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This French study aimed to evaluate oncologists' and patients' perception of physical activity, particularly adapted physical activity, in order to identify the obstacles and levers to its practice in patients with metastatic cancer.Between October 2019 and March 2020, 60 medical oncologists and 305 patients with metastatic cancer were asked to fill in a self-completed questionnaire.The benefits of physical activity are recognised by most oncologists and patients. These benefits were perceived more by oncologists in prevention (78%) or in the early stage (72%) of the disease than in the metastatic stage (55%) (P=0.01). Patient's physical condition (45%) and age (37%) but also the lack of time during the consultation to explain supportive care (35%) are the main obstacles identified by the oncologist to the integration of physical activity into patient care. Furthermore, lack of knowledge of adapted programmes is the main reason given by the physicians who have never prescribed physical activity (51%). On the patient side, while 88% of them had heard of the benefits of physical activity, only 11% had received a prescription. Most oncologists and patients were very interested in receiving information on where and what types of activities to practice, as well as what to avoid.Efforts in terms of information for both oncologists and patients seem necessary to increase the level of physical activity prescription and practice for patients followed for metastatic cancer.

Resume Objectif de l’etude Les ressources humaines, materielles et financieres etant limitees, l’organisation du systeme de soins doit permettre une allocation des ressources efficiente. La prise en charge des cancers amene a des soins specifiques et repetitifs pour lesquels le remboursement des frais de transports represente un cout important. Nous avons realise une analyse du surcout de transport, lies a la prise en charge des patients franciliens, dans un centre autre, que le centre de radiotherapie le plus proche de leur domicile. Materiel et methodes A partir de donnees de l’Agence regionale de sante d’Ile-de-France, nous avons cree un modele evaluant le surcout lie aux transports engendres par la prise en charge d’un patient en radiotherapie a distance de son domicile. Afin de prendre en compte les incertitudes lies aux hypotheses faites dans l’elaboration du modele nous avons realises des analyses de sensibilite deterministe et probabiliste. Resultats Dans le cas de base, le surcout annuel lie au transport etait de 841 176 euros en Ile-de-France. L’analyse de sensibilite probabiliste rapporte un surcout total annuel de 2 817 481 euros. Conclusion Nos resultats se rapprochent d’un rapport de l’Inspection generale des affaires sociales publie en juillet 2011 qui pointait alors un surcout compris entre 4 et 6 millions d’euros annuels. La prise en charge a distance de leur domicile des patients atteints de cancer participe a une degradation de la qualite de vie liee aux temps de transport, a un retard a la prise en charge de potentielles complications des traitements et a la diffusion de maladies infectieuses, telle que le COVID-19, et de bacteries resistantes aux antibiotiques.

Objectif de l’étude Les ressources humaines, matérielles et financières étant limitées, l’organisation du système de soins doit permettre une allocation des ressources efficiente. La prise en charge des cancers amène à des soins spécifiques et répétitifs pour lesquels le remboursement des frais de transports représente un coût important. Nous avons réalisé une analyse du surcoût de transport, liés à la prise en charge des patients franciliens, dans un centre autre, que le centre de radiothérapie le plus proche de leur domicile. Matériel et méthodes À partir de données de l’Agence régionale de santé d’Île-de-France, nous avons créé un modèle évaluant le surcoût lié aux transports engendrés par la prise en charge d’un patient en radiothérapie à distance de son domicile. Afin de prendre en compte les incertitudes liés aux hypothèses faites dans l’élaboration du modèle nous avons réalisés des analyses de sensibilité déterministe et probabiliste. Résultats Dans le cas de base, le surcoût annuel lié au transport était de 841 176 euros en Île-de-France. L’analyse de sensibilité probabiliste rapporte un surcoût total annuel de 2 817 481 euros. Conclusion Nos résultats se rapprochent d’un rapport de l’Inspection générale des affaires sociales publié en juillet 2011 qui pointait alors un surcoût compris entre 4 et 6 millions d’euros annuels. La prise en charge à distance de leur domicile des patients atteints de cancer participe à une dégradation de la qualité de vie liée aux temps de transport, à un retard à la prise en charge de potentielles complications des traitements et à la diffusion de maladies infectieuses, telle que le COVID-19, et de bactéries résistantes aux antibiotiques.

Summary Background & aims To assess the prevalence of sarcopenia before cancer treatment and its predictive value during the treatment. Methods We searched MEDLINE via PubMed for articles published from 2008 to 2016 that reported prospective observational or interventional studies of the prevalence of pre-therapeutic sarcopenia and its consequences in adults with cancer who were 18 years or older. Two independent reviewers selected articles based on titles and/or abstracts before a complete review. Sarcopenia had to be measured before cancer treatment. Methods recommended by consensuses (CT scan, MRI, dual X-ray absorptiometry or bio-impedancemetry) to assess sarcopenia were considered. Characteristics of the studies included the prevalence of pre-therapeutic sarcopenia and the prognostic value for outcomes during the cancer treatment. Results We selected 35 articles involving 6894 participants (in/out patients, clinical trials). The mean age ranged from 53 to 69.6 years. Pre-therapeutic sarcopenia was found in 38.6% of patients [95% CI 37.4–39.8]. Oesophageal and small-cell lung cancers showed the highest prevalence of pre-therapeutic sarcopenia. Pre-therapeutic sarcopenia was significantly and independently associated with post-operative complications, chemotherapy-induced toxicity and poor survival in cancer patients. Conclusions Pre-therapeutic sarcopenia is highly prevalent in cancer patients and has severe consequences for outcomes of cancer patients.

Cancer-related fatigue is serious and complex, as well as one of the most common symptoms experienced by patients with colorectal cancer, with the potential to compromise quality of life, activities of daily living, and ultimately survival. There is a lack of consensus about the definition of cancer-related fatigue; however, definitions have been put forward by the European Association for Palliative Care (EAPC) and the National Comprehensive Cancer Network (NCCN). Numerous cancer- and treatment-related factors can contribute to fatigue, including disease progression, comorbidities, medical complications such as anemia, side effects of other medications, and a number of physical and psychologic factors. This underlines the importance of tackling factors that may contribute to fatigue before reducing the dose of treatment. NCCN guidelines and the EAPC have proposed approaches to managing fatigue in cancer patients; however, relatively few therapeutic agents have been demonstrated to reduce fatigue in randomized controlled trials. It is recognized that physical activity produces many beneficial physiologic modifications to markers of physical performance that can help to counteract various causes of fatigue. In appropriately managed and monitored patients with colorectal cancer, emerging evidence indicates that exercise programs may have a favorable influence on cancer-related fatigue, quality of life, and clinical outcomes, and therefore may help patients tolerate chemotherapy. This review assesses fatigue in patients with colorectal cancer and proposes updates to a treatment algorithm that may help clinicians manage this common problem.

Resume Introduction Les reins constituent des organes ayant une dose limitante pour les irradiations corporelles totales ou abdominales. La toxicite renale radio-induite est probablement sous-estimee du fait de sa latence et de facteurs confondants comme la chimiotherapie et les facteurs propres au patient. Materiel et methodes Une revue critique de la litterature reprenant les relations dose-volume publiee a ete rapportee. Resultats La plupart des toxicites surviennent aux alentours de 18 mois. La mobilite des reins n’est pas negligeable en termes dosimetriques, en particulier chez le jeune enfant. En cas d’irradiation corporelle totale, la dose responsable de 5 % de toxicite est de 16 Gy realisee en fractionnement classique avec un etalement sur deux semaines. En cas d’irradiation partielle renale, le volume des reins recevant 20 Gy doit etre inferieur a 32 % du volume du parenchyme renal total. Une compensation renale par le parenchyme renal recevant moins de 12 Gy a raison de seances de 1 Gy est possible lorsque le rein a recu par ailleurs une dose toxique responsable d’une atrophie. En cas de chimiotherapie associee par cisplatine, la dose doit etre limitee a moins de 12 Gy a l’ensemble du rein. Les inhibiteurs de l’enzyme de conversion ou les antagonistes de l’angiotensine peuvent etre utilises devant une nephropathie radique constituee. Discussion/conclusion Le recueil prospectif des histogrammes dose-volume et la prise en compte de la mobilite renale, avec l’amelioration des techniques d’irradiation, devraient permettre d’ameliorer la connaissance des relations dose-effets sur les reins et d’optimiser les irradiations incluant une partie ou totalite des reins.

The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.

Anal epidermoid carcinoma is a rare malignant tumor, comprising less than 5% of all carcinomas of the colon, rectum, and anus. The primary therapy now includes radiotherapy, often in combination with chemotherapy. Radical surgery is now rarely indicated. Therapeutic indications are based on locoregional staging, the presence of visceral metastases and an evaluation of the medical history. Anorectal endosonography is helpful in evaluating locoregional extension. In addition, magnetic resonance imaging, positron emission tomography scanning and inguinal sentinel lymph node procedure should play a role in a more selective approach in patients with anal carcinoma.

L’endosonographie est un outil performant, de mise au point recente, plus fiable que l’examen clinique et la tomodensitometrie, presentant de nombreux interets en pathologie tumorale anale. Elle permet d’obtenir un bilan, d’extension tumorale et ganglionnaire satisfaisant et la detection d’un residu tumoral ou une recidive eventuelle apres traitement. Elle devrait beneficer de l’apport des ponctions cytologiques et/ou biopsies echo-guidees. Son impact therapeutique peut etre majeur: chimiotherapie adjuvante a la radiotherapie en cas de tumeur volumineuse et/ou en cas d’adenopathies supposees envahies, contre-indication a une curietherapie en cas d’adenopathies envahies, radiotherapie de surdosage ou amputation abdomino-perineale en cas de residu tumoral ou de recidive.

Purpose : The study assessed the efficacy of combination therapy with vinorelbine and ifosfamide in patients with unresectable non-small cell lung cancer. Patients and methods : Forty patients with non-small cell lung cancer whose tumour was unresectable by virtue of the extent of disease or severity of impairment of lung function and who were considered unsuitable for treatment with a cisplatin based treatment were entered onto the study. Thirty-four patients received two cycles of treatment and were considered to be evaluable for response. The treatment schedule consisted of vinorelbine (Navelbine, Pierre Fabre Medicament) 25 mg/m 2 on days 1 and 8, and ifosfamide 2 g/m 2 per day with mesna 0.5 g/m 2 three times daily given on days 1 to 3; cycles were repeated every 21 days and treatment continued in responding patients until progression occurred. Results : Objective responses were observed in 12 patients (30%; CI 95 , 16–44) with one complete response (CR) and 11 partial response (PR). Conclusion : This schedule achieves good levels of response without the use of cisplatin so it is suitable for patients whose performance status or concomitant medical condition precludes the use of platinum based chemotherapy.

Approximately 10% of patients with non-small cell lung cancer (NSCLC) have brain metastases at the time of diagnosis. When surgical resection is not possible, whole brain radiotherapy is the standard of care, with a cerebral response rate of approximately 30%. We report our experience with an upfront association of carboplatin and pemetrexed (areas under the curve, 5 and 500 mg/m(2), respectively), every 3 weeks, in 30 patients presenting with newly diagnosed brain metastases and NSCLC. Cerebral MRIs were performed every 6-9 weeks. The radiologic response rates were assessed according to Response Evaluation Criteria in Solid Tumors. Overall survival was also determined. Twenty-six patients were evaluable for response, and the objective cerebral response rate (complete and partial response) in the intent-to-treat population was 40% (12 of 30 patients). Event-free survival was 31 weeks, and median overall survival was 39 weeks. The upfront association of carboplatin plus pemetrexed allows simultaneous treatment of cerebral and systemic disease in patients with NSCLC with newly diagnosed brain metastases and appears to be particularly interesting in terms of radiologic response and overall survival. Further clinical studies are warranted.

The kidneys are dose-limiting organs when total body irradiation or irradiation of the digestive tract is planned. The incidence of radiation-induced toxicity is probably underestimated due to its latency and confounding factors like chemotherapy.A search of the literature for radiation induced renal toxicity was performed.Most toxicities occur around 18 months. Renal mobility is significant in terms of dosimetric consequences, in particular in the young child. In case of total body irradiation, the dose responsible for a 5% risk of toxicities is around 16 Gy in 2 Gy fractions over 2 weeks. For partial renal irradiation, the volume receiving 20 Gy should be below 32% of the total renal volume. Compensatory mechanisms remain possible in areas receiving 12 Gy or less in 1 Gy fractions. When nephrotoxic chemotherapy, these tolerance doses must be lowered. Treatment of radiation-induced nephropathy may include ACE inhibitors.Prospective assessment of dose-volume histograms and consideration of renal mobility in treatment plans along with improving radiation techniques should help to improve treatment plans including the kidneys.

Malgre les nombreuses avancees therapeutiques, le cancer reste la deuxieme cause de deces dans le monde occidental. En revanche, il existe egalement une population croissante de survivants souvent atteints de sequelles de la maladie et de ses traitements, posant un probleme de sante publique (1). La fatigue liee au cancer est une asthenie profonde et invalidante, desormais reconnue comme une plainte frequente parmi les survivants de cancer (2). Cette fatigue concerne pres de 3 patients sur 4 a des degres divers (3) et peut avoir un retentissement sur la vie courante a tous les niveaux de la quotidienne y compris dans la vie sociale (4). Cette fatigue n’est pas limitee a la periode du traitement et peut durer plus de 1 an (5). Malgre la recherche de plus en plus abondante qui lui est consacree, la fatigue liee au cancer reste diffi cile a defi nir. Une defi nition pratique est donnee par le National Comprehensive Cancer Network americain: «la fatigue liee au cancer est une fatigue persistante, une sensation subjective de lassitude en rapport avec un antecedent de cancer ou de son traitement et qui interfere avec le bon deroulement de la vie quotidienne» (NCCN Cancer related fatigue and Anemia: treatment guidelines for patients). La fatigue liee au cancer est differente de la fatigue due a l’exercice parce qu’elle est plus profonde, persistante et qu’elle ne s’ameliore pas avec du repos (6). Elle peut egalement etre definie comme une fatigue plus importante que celle qui devrait normalement resulter d’un exercice physique ou d’un effort mental (7).

Les patients au decours du traitement, que ce soit par radiotherapie ou chimiotherapie, decrivent une notion de fatigue, une sensation d’epuisement persistante, interferant avec la vie quotidienne et ne cedant pas au repos. Leur frequence est tres importante et elles sont presentes chez 60 % a 95 % des patients pour une longue duree (1, 2, 3). La fatigue importante est associee a la depression, l’anxiete et une qualite de vie inferieure. En analyse multivariee, la fatigue est predictible d’une mauvaise qualite de vie ulterieure (1, 2, 4). Son amelioration aboutit a une amelioration de l’anxiete, de la depression et de la qualite de vie.

La question des troubles cognitifs chez des patients traites par chimiotherapie a ete pour la premiere fois evoquee dans les annees 1980 par Silberfab et al. (1). On reproche generalement a cette etude, comme a la plupart de celles publiees dans les annees suivantes, un manque de rigueur methodologique tel que la comparaison avec des donnees publiees, ou une confusion entre toxicite des traitements et retentissements cognitifs inherents aux reactions psychologiques d’ordre depressif accompagnant la prise en charge initiale d’une maladie cancereuse. Nous disposons depuis d’etudes randomisees, et effectuees dans le but de differentier la toxicite des traitements, des effets cognitifs de l’anxiete, de la fatigue, la depression ou de la menopause.

Anal epidermoid carcinoma is a rare malignant tumor, comprising less than 5% of all carcinomas of the colon, rectum, and anus. The primary therapy now includes radiotherapy, often in combination with chemotherapy. Radical surgery is now rarely indicated. Therapeutic indications are based on locoregional staging, the presence of visceral metastases and an evaluation of the medical history. Anorectal endosonography is helpful in evaluating locoregional extension. In addition, magnetic resonance imaging, positron emission tomography scanning and inguinal sentinel lymph node procedure should play a role in a more selective approach in patients with anal carcinoma.

The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.

Paclitaxel and vinorelbine are two drugs active against breast cancer. A phase II study was initiated with the aim of assessing the efficacy and feasibility of the combination. Twenty-six patients presenting with advancedbreast cancer with a taxane- and vinorelbine-free line of chemotherapy were included and treated with vinorelbine (20 mg/m 2 on D1, D15), followed by paclitaxel (175 mg/m 2 on Dl), every 3 weeks. A 48% (95% CI: 35-61) response rate was obtained in the 23 patients evaluable for response. Vinorelbine was administered on D15, as scheduled, in 72% of cycles. The main toxicity observed was grade III to IV neutropenia in 73% of patients. Febrile neutropenia was reported in three patients. Disease-free survival was 118 days, and overall median survival was 361 days. This combination of paclitaxel and vinorelbine is feasible and effective in patients with early relapse or previously treated with first-line chemotherapy for metastatic disease.

Surgery remains the standard treatment of rectal cancer. The risk of local recurrence is still a serious problem with an incidence of between 15 and 45%. This depends on the initial TNM stage and the surgical technique. In order to optimally improve local control and survival of the patients, radiotherapy has become an unavoidable adjuvant treatment in specific situations.For locally advanced cancers (T3 or T4), pre-surgical radiotherapy followed by curative surgery is the standard treatment because of the improvement in global survival and good local control that has recently been confirmed. With radiotherapy it is also possible to schedule conservative sphincter surgery in the case of low rectal lesions and permit surgery of initially inoperable lesions. THE CONCOMITANT ASSOCIATION OF RADIOTHERAPY AND CHEMOTHERAPY DURING THE PRE-SURGICAL PERIOD: In rare cases in which the tumour stage was underestimated in the pre-surgical controls, post-surgical concomitant radio-chemotherapy is required. In cases in which surgery was performed first line, in the presence of histological factors of poor prognosis, post-surgical radio-chemotherapy is warranted. In the United States, the reference chemotherapy used in this association is 5 FU in continuous intravenous infusion. In the rare cases of contraindication for surgery, exclusive concomitant radio-chemotherapy is an appropriate solution, even if no treatment has been validated in this indication. Palliative surgery can be proposed in supplement: usually a colostomy or, more rarely excision using the endorectal route.Exclusive radio-chemotherapy has only demonstrated interest in the palliative treatment of inoperable loco-regional relapses that have already undergone radiation or in metastatic stages as in colon cancers. Currently post-surgical chemotherapy is recommended in stage III cancer of the rectum as in colon cancers at the same stage.

1583 Background: Colorectal cancer (CRC) predominates in developed countries among sedentary populations. A meta-analysis (MA) showed that physical activity (PA) decreased the incidence of new cases of CRC. The impact of PA on recurrence and mortality of non-metastatic CRC patients is still controversial. Methods: We performed a literature-based meta-analysis of all published observational studies, using the following keywords (colorectal cancer, physical activity, survival) in PubMed and EMBASE. We searched for a dedicated MA in the Cochrane Library (none found). We cross-checked all references. Pre- and post-diagnostic PA levels were assessed with MET (Metabolic Equivalent Task). Usually, high PA levels corresponded to > 17 MET hours/week. Overall survival (OS) and cancer-specific survival (CSS) were assessed by means of Hazard Ratios (HRs) with their 95 % Confidence Interval (CI). We pooled adjusted HRs since the variables of adjustment were almost identical between studies (age, sex, BMI, tobacco use, alcohol and red meat consumptions ). By convention, when higher PA levels were associated to an improved survival compared with lower PA levels, HRs for detrimental events were < 1. We used EasyMA software. We used fixed effect model whenever possible and random effect model only in case of between-study heterogeneity. Results: Eight studies (11298 participants) published from 2006 to 2013 met the inclusion criteria, representing 3110 males and 3710 females, 3072 colon and 1318 rectum cancers. Mean age was 67 years (range 21-82 years). HR CSS for post-diagnostic PA (higher PA level vs. lower) was 0.61 (CI: 0.44-0.86; random effect model). The corresponding HR for OS was 0.62 (CI: 0.54-0.71). HR CSS for pre-diagnostic PA was 0.80 (CI: 0.69-0.92). The corresponding HR for OS was 0.74 (CI: 0.63-0.86). Conclusions: This MA is the first to show that higher PA levels are associated with a better CSS, suggesting that sustained PA should be advised for non-metastatic CRC patients. OS also significantly improved, not surprisingly since PA should reduce risk of cardio-vascular events. These findings should be tempered by the rather small number of studies included.

4077 Background: Curative treatment of liver metastases from colorectal cancer (CRC) relies upon R0 surgery whenever feasible (5-year survival: 40 %). Whether or not addition of adjuvant systemic o...

Background: More than half of cancers occur after the age of 65 and this should grow progressively. Unfortunately elderly people are rarely included in therapeutic surveys and in screening tests, so they miss optimal treatment of their cancer (surgery, chemotherapy, radiotherapy) most of the time. At the Ambroise Pare academic hospital, a 440 beds urban hospital, a geriatric intervention team (GIT) has been created since February 2004. One of its aims is to help others specialists to assess the better treatment for their patients. Patients: In 3 years, 2800 evaluations were done by the GIT in the whole hospital, 234 on inpatients of the pneumology department. On those, 53 were hospitalised for the diagnosis or the treatment of a cancer. Results: Patients average age was 80±6 years old, 53% were female. The mini-GDS was positive in 53% and a time and space disorientation was observed in 41%. 67% patients had cognitive troubles, with high risk of falls for 86%. In 28%, patients received a chemotherapy. In the end, 4 groups of patients could be observed “primary” (2%) who will have an optimal treatment “intermediate” (37%) at whom will be proposed an adjusted treatment “secondary”(50%) who will have a symptomatic treatment “near death” (11%) with palliative care Conclusion: This collaboration have afforded us to identify better patients likely to receive an optimal treatment. The main contribution of the EIG in this collaboration was to afford a fast geriatric assessment to the others physicians in order to make up one’s mind to the best treatment.

7348 Background: Gefitinib (Iressa), an inhibitor of the intracellular tyrosine kinase domain, has demonstrated useful activity in advanced pre-treated NSCLC (IDEAL I/II). Methods: Patients (pts) were treated with gefitinib 250mg/day. Endpoints included time to treatment failure (TTF). Results: 33 patients were assessed: median age (range), 61 (38–82) years; male/female, 21/12; performance status (PS) 1/2, 11/22; advanced disease (III A/IIIB/IV) 1/1/29, 31 pts were treated; median number of prior chemotherapy regimens (range), 3(1–4). 31 patients were treated and evaluable for time to Failure (TTF) according to PS status: 4.8 months (PS 1) and 5 months (PS 2). Median duration of disease control (stable disease and symptom control) was 4.9 months. Median TTF for Patients with bronchoalveolar adenocarcinoma (BAC) and adenocarcinoma (n=18) was 4 months and 3 months for patients with squamous-cell carcinoma and large cell carcinoma (n= 13). One patient treated for BAC with leptomeningeal carcinomatosis was fr...