Last week, I attended the 2009 Annual Society of Clinical Oncologists (ASCO) meeting. The theme this year was personalized medicine in cancer.
The takeaway message of the meeting is that we need to move beyond thinking of malignancies that affect a certain area of the body as single diseases. In addition. pharmaceutical companies and oncologists must not view treatments with a "one-size-fits-all" perspective.
Finally, the government must devote more money to cancer research. This funding had stalled under the Bush administration, resulting in a de facto budget cut, according to the president of the National Cancer Institute (NCI). Thanks to the stimulus package and President Obama's budget, the NCI will be able to fund many more studies and future researchers.
The conference presented the results of thousands of oncology studies from all across the globe. Studies
-Identified new genetic biomarkers that increase a person's risk for certain types of cancer;
-Identified genetic and molecular biomarkers that suggest the likelihood of responding to a particular treatment;
-Presented data on different vaccines that show promise in some types of cancer; Note: These vaccines do not prevent cancer; they work to treat cancer.
--Discussed patient behaviors and characteristics that (a) predict poorer response to treatment; (b) suggest more aggressive disease; (c) point to the need for improvement in physician-patient communication.
One of the biggest issues identified by ASCO's president and the head of the NCI, who spoke at the meeting, is the need to increase patient participation in clinical trials.
Many patients are afraid of clinical trials because of the treatment-related side effects, the untested nature of some of the tratments, and concerns about the expense of medications needed to treat side effects, which are not covered in clinical trials.
For some malignancies that have few approved treatment options, like triple-negative breast cancer, metastatic melanoma, pancreatic cancer, and glioblastoma multiforme (a brain malignancy), clinical trials can represent a patient's best opportunity for prolonging life for a little while.
With the large financial burden of cancer care on the healthcare systems of various countries, some of the sessions addressed the need for physicians to communicate more with patients about making end-of-life plans rather than administering treatments that do little to prolong life and only serve to erode the quality of life for the patient's remaining weeks.
Here are a few important highlights from ASCO 2009:
*Dr. Eric Van Cutsem and colleagues from Denmark discovered that nearly 25% of cancers are HER2-positive (most commonly associated with breast cancer). These patients responded to trastuzumab (Herceptin), a "gold standard" in treating HER2-positive breast cancer. This is expected to be a practice-changing study.
*Final data on a trial bevacizumab (Avastin) in patients with early stage colon cancer was presented. The trial was considered a failure. Why is this news? Because many physicians used it off-label, assuming that its success in treating patients with advanced colon cancer would translate to success in early stage disease. It did not.
*Vaccine (BiovaxID) shows promise in follicular lymphoma, an incurable disease. The drug is the epitome of individualized care: it uses cancer cells from the patient to create a personal vaccine. The vaccine nearly doubled the time to relapse, extending it by more than a year.
*At least one study showed that in women with breast cancer who are being treated with tamoxifen, SSRI antidepressants (like Prozac, Paxil) may reduce the effectiveness of their treatment by inhibiting one of the pathways used by the anticancer drug. (Many breast cancer survivors use SSRIs to address hot flashes caused by tamoxifen.)
*Women who use combined hormonal treatment with estrogen and progestin to treat menopause symptoms face a significantly higher rate of death if they later develop non-small cell lung cancer (the most common type of lung cancer). This cancer is the #1 cause of cancer deaths in women. The risk is especially great in smokers, and the researchers for this study suggest female smokers not receive hormonal treatment.
*Surgery to remove a primary colorectal tumor in metastatic colorectal cancer may do more harm than good. Chemotherapy is often relatively effective, and surgery can delay the use of chemotherapy.
*Survivors of childhood cancers are likely to neglect recommended cancer screenings yet they are 15% more likely to get cancer as adults than the general population. Those in the high-risk category were most likely not to get cancer screenings.
There were many studies with important findings, and it is impossible to discuss them all. I encourage you to do a search on "ASCO 2009" to see some of the more important ones.
Also, in case you missed it, if you have metastatic colorectal cancer, make sure your doctor tests you for KRAS status before treatment. This is a genetic biomarker, and patients who have a KRAS mutation are very unlikely to respond to treatment with EGFR inhibitors like Vectibix and Erbitux (cetuximab). Patients with wild-type KRAS do often benefit from these agents.
In addition, when using these drugs, skin rash is a common adverse effect. Studies at ASCO suggest that the more severe the skin rash, the more effective the drug. Look online for the STEPP trial for a possible skin treatment regimen that might help reduce some of the skin reaction and allow you to continue treatment.
UPDATE: Comment below made me think of one more thing I wanted to add, which was highlighted at ASCO. Advances in treatment have turned many cases of cancer from terminal diseases to something people are living with. Some breast cancer survivors are now more likely to die of other conditions than breast cancer.
UPDATE II: Since I made the rec list, I decided to add a few more studies:
*The Dutch MIRROR study shows that women with micrometastases in the sentinel lymph nodes should be treated with axillary lymph node dissection or radiation to reduce the risk of recurrence. Women whose micrometastases were untreated had nearly double the rate of recurrence compared with women who were treated. Treating cancer-free lymph sentinel nodes or those with a few isolated cells did not provide benefit.
*Pemetrexed (Alimta) given as maintenance therapy in patients with stable nonsquamous non-small cell lung cancer after chemotherapy added about 3 months to progression-free survival (survival without the disease growing) and showed signs of improving overall survival (how long someone survives in total).
*The tumors of nearly 30% of patients with advanced renal cell carcinoma responded to pazopanib, an oral drug the FDA has under review. Pazopanib reduced the chances of tumor progression or death by 54%.
*In biliary tract cancer, which has few treatment options, the addition of gemcitabine (Gemzar) to cisplatin chemotherapy reduced risk of death by 30%. Overall and progression-free survival improved and side effects were not significantly worse.
*A new pathway--PARP-1--has been identified and two drugs that operate on these receptors to inhibit production of the PARP-1 enzyme (associated with tumor proliferation and spread) showed promise. BSI-201 added to chemotherapy benefited 61% of women with triple-negative breast cancer, a malignancy that is especially resistant to most treatments. Olaparib, another PARP inhibitor, produced tumor shrinkage in 40% of patients enrolled in a trial who had treatment-resistant BRCA1/2 deficient breast cancer.
A phase II study of the unapproved drug picoplatin noted response when added to docetaxel and prednisone as the initial treatment for patients with metastatic castration-resistant (does not respond to hormonal treatment) prostate cancer. A total of 58% of patients had complete response (tumor disappearance), partial response (some tumor shrinkage), or stable disease (no shrinkage but no growth). Levels of prostate-specific antigen (PSA), a sign of disease activity, were reduced to aimed-for levels in 78% of patients.