The oral kinase inhibitor tucatinib (Tukysa – Seagen) has received accelerated approval from the FDA for use in combination with trastuzumab (Herceptin) for treatment of adults with RAS wild-type human epidermal growth factor receptor 2 (HER2)-positive unresectable or metastatic colorectal cancer that has progressed following treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy regimens. Tucatinib was approved in 2020 for use in combination with trastuzumab and capecitabine (Xeloda, and generics) for treatment of adults with advanced unresectable or metastatic HER2-positive breast cancer, including those with brain metastases, who received at least one prior anti-HER2-based regimen for metastatic disease.

The immune checkpoint inhibitor pembrolizumab (Keytruda – Merck), a programmed death receptor-1 (PD-1) inhibitor, has been granted accelerated approval by the FDA for use in adults and children who have unresectable or metastatic microsatellite-instability-high (MSI-H) or mismatch-repair-deficient (dMMR) solid tumors that have progressed following treatment, and do not have any satisfactory alternative treatment options. For metastatic colorectal cancer, the indication is limited to tumors that have progressed following combination treatment with a fluoropyrimidine, oxaliplatin, and irinotecan. This is the first approval of a cancer drug based solely on the presence of certain biomarkers, regardless of the organ in which the cancer originated or the histology of the tumor.

MSI-H and dMMR are markers for abnormalities in cancer cells that prevent DNA replication and postreplicative DNA repair.1 These biomarkers are found most commonly in cancers of the endometrium, stomach, and colon. The incidence of MSI-H or dMMR in these tumors appears to be lower in advanced disease than in early-stage disease; about 5% of patients with metastatic colorectal cancer have MSI-H or dMMR tumors.2

FDA approval was based on data from five unpublished, single-arm trials of pembrolizumab (summarized in the package insert) that included a total of 149 previously treated adults with various MSI-H or dMMR metastatic or unresectable tumors (90 patients had colorectal cancer). The overall objective response rate was 39.6% and the complete response rate was 7.4%. The median duration of response had not been reached by the end of the study; 78.0% of patients had a response duration of ≥6 months. Adverse reactions, including immune-mediated effects, were similar to those reported previously with pembrolizumab.

The recommended adult dosage of pembrolizumab for this indication is 200 mg IV (2 mg/kg up to a maximum of 200 mg for children) every 3 weeks for a maximum of 24 months. The cost for one adult dose is about $9162.3

Pembrolizumab was previously approved for treatment of unresectable or metastatic melanoma,4 metastatic non-small cell lung cancer (NSCLC), including nonsquamous NSCLC in combination with pemetrexed and carboplatin,5 recurrent or metastatic head and neck squamous cell carcinoma, refractory classical Hodgkin lymphoma, locally advanced or metastatic urothelial carcinoma,6 and recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma.

1. A Copija et al. Clinical significance and prognostic relevance of microsatellite instability in sporadic colorectal cancer patients. Int J Mol Sci 2017 Jan 6 (epub).
2. S Lemery et al. First FDA approval agnostic of cancer site - when a biomarker defines the indication. N Engl J Med 2017; 377:1409.
3. Approximate WAC. WAC represents a published catalogue or list price and may not represent an actual transactional price. Source: AnalySource® Monthly. December 5, 2017. Reprinted with permission by First Databank, Inc. All rights reserved. ©2017. www. fdbhealth.com/policies/drug-pricing-policy.
4. Pembrolizumab (Keytruda) for metastatic melanoma. Med Lett Drugs Ther 2014; 56: e114.
5. Pembrolizumab (Keytruda) for first-line treatment of metastatic NSCLC. Med Lett Drugs Ther 2017; 59:22.
6. Three more immune checkpoint inhibitors for advanced bladder cancer. Med Lett Drugs Ther 2017; 59:e202.

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The FDA has approved naloxegol (Movantik – AstraZeneca), a pegylated derivative of the opioid antagonist naloxone, for oral treatment of opioid-induced constipation in adults with chronic noncancer pain. It is the only oral opioid antagonist approved for this indication in the US.

The FDA has approved the use of the oral multikinase inhibitor sorafenib (Nexavar – Bayer) for treatment of locally recurrent or metastatic, progressive, differentiated thyroid cancer (papillary or follicular) refractory to radioactive iodine treatment. Sorafenib was approved earlier for treatment of advanced renal cell and unresectable hepatocellular cancer.

Electronic cigarettes, also called e-cigarettes, are advertised as a safer, more convenient, and socially acceptable alternative to smoking tobacco cigarettes. Widely available in retail stores and on the Internet, their use has been increasing over recent years, primarily among smokers, but also among non-smokers.

Radium Ra 223 dichloride (Xofigo – Bayer), a radiotherapeutic drug, has been approved by the FDA for intravenous treatment of castration-resistant prostate cancer with symptomatic bone metastases and no known visceral metastatic disease.

The FDA has approved two new oral kinase inhibitors for treatment of unresectable or metastatic melanoma: dabrafenib (Tafinlar – GSK) for melanomas with BRAF V600E mutations and trametinib (Mekinist – GSK) for melanomas with either BRAF V600E or V600K mutations. Dabrafenib is not recommended for patients with wild-type BRAF (BRAF-negative) melanoma, and trametinib is not recommended for patients who have received prior BRAF-inhibitor therapy.

The FDA has approved use of lubiprostone (Amitiza) for treatment of opioid-induced constipation in adults with chronic non-cancer pain. The drug was previously approved for chronic idiopathic constipation and irritable bowel syndrome with constipation.

Two FDA advisory committees recently concluded that use of a nasal spray formulation of the peptide hormone salmon calcitonin for treatment of postmenopausal osteoporosis is associated with an increased risk of cancer. Salmon calcitonin is available as 2 nasal sprays (Miacalcin, Fortical) and an injectable formulation (Miacalcin Injection) for use in osteoporosis.1

The new cancer concern arose from the results of an unpublished meta-analysis that included 18 studies of Miacalcin Nasal Spray in which the risk of any cancer was 1.54 times greater (95% CI: 1.06, 2.23) in patients who used the drug compared to controls.2

An earlier 5-year trial in >1200 postmenopausal women with osteoporosis also found that use of calcitonin was associated with a small, but statistically significant, increase in the risk of any malignancy (OR 1.62, 95% CI: 1.00, 2.61).2 New vertebral fractures occurred in 51 of 287 women (18%) receiving a 200 IU dose of calcitonin nasal spray once daily and in 70 of 270 women (26%) receiving placebo, a statistically significant difference.3

The advisory committees, meeting jointly, weighed the risk against the benefits of the drug and concluded that women should no longer use salmon calcitonin nasal spray for treatment of postmenopausal osteoporosis. The FDA now has to decide whether to approve their recommendations.

1. Drugs for postmenopausal osteoporosis. Treat Guidel Med Lett 2011; 9:67.

2. Novartis. FDA Joint Reproductive Health Drugs and Drug Safety and Risk Management Advisory Committee meeting on the benefit/risk of salmon calcitonin for the treatment of postmenopausal osteoporosis. Briefing book. Available at www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/ReproductiveHealthDrugsAdvisoryCommittee/UCM341781.pdf. Accessed April 4, 2013.

3. CH Chesnut 3rd et al. A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporotic fractures study. PROOF Study Group. Am J Med 2000; 109:267.

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Use of screening tests to identify cancers before they cause symptoms can lead to earlier therapy and may improve outcomes. Screening tests for some common cancers are reviewed below.

Electronic cigarettes, also called e-cigarettes, are battery-operated nicotine-delivery devices that resemble tobacco cigarettes. They deliver vapor containing a mixture of nicotine and either propylene glycol or glycerol. E-cigarettes are widely available in retail stores and on the internet in labeled strengths ranging from zero to high levels of nicotine and in flavors such as tobacco, mint, coffee, cherry, bubblegum, and chocolate. They are advertised as a healthier alternative to smoking a tobacco cigarette and, although not FDA-approved, as a smoking cessation tool.

Axitinib (Inlyta – Pfizer), an oral tyrosine kinase inhibitor, has been approved by the FDA for treatment of advanced renal cell carcinoma after failure of one prior systemic therapy. It is the fourth oral tyrosine kinase inhibitor to be approved for treatment of advanced renal cell carcinoma.

The FDA, which recently approved subcutaneous (SC) administration of denosumab (Prolia – Amgen) for treatment of postmenopausal osteoporosis,1 has now approved the same drug with a different brand name (Xgeva – Amgen) and dosage for prevention of skeletal-related events (such as pathologic fracture, spinal cord compression or radiation to bone) in patients with bone metastases from solid tumors. Denosumab is a fully human anti-RANK ligand antibody that inhibits the formation, activation and survival of osteoclasts.2

A prospective, randomized, double-blind trial in 1901 patients with bone metastases from castration-resistant prostate cancer found that denosumab 120 mg injected SC every 4 weeks, compared to the bisphosphonate zoledronic acid (Zometa) 4 mg IV, delayed the time to a first skeletal event by 3.6 months (20.7 vs. 17.1 months).3 In 1776 patients with bone metastases from solid tumors or multiple myeloma, the mean time to a first skeletal event was 20.6 months with SC denosumab and 16.3 months with IV zoledronic acid.4

Denosumab can lower serum calcium concentrations, especially in patients with impaired renal function. Fatigue is the most commonly reported adverse effect. Other adverse effects of both denosumab and zoledronic acid in clinical trials have included nausea, dyspnea and diarrhea. Acute-phase reactions and renal toxicity have been less frequent with denosumab than with zoledronic acid. Osteonecrosis of the jaw, which can occur with bisphosphonates, has also been reported with denosumab.

1. Denosumab (Prolia) for postmenopausal osteoporosis. Med Lett Drugs Ther 2010; 52: 81.

2. A Lipton and C Goessl. Clinical development of anti-RANKL therapies for treatment and prevention of bone metastasis. Bone 2011; 48:96.

3. K Fizazi et al. A randomized phase III trial of denosumab versus zoledronic acid in patients with bone metastases from castration-resistant prostate cancer. J Clin Oncol 2010; 28:18s (abstr LBA4507).

4. D Henry et al. A double-blind, randomized study of denosumab versus zoledronic acid for the treatment of bone metastases in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma. Eur J Cancer Suppl 2009; 7:11 (abstr 20LBA).

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The FDA has approved 2 new treatments for castration-resistant (formerly called hormone-refractory) prostate cancer. Sipuleucel-T (Provenge – Dendreon) is the first immunotherapy approved for treatment of prostate cancer. Cabazitaxel (Jevtana – Sanofi-Aventis) is approved for second-line treatment of metastatic castration-resistant prostate cancer previously treated with docetaxel (Taxotere).

The FDA has approved ofatumumab (Arzerra – GlaxoSmithKline), a human anti-CD20 monoclonal antibody, for treatment of patients with chronic lymphocytic leukemia (CLL) refractory to fludarabine (Fludara, and others) and alemtuzumab (Campath). It is the second anti-CD20 antibody approved for treatment of CLL; rituximab (Rituxan), a chimeric murine/human antibody, was the first.

The FDA has approved romidepsin (Istodax – Celgene), an IV histone deacetylase (HDAC) inhibitor, for treatment of cutaneous T-cell lymphoma (CTCL) in patients who have received at least one prior systemic therapy. The most common types of CTCL are mycosis fungoides, a low-grade lymphoma usually confined to the skin, and Sézary syndrome, a more aggressive disease with malignant lymphocytes in the blood. Both can progress to fatal systemic involvement. Romidepsin is the second HDAC inhibitor approved for this indication; vorinostat (Zolinza), an oral HDAC inhibitor, was approved earlier.

The FDA has approved a recombinant human papillomavirus (HPV) vaccine (Cervarix – GlaxoSmithKline) for use in girls and women 10-25 years old to prevent infection with HPV types 16 and 18, which have been associated with cervical cancer. A recombinant quadrivalent HPV vaccine (Gardasil – Merck) already on the market in the US prevents infection with HPV types 6, 11, 16 and 18.

Fentanyl buccal soluble film (Onsolis – Meda) has been approved by the FDA for treatment of breakthrough pain in adult cancer patients who are already taking and are tolerant to around-the-clock opioid therapy. It is designated as a Schedule II controlled substance Two other oral transmucosal formulations of fentanyl are already available for this indication.

Fourteen states in the US - Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Jersey, New Mexico, Oregon, Rhode Island, Vermont and Washington - now permit, or soon will permit, some medical use of marijuana (Cannabis sativa). In some states, licensed facilities dispense botanical cannabis by prescription. In others, limited self-cultivation is permitted for medical use.

Several large European observational studies published on-line this summer have raised questions about whether use of insulin glargine increases the risk of cancer.

The incidence of oral cancer appears to be increasing, especially in younger patients. Risk factors include use of tobacco and alcohol, and exposure to human papillomavirus. ViziLite Plus (Zila Pharmaceuticals) is a combination device that uses fluorescent light and toluidine blue tissue staining to help dentists identify abnormal changes in the mucous membranes of the oral cavity. Originally developed for detecting abnormal growths on the uterine cervix, in 2001 it received FDA clearance for "identification, evaluation, and monitoring of oral mucosal abnormalities in a patient population at increased risk for oral cancer." The toluidine blue marking system was cleared for inclusion in 2005.

The US Preventive Services Task Force (USPSTF) has recently concluded that available evidence is insufficient to assess the balance between potential benefits and harms of using the prostate-specific antigen (PSA) to screen men < 75 years old for prostate cancer and has recommended against screening men > 75 years old.

Sunscreens are an important component of photoprotection. A new definition of their effectiveness has been proposed, and some issues have arisen concerning their safety.

Patients are asking physicians about an article on the front page of the June 15th New York Times, in which some prostate cancer experts were quoted as suggesting that men 55 and older might be well advised to take finasteride (Proscar, and others) to prevent prostate cancer.

Ixabepilone (ix ab ep' i lone; Ixempra - Bristol-Myers Squibb), a semisynthetic epothilone analog, has been approved by the FDA for treatment of advanced breast cancer. It is indicated for use in combination with capecitabine (Xeloda - Roche) for treatment of locally advanced or metastatic breast cancer after failure of an anthracycline such as doxorubicin (Adriamycin) and a taxane such as paclitaxel (Taxol, and others). It is also approved as monotherapy for treatment of metastatic or locally advanced breast cancer after an anthracycline, a taxane and capecitabine have failed.

Temsirolimus (Torisel - Wyeth), an mTOR (mammalian target of rapamycin) kinase inhibitor that is metabolized to sirolimus (rapamycin), has been approved by the FDA for intravenous treatment of advanced renal cell carcinoma.

Lapatinib (Tykerb - GlaxoSmithKline), an oral inhibitor of both HER-2 and epidermal growth factor receptor type 1 (EGFR-1 or ErbB-1), has been approved by the FDA for use in combination with capecitabine (Xeloda) to treat advanced or metastatic breast cancer that overexpresses HER-2 in patients who have received prior therapy that included an anthracycline, a taxane and trastuzumab (Herceptin), an intravenous monoclonal antibody that also inhibits HER-2.

The erythropoiesis-stimulating agents (ESAs) epoetin alfa (Epogen, Procrit) and darbepoetin alfa (Aranesp) are widely used for treatment of anemia and to reduce the need for red blood cell transfusions. Based on the results of recent clinical trials indicating an increased risk of serious adverse events and death associated with ESAs, particularly when used to achieve a hemoglobin concentration ≥12 g/dL, the FDA has revised the prescribing information for these drugs to include a black box warning.

A variety of cancer chemotherapy drugs are used, mostly in combination, for treatment of locally advanced and metastatic esophageal, gastric and colorectal cancers. The mechanism of action, indications and adverse effects of some of these drugs are discussed in thei article.

The FDA has approved a new genetic test to identify patients who may be at increased risk of severe toxicity when treated with the cancer chemotherapy drug irinotecan (Camptosar). The Invader UGT1A1 Molecular Assay (Third Wave Technologies) detects the UGT1A1*28 allele, a variation in the uridine diphosphate glucuronosyltranferase 1A1 (UGT1A1) gene. The FDA recently revised the safety labeling for irinotecan, recommending that the dosing of irinotecan be reduced for patients who are homozygous for the UGT1A1*28 allele.

Nelarabine (Arranon - GlaxoSmithKline), a prodrug of the deoxyguanosine analog 9-β-D-arabinofuranosylguanine (ara-G), has been approved by the FDA for treatment of patients with T-cell acute lymphoblastic leukemia (T-ALL) and T-cell lymphoblastic lymphoma (T-LBL) that has not responded to, or has relapsed following, treatment with at least two chemotherapy regimens.

Use of screening tests to identify cancers before they cause symptoms can lead to earlier therapy and may improve outcomes. Screening tests for some common cancers are reviewed.

Abarelix (Plenaxis - Praecis Pharmaceuticals), an injectable gonadotropin-releasing hormone (GnRH) antagonist, has been approved by the FDA for treatment of advanced symptomatic prostate cancer in patients who should not take luteinizing hormone-releasing hormone (LHRH) agonists and who refuse treatment with surgical castration.

Oxaliplatin (Eloxatin -Sanofi-Synthelabo) has been approved by the FDA for use in combination with fluorouracil (5-FU; Adrucil, and others) and leucovorin (LV; Wellcovorin) for patients with metastatic colorectal cancer whose disease has recurred or progressed despite treatment with 5-FU/LV plus irinotecan (Camptosar - Medical Letter 1997; 39:8).

Yttrium-90 ibritumomab tiuxetan (Zevalin -IDEC) was approved by the FDA for treatment of patients with relapsed or refractory low-grade follicular or transformed B-cell non-Hodgkin's lymphoma (NHL), including patients with follicular lymphoma refractory to rituximab (Rituxan -Medical Letter 1998; 40:65). Zevalin is the first radioimmunoconjugate to be approved for treatment of cancer.

Three types of analgesic drugs are available: first, non-opioids, including aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen; second, opioids; and third, drugs not usually thought of as analgesics, which act as adjuvants when given with NSAIDs or opioids, or have analgesic activity of their own in some types of pain. Non-opioids can be given concurrently with opioids for an additive analgesic effect.

Gemcitabine (jem site a been) hydrochloride (Gemzar - Lilly), a nucleoside analog, has been approved by the US Food and Drug Administration for intravenous (IV) use in the first-line treatment of locally advanced or metastatic adenocarcinoma of the pancreas and in patients with pancreatic cancer previously treated with fluorouracil (Adrucil, and others). No previously available drug has had more than minor activity in treating this disease.

High-dose chemotherapy, with or without total body radiation, followed by bone marrow transplantation to restore bone marrow function has been used widely in the treatment of malignant diseases in recent years (Medical Letter, 34:79, 1992; 37:25, 1995). Now, however, instead of using bone marrow itself to restore function destroyed by chemotherapy and radiation, many centers infuse hematopoietic stem cells harvested from peripheral blood. Most stem cell transplants have been autologous; allogeneic stem cells have been tried in a small number of patients (WI Bensinger et al, Blood, 85:1655, March 15, 1995).

Vinorelbine (Navelbine - Burroughs Wellcome), a semisynthetic vinca alkaloid, has been approved by the US Food and Drug Administration for parenteral use in the treatment of advanced non-small-cell lung cancer (NSCLC). Various combinations of cisplatin (Platinol), vinblastine (Velban, and others), mitomycin (Mutamycin), ifosfamide (Ifex), etoposide (VePesid) and paclitaxel (Taxol) have been used previously for this indication.

Several currently available antiemetic drugs can prevent vomiting caused by cancer chemotherapy. Anticancer drugs that cause vomiting are listed in the table below.

Strontium-89 chloride was recently approved for marketing by the US Food and Drug Administration. It is offered for relief of pain caused by metastatic bone lesions

Indium 111 In-satumomab pendetide (CYT-103, OncoScint CR/OV Kit - Cytogen), a new intravenous imaging agent, has been approved by the US Food and Drug Administration for detection of extrahepatic spread of colorectal and ovarian tumors.

Paclitaxel (Taxol - Bristol-Myers Squibb) is now available in the USA for treatment of metastatic ovarian cancer refractory to other drugs. The new drug is a natural product extracted in small amounts from the inner bark of the Western yew tree found mainly in the Pacific northwest (Taxus brevifolia). Efforts to synthesize the drug have been unsuccessful to date, but a semi-synthetic product (taxotere) prepared from the needles of European yews has shown some promise (R Pazdur et al, J Natl Cancer Inst, 89:1781, 1992), and a fungus (Taxomyces andreanae) growing on the Pacific yew was recently found to produce paclitaxel even after removal from the tree (A Stierle et al, Science, 260:214, April 9, 1993). In any case, supply of the drug is currently keeping up with demand.

Fentanyl, a synthetic opioid previously available for parenteral use in anesthesia (Sublimaze), has now been marketed in a controlled-release transdermal formulation (Duragesic - Janssen) for use in patients with chronic pain severe enough to require opioid analgesia. It is not recommended for treatment of postoperative pain because of the drug's slow onset and prolonged duration of action.

Serum measurements of prostate specific antigen (PSA) are now being used in the diagnosis and management of prostate cancer. Produced by prostatic epithelium, PSA is a protease involved in liquefaction of the seminal coagulum. Whether this test should be used for routine screening is a matter of controversy; it is currently approved by the US Food and Drug Administration (FDA) only for monitoring after treatment for prostate cancer.

Intensive chemotherapy, with or without total body radiation, followed by bone marrow transplantation is now widely used in the treatment of malignant diseases. The drugs and radiation needed to try to eradicate the malignancy unavoidably destroy the bone marrow; intravenous infusion of bone marrow cells restores the marrow by repopulating it. Diseases for which bone marrow transplantation has been used include the leukemias and lymphomas, breast cancer, neuroblastoma, ovarian cancer, germ cell tumors, melanoma, multiple myeloma, and malignant gliomas (NC Gorin, Am J Clin On-col, 14 suppl 1:S5, 1991; Medical Letter, 33:39, 1991; G Gahrton et al, N Engl J Med, 325:1267, 1991).

Disodium pamidronate (Aredia - Ciba-Geigy), an aminohydroxypropilidene bisphosphonate, has been approved by the US Food and Drug Administration for intravenous (IV) treatment of hypercalcemia associated with malignancy, with or without bone metastases. The drug is also being investigated for use in Paget's disease of bone, hyperparathyroidism, and postmenopausal osteoporosis. An oral formulation of pamidronate has been used in Europe, but is not available in the USA.

The US Food and Drug Administration recently approved the marketing of goserelin acetate (Zoladex - ICI Pharma), an implant for palliative treatment of advanced prostate cancer. Goserelin acetate is a synthetic decapeptide luteinizing hormone-releasing hormone (LH-RH) analog similar to leuprolide (Lupron; Lupron Depot) (Medical Letter, 27:71, 1985).

Automated intravenous delivery systems have recently become commercially available for intermittent self-administration of analgesics. Patient-controlled analgesia (PCA) has been used effectively to relieve after a wide variety of surgical procedures. It has also been effective for pain associated with labor, sickle cell crisis, and chronic pain caused by cancer.

Carboplatin (Paraplatin - Bristol-Myers), a cytotoxic platinum-containing drug chemically related to cisplatin (Platinol), was recently approved by the US Food and Drug Administration (FDA) for palliative treatment of patients with recurrent ovarian cancer, including those previously treated with cisplatin.