Appointment sheet
Mismatch-repair deficient (MSI-high) colorectal cancer
Prepared with OnCo (onco.cc/prep/msi-high-colorectal/). Orientation, not medical advice; your team knows your case.
My details
Name
Date of appointment
Hospital and clinician
Who is coming with me
What I know, what is unclear, changes to discuss
Saved in this browserWhat I know so far
What is unclear to me
Changes since last time
My questions
20 on the sheetNewly diagnosed
- 1.What is my exact diagnosis, stage, and grade, and which tests established them?
- 2.Which biomarkers have been tested on my tumour (for example Mismatch repair immunohistochemistry, Microsatellite instability by PCR or sequencing, MLH1 promoter methylation and BRAF V600E, Germline testing of mismatch repair genes, Tumour mutational burden), and what were the results?
- 3.Which subtype is my cancer, and does that change the recommended treatment?
- 4.Is germline (inherited) genetic testing recommended for me or my family?
Metastatic, first line
- 5.For my situation (metastatic, first line), which of the standard options do you recommend and why?
- 6.Am I a candidate for Pembrolizumab, Nivolumab, Ipilimumab, and what side effects should I expect?
- 7.How do the results of KEYNOTE-177 and CheckMate 8HW apply to someone like me?
Localised colon cancer
- 8.For my situation (localised colon cancer), which of the standard options do you recommend and why?
- 9.Am I a candidate for Nivolumab, Ipilimumab, Atezolizumab or related drugs, and what side effects should I expect?
- 10.How do the results of NICHE-2 and ATOMIC (Alliance A021502) apply to someone like me?
Rectal cancer
- 11.For my situation (rectal cancer), which of the standard options do you recommend and why?
- 12.Am I a candidate for Dostarlimab, and what side effects should I expect?
- 13.How do the results of AZUR-1 apply to someone like me?
Lynch syndrome carriers
- 14.For my situation (lynch syndrome carriers), which of the standard options do you recommend and why?
- 15.Am I a candidate for Aspirin, and what side effects should I expect?
Any stage
- 16.Are there clinical trials I could join, for example of WRN inhibitors: a second synthetic-lethal win for mismatch-repair cancers, EIK1005, Cadonilimab, Neoadjuvant/Adjuvant AK104 in Microsatellite Instability-high or Mismatch Repair-deficient, Resectable Colon Cancer?
- 17.Would a second opinion at a high-volume centre change anything, and can you help arrange it?
- 18.What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?
- 19.I read that “A third of metastatic patients progress early on immunotherapy and the resistance mechanisms are only partly understood”. How does that affect my plan?
- 20.I read that “Whether surgery can be omitted after complete response in colon, as in rectal, cancer is untested”. How does that affect my plan?
The words I may hear
- Consensus molecular subtypes (CMS1-4): The consensus molecular subtypes are four gene-expression groups of bowel cancer: immune (CMS1), canonical (CMS2), metabolic (CMS3), and mesenchymal (CMS4), with different prognoses.
- Tumour mutational burden (TMB): How many mutations a tumour has.
- Clinical complete response (cCR): No sign of tumour on examination, endoscopy, and MRI after treatment, without surgery to confirm it.
- Lynch syndrome: Lynch syndrome is the most common inherited cancer syndrome: a faulty mismatch-repair gene raises lifetime bowel cancer risk to 40-80% and also endometrial and other cancers.
- Organ preservation (watch-and-wait, bladder-sparing, larynx preservation): Curing a cancer with drugs and radiotherapy so that the organ (rectum, bladder, larynx, limb) does not have to be removed, keeping surgery in reserve for the minority whose cancer regrows.
- Tumour-agnostic (tissue-agnostic) approval: A tumour-agnostic approval lets a drug be used for any cancer carrying a specific molecular feature, regardless of where it started.
- Microsatellite instability (MSI-H) / mismatch repair deficiency (dMMR): Microsatellite instability is the mark of a broken DNA spell-checker (loss of MLH1, MSH2, MSH6 or PMS2) that leaves thousands of mutations, so the tumour displays abnormal proteins that T cells can recognise.
Tests and results to bring
Biomarker results to ask for: Mismatch repair immunohistochemistry (MLH1, MSH2, MSH6, PMS2), Microsatellite instability by PCR or sequencing, MLH1 promoter methylation and BRAF V600E (sporadic versus Lynch), Germline testing of mismatch repair genes, Tumour mutational burden, Circulating tumour DNA after curative treatment.
Scans and tests linked to this cancer: Colorectal cancer screening (colonoscopy, FIT, stool DNA, blood), Germline (hereditary) testing, Histopathology & immunohistochemistry, MRD / molecular residual disease testing.
Bring copies of scan reports, pathology and blood results, and a list of every medicine and supplement.
The treatments I may be offered
- Localised colon cancer: Neoadjuvant nivolumab plus ipilimumab for locally advanced tumours (NICHE-2) where available; surgery; adjuvant FOLFOX plus atezolizumab for stage III (ATOMIC); no fluoropyrimidine alone. (NICHE-2, ATOMIC (Alliance A021502), Nivolumab, Ipilimumab, Atezolizumab, FOLFOX (5-FU, leucovorin, oxaliplatin))
- Metastatic, first line: Pembrolizumab alone (KEYNOTE-177) or nivolumab plus ipilimumab (CheckMate 8HW); chemotherapy only if immunotherapy is contraindicated. (Pembrolizumab, Nivolumab, Ipilimumab, KEYNOTE-177, CheckMate 8HW, Immune checkpoint inhibitors)
- Rectal cancer: Six months of dostarlimab or another PD-1 antibody with non-operative management for complete responders (AZUR-1). (Dostarlimab, AZUR-1, Organ preservation (watch-and-wait, bladder-sparing, larynx preservation), Clinical complete response (cCR))
- Lynch syndrome carriers: Colonoscopy every one to two years from age 25 (earlier for MLH1 and MSH2), daily aspirin (CAPP2), cascade germline testing of relatives, hysterectomy and oophorectomy after childbearing for women. (Lynch syndrome, Aspirin, Colorectal cancer screening (colonoscopy, FIT, stool DNA, blood), Germline (hereditary) testing, Chemoprevention & risk-reducing surgery)
From the standard of care recorded for this cancer; which apply depends on your stage and biomarkers. Ask which the team recommends and why.
Answers and next steps
Saved in this browserWhat I was told
Agreed next steps, dates and who to call