Commercial Support

This activity is supported by educational grants from Array BioPharma, Inc., Celgene Corporation, Exelixis Inc., Incyte Corporation, Lilly, and Merck & Co., Inc.

Community Practice Connections™: 4th Annual School of Gastrointestinal Oncology™

Release Date: June 30, 2019
Expiration Date: June 30, 2020
Media: Internet - based

Activity Overview

Gastrointestinal cancers are among the most complex solid tumors, requiring a high level of multidisciplinary care and cooperation for optimal management. This online educational activity recaps the key findings of the practice-changing 4th Annual School of Gastrointestinal Oncology™ (SOGO®) is a 1-day, multidisciplinary educational conference featuring John Marshall, MD, director of the Ruesch Center for the Cure of Gastrointestinal Cancers in Washington, DC and Michael A. Choti, MD, Chief of Surgery at Banner MD Anderson Cancer Center in Phoenix, AZ. Key topics covered include the current appropriate management and future directions in colorectal cancer, hepatocellular carcinoma (including both locoregional and systemic approaches), as well as pancreatic cancer.

Benefits of Participating

  • Recognize best practices and areas of controversy in the management of GI malignancies
  • Update your practice with perspectives from top experts in the field of GI malignancies
  • Learn to effectively identify and manage adverse events that may occur with treatments across GI malignancies
  • Incorporate clinical trial results into your practice to provide the best possible treatments for patients with GI malignancies

Acknowledgement of Commercial Support

This activity is supported by educational grants from Array BioPharma, Inc., Celgene Corporation, Exelixis Inc., Incyte Corporation, Lilly, and Merck & Co., Inc.

Instructions for This Activity and Receiving Credit

  • You will need to log in to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review video files/content until you finish the presentation.
  • At the end of the activity, educational content/video files will be available for your reference.
  • In order to receive a CME/CE certificate, you must complete the activity.
  • Complete the Posttest and pass with a score of 70% or higher, complete the Evaluation, and then click on “Request for Credit.” You may immediately download a CME/CE certificate upon completion of these steps.


Target Audience

This educational activity is directed toward oncologists, as well as surgeons, pathologists, nurses, and fellows, involved in the treatment and management of patients with GI cancers. Physician assistants, pharmacists, researchers, and other healthcare professionals interested in the treatment of GI malignancies may also participate.

Learning Objectives

Upon successful completion of this activity, you should be better prepared to:

  • Describe the patient- and tumor-related prognostic factors and biomarkers important to the stratification of risk and clinical decision-making in the management of patients with GI malignancies
  • Explain pivotal trial evidence to inform multidisciplinary clinical decision-making in the personalized management of advanced forms of GI cancers
  • Assess strategies to proactively plan for, prevent, and mitigate predictable toxicities associated with therapies used to treat GI tumors
  • Apply emerging clinical trial data to manage cases in the context of evolving treatment paradigms for GI cancers

Faculty, Staff, and Planners’ Disclosures

Faculty

John L. Marshall
John L. Marshall, MD
Chief, Division of Hematology/Oncology
Medstar Georgetown University Hospital
Director, Ruesch Center for the Cure of Gastrointestinal Cancers
Washington, DC

Disclosures: Grant/Research Support: Genentech, Amgen, Bayer, Taiho Pharmaceutical, Celgene, Caris Life Sciences, Merck; Consultant: Genentech, Amgen, Bayer, Taiho Pharmaceuticals, Celgene, Caris Life Sciences, Merck; Speakers Bureau: Genentech, Amgen, Bayer, Taiho Pharmaceutical, Celgene, Caris Life Sciences, Merck.

Michael A. Choti
Michael A. Choti, MD
Chief of Surgery
Banner MD Anderson Cancer Center
Phoenix, AZ

Disclosures: Michael A. Choti has no relevant financial relationships with commercial interests to disclose.

Wells Messersmith
Wells Messersmith, MD, FACP
Professor and Head, Division of Medical Oncology
Director, GI Medical Oncology Program
Co-Leader, Developmental Therapeutics Program
University of Colorado Cancer Center
University of Colorado School of Medicine
Denver, CO

Disclosures: Grant/Research Support: Pfizer, Roche, OncoMed, Aduro Biotech, Inegte; Data Safety Monitoring Board: Five Prime.

Bassel F. El-Rayes
Bassel F. El-Rayes, MD
John Kauffman Family Professor for Pancreatic Cancer Research
Georgia Cancer Coalition Distinguished Scholar
Director, Gastrointestinal Oncology Program
Vice Chair for Clinical Research
Department of Hematology and Medical Oncology
Associate Director for Clinical Research, Winship Cancer Institute
Emory University
Atlanta, GA

Disclosures: Grant/Research Support: Merck, Five Prime Therapeutics, BBI, Bristol-Myers Squibb, Taiho Oncology, ICON HCRN, Bayer, Cleave Biosciences; Consultant: Bayer, Loxo Oncology.

Anthony El-Khoueiry
Anthony El-Khoueiry, MD
Associate Professor of Clinical Medicine
Medical Director, Clinical Investigations Support Office
Phase I Program Director
USC Norris Comprehensive Cancer Center
Los Angeles, CA

Disclosures: Grant/Research Support: AstraZeneca, Astex; Consultant: EMD Serono, Bristol-Myers Squibb, Bayer, Merck, Eisai, Agenus, CytomX, Pieris.

The staff of Physicians' Education Resource®, LLC (PER®), have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent clinical judgment of a physician or nurse relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members, and do not reflect those of PER® or any of the companies that provided commercial support for this program.

PER Pulse Recaps

1 of 3
Insight From John L. Marshall, MD–PER Pulse™ Recap:
Community Practice Connections™: 4th Annual School of Gastrointestinal Oncology™

Community Practice Connections™: 4th Annual School of Gastrointestinal Oncology™ is a continuing medical education–certified program. For this program, cochairs John L. Marshall, MD, and Michael A. Choti, MD, MBA, were joined by numerous expert faculty across gastrointestinal malignancies to discuss the latest data and clinical best practices.

This first of 3 PER Pulse™ Recaps summarizing the online activity focuses on strategies for individualizing decision making with regard to appropriate use of treatment strategies across gastrointestinal malignancies. Below are some highlights from the activity featuring Dr Marshall:

  • Colorectal cancer (CRC) is the third leading cause of death in the United States, and within CRC, metastatic disease is the leading cause of death. With 20% to 25% of patients presenting with metastases and another 50% to 60% developing metastases over the course of disease, managing metastatic CRC is crucial to improving outcomes.1,2
  • Multiple treatment options are available for patients with advanced or metastatic colon cancer, including combinations with VEGF inhibitors, such as bevacizumab, ziv-aflibercept, or ramucirumab. Patients with EGFR-mutant disease may receive EGFR inhibitors, such as cetuximab or panitumumab.1
  • BRAF/MEK inhibitors, such as vemurafenib, dabrafenib/trametinib, or encorafenib/binimetinib, are also available options in combination with EGFR inhibitors, such as cetuximab or panitumumab, in patients with the BRAF V600E mutation.1,3
  • The checkpoint inhibitors pembrolizumab and nivolumab with or without ipilimumab are available for patients with DNA mismatch repair (dMMR) genetic mutations and microsatellite instability–high (MSI-H) disease.4,5
  • For a small proportion of patients (approximately 1% with metastatic CRC), NTRK fusions may be targeted with larotrectinib.1,3,6

“Every single patient with cancer, regardless of type, should have microsatellite testing…We have a broad approval in MSI-H–positive cancers for immunotherapy.”

— John Marshall, MD

References

  1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Colon cancer. Version 2.2019. NCCN website. nccn.org/professionals/physician_gls/pdf/colon.pdf. Published May 15, 2019. Accessed June 26, 2019.
  2. Xing M, Kooby DA, El-Rayes BF, Kokabi N, Camacho JC, Kim HS. Locoregional therapies for metastatic colorectal carcinoma to the liver--an evidence-based review. J Surg Oncol. 2014;110(2):182-196. doi: 10.1002/jso.23619.
  3. Drilon A, Laetsch TW, Kummar S, et al. Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children. N Engl J Med. 2018;378(8):731-739. doi: 10.1056/NEJMoa1714448.
  4. Le DT, Uram JN, Wang H, et al. PD-1 blockade in tumors with mismatch-repair deficiency. N Engl J Med. 2015;372(26):2509-2520. doi: 10.1056/NEJMoa1500596.
  5. Andre T, Lonardi S, Wong M, et al. Nivolumab + ipilimumab combination in patients with DNA mismatch repair-deficient/microsatellite instability-high (dMMR/MSI-H) metastatic colorectal cancer (mCRC): first report of the full cohort from CheckMate-142. J Clin Oncol. 2018;36(suppl 4). ascopubs.org/doi/abs/10.1200/JCO.2018.36.4_suppl.553. Published February 26, 2018. Accessed June 27, 2019.
  6. Bonneville R, Krook MA, Kautto EA, et al. Landscape of microsatellite instability across 39 cancer types [published online October 3, 2017]. JCO Precis Oncol. ascopubs.org/doi/full/10.1200/PO.17.00073. Accessed June 27, 2019.

2 of 3
Insight From Anthony B. El-Khoueiry, MD–PER Pulse™ Recap:
Community Practice Connections™: 4th Annual School of Gastrointestinal Oncology™

Community Practice Connections™: 4th Annual School of Gastrointestinal Oncology™ is a continuing medical education–certified program. For this program, cochairs John L. Marshall, MD, and Michael A. Choti, MD, MBA, were joined by numerous expert faculty, including Dr El-Khoueiry, to discuss the state of the art in gastrointestinal malignancies, including the latest data and clinical best practices.

This second of 3 PER Pulse™ Recaps summarizing the online activity focuses on strategies for individualizing decision making with regard to appropriate use of treatment strategies across gastrointestinal malignancies. Below are some highlights from the activity featuring Dr El-Khoueiry:

  • In patients with cancers of the liver and intrahepatic bile duct, the American Cancer Society projects 42,030 diagnoses in 2019. These new cases, combined with new cases diagnosed in previous years, will result in an estimated 31,780 deaths. Of the total diagnoses, 29,480 are expected to occur in men and the remaining 12,550 in women. Annual deaths are estimated at 21,600, and 10,180 cases, respectively.1
  • Sorafenib as first-line therapy was studied in the SHARP trial. Those results demonstrated that sorafenib improves overall survival and is safe for patients with advanced hepatocellular carcinoma. In this study, the median overall survival was 10.7 months in the sorafenib group and 7.9 months in the placebo group (HR, 0.69; P <.001).2,3
  • The pivotal clinical trial of lenvatinib, REFLECT, compared overall survival in patients treated with lenvatinib versus sorafenib as a first-line treatment for unresectable hepatocellular carcinoma. In this study, treatments included lenvatinib (12 mg/day for bodyweight ≥60 kg or 8 mg/day for bodyweight <60 kg) and sorafenib 400 mg twice daily in 28-day cycles. In this study, the median survival time was 13.6 months with lenvatinib and 12.3 months with sorafenib (HR, 0.92; 95% CI, 0.79-1.06), meeting criteria for noninferiority.1,4
  • 1:
    • Regorafenib (Child-Pugh Class A only): category 1
    • Cabozantinib (Child- Pugh Class A only): category 1
    • Ramucirumab (AFP ≥ 400 ng/mL only): category 1
    • Nivolumab (Child-Pugh Class A or B7)
    • Sorafenib (Child-Pugh Class A or B7), after first-line lenvatinib
    • Pembrolizumab (Child-Pugh Class A only): category 2B

“Liver cancer is a very heterogeneous tumor with various etiologies that is also complicated by the presence of underlying liver cirrhosis.”

— Anthony El-Khoueiry, MD

References

  1. American Cancer Society. Cancer facts & figures 2019. ACS website. cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2019.html. Accessed June 26, 2019.
  2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Hepatobiliary cancers. Version 2.2019. NCCN website. nccn.org/professionals/physician_gls/pdf/hepatobiliary.pdf. Published March 6, 2019. Accessed June 26, 2019.
  3. Llovet JM, Ricci S, Mazzaferro V, et al; SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008;359(4):378-390. doi: 10.1056/NEJMoa0708857.
  4. Kudo M, Finn RS, Qin S, et al. Lenvatinib versus sorafenib in first-line treatment of patients with unresectable hepatocellular carcinoma: a randomised phase 3 non-inferiority trial. Lancet. 2018;391(10126):1163-1173. doi: 10.1016/S0140-6736(18)30207-1.

3 of 3
Insight From Bassel F. El-Rayes, MD–PER Pulse™ Recap:
Community Practice Connections™: 4th Annual School of Gastrointestinal Oncology™

Community Practice Connections™: 4th Annual School of Gastrointestinal Oncology™ is a continuing medical education–certified program. For this program, cochairs John L. Marshall, MD, and Michael A. Choti, MD, MBA, were joined by numerous expert faculty, including Bassel F. El-Rayes, MD, to discuss the state of the art in gastrointestinal malignancies, including the latest data and clinical best practices.

This third of 3 PER Pulse™ Recaps summarizing the online activity focuses on strategies for individualizing decision making with regard to appropriate use of treatment strategies across gastrointestinal malignancies. Below are some highlights from the activity featuring Dr El-Rayes:

  • Colorectal cancer is the third leading cause of death in the United States, and within colorectal cancer, metastatic disease is the leading cause of death. With 20% to 25% of patients presenting with metastases, and another 50% to 60% of patients developing metastases over the course of disease, managing metastases in colorectal cancer is crucial to improving outcomes.1,2
  • Due to its proximity to the mesenteric system, the liver is the most common site of metastasis in CRC. As a result, locoregional treatment options such as ablation, arterially directed therapy, or radiation therapy are important modalities for managing disease.1,2
  • In defining patient risk factors, it is important to consider whether or not patients are good candidates for surgery based on their comorbidities, preferences, anatomy-related factors, and disease biology. Several nonsurgical options are available for patients who do not quality for surgical therapy, including ablative technologies such as radiofrequency ablation, microwave ablation, stereotactic body radiotherapy, and localized transarterial radioembolization. Catheter-directed options include transarterial catheter chemoembolization, transarterial radioembolization, and hepatic artery infusion.1,2
  • In the modern era, ablative technologies are preferred in patients with lower disease extent and intra-arterial options are preferred in patients with greater disease extent.3
  • Multiple ongoing prospective studies, such as SIRFLOX and FOXFIRE, will answer important questions about the role of emerging technologies in different patient populations.3

“Management of patients with locoregional therapy in colorectal cancer requires multiple specialties, like medical oncology, surgical oncology, interventional radiology, radiation oncology, and radiology.”

— Bassel F. El-Rayes, MD

References

  1. National Comprehensive Cancer Network. Colon Cancer. V2.2019. https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf. Published May 15, 2019. Accessed June 26, 2019.
  2. Xing M, Kooby DA, El-Rayes BF, Kokabi N, Camacho JC, Kim HS. Locoregional therapies for metastatic colorectal carcinoma to the liver--an evidence-based review. J Surg Oncol. 2014;110(2):182-196. doi: 10.1002/jso.23619.
  3. Virdee PS, Moschandreas J, Gebski V, et al. Protocol for combined analysis of FOXFIRE, SIRFLOX, and FOXFIRE-global randomized phase III trials of chemotherapy +/- selective internal radiation therapy as first-line treatment for patients with metastatic colorectal cancer. JMIR Res Protoc. 2017;6(3):e43. doi: 10.2196/resprot.7201.

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