Managing Therapies in Patients With Cervical and Endometrial Cancers

Pharmacists play a key role in educating patients on risk factors for cervical and endometrial cancers, and disease prevention, and can also assist with treatment decisions, and management of potential adverse effects in patients with these cancers, according to a virtual session at the American Society of Health-System Pharmacists 2020 Midyear Clinical Meeting and Exhibition.

In the cervical and endometrial cancer overview, Allison Baxley, PharmD, BCOP, discussed the current systemic treatment options in cervical and endometrial cancers, such as traditional chemotherapy, targeted therapy, and immunotherapy. According to Baxley, cervical cancer is the 4^th most common cancer in women worldwide. Incidence of cervical cancer is significantly higher in underdeveloped countries, due to the lower rates of and limited access to screening and vaccination against persistent human papillomavirus (HPV) infection, the primary cause of cervical cancer.

Further, 80% of cervical cancers are squamous cell carcinoma, with the remainder are adenocarcinoma or mixed histology. HPV infection is associated with all histologic subtypes of cervical cancer.

As for treatment, Baxley described how cervical cancer treatments tend to combine different types of therapies depending on the stage of disease to see which ones work the best on patients. “We often combine chemotherapy with targeted therapy to look at how they work and how we use those,” Baxley added.

Endometrial cancer is the most common gynecologic malignancy in the United States, primarily affecting women in peri- and post-menopausal years. In addition, endometrial adenocarcinoma accounts for approximately 80% of all endometrial cancers, according to Baxley. The treatments for this type of cancer include surgery and adjuvant therapy with either radiation or systemic therapy, or surgery and systemic therapy with or without radiation.

Biomarkers become crucial in both cervical and endometrial cancers, since they allow for patient-specific treatment options based on disease characteristics. According to the National Cancer Institute, a biomarker is “a biological molecule found in blood, other body fluids, or tissues that is a sign of a normal or abnormal process, or of a condition or disease.” In the oncology spectrum, a biomarker may be a molecule secreted by a tumor or a specific response of the body to the presence of cancer.

Baxley concluded that biomarkers, including MSI-H/dMMR, TMB, and NTRK gene fusion are used to help guide therapy decisions in patients with cervical or endometrial cancer. Further, she added that numerous agents are FDA-approved in the treatment of cervical and endometrial cancers with more under investigation.

The pharmacist’s role in terms of cervical and endometrial cancers includes educating patients, assessing and monitoring treatment adherence, and assisting with medication access for targeted and immunotherapies, according to Laura Alwan, PharmD, BCOP.

As for prevention and risk reduction strategies, the American Cancer Society 2020 update lists that for individuals of average risk younger than age 25 years do not need to be screened for cervical cancer. However, those between age 25 and 65 years should get a primary HPV test every 5 years, anyone older than 65 years should discontinue screening if adequate prior negative screening.

A risk reduction strategy for cervical cancer includes smoking cessation, such as counseling and support groups, according to Alwan. Prevention would be to receive an HPV vaccination, which is recommended for all males and females between the ages of 9 and 26 years. For those between ages 27 and 45 years, the vaccine may be beneficial, but getting screened is more important at this point in time.

“It’s really important to talk to patients and caregivers that even if they have the HPV vaccine, it is important that they are screened regularly,” Alwan said.

Screening for endometrial cancer is currently not effective and is not recommended in healthy women. As for risk reduction, health care providers encourage healthy weight loss in overweight and obese patients, and to avoid estrogen-only hormone replacement if the uterus is intact, according to Alwan.

The pharmacist plays an important role in medication adherence and access, specifically in identifying barriers to access and adherence, such as cost of treatment, past medical and family histories, current medications, and preferred contact and method of follow-up care.

Alwan emphasized that patient education to improve adherence is key. For example, in adherence assessment, the pharmacist can implement the use of memory aids and planned follow-up communication in addition to collaborating with a dispensing pharmacy to monitor refills.

In terms of adverse effects (AEs) from medications, at-home symptom management and when to seek immediate care are crucial topics for the pharmacist to educate patients on.

Alwan concluded that targeted and immunotherapy agents have unique AEs, dosing considerations, and monitoring parameters for patients compared with conventional chemotherapy. Further, she reminded viewers that biomarkers are useful in guiding treatment decisions in cervical and endometrial cancers in the first- and second-line treatment settings.

REFERENCE

Alwan L, Baxley A. Advanced or metastatic cervical and endometrial cancers: the pharmacist’s role in caring for patients on targeted and immunotherapies. Presented at: American Society of Health-System Pharmacists 2020 ASHP Midyear Clinical Meeting and Exhibition; December 9, 2020: virtual.