Highlights from the 2010 San Antonio Breast Cancer Symposium

By Jane Zones, Kim Irish, and Lindsey Collins

This year, three members of the BCA team, Program Manager Kim Irish and BCA Board Members Jane Zones and Lindsey Collins, attended the San Antonio Breast Cancer Symposium (SABCS), the largest annual scientific meeting focused on breast cancer. Following is their report on what they learned.

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Jane Zones:
Before SABCS had its official welcoming Thursday morning, a series of educational meetings for physicians and advocates covered a range of basic topics of interest to women living with breast cancer. The talks on Wednesday, sponsored by the Susan G. Komen for the Cure Foundation, were easier to understand and of broader scope than the very focused research reports that began Thursday. I attended talks that focused on genetic testing, radiation techniques, and symptom management.

Sharon Plon, a physician at Baylor University, described family-based genetic sequencing, which identifies the specific mutation or mutations in a person who has breast cancer, so that subsequent testing of a family member who may be at higher risk will hone in on that particular variant. If the cancer patient tests negative, or if variants of uncertain significance (VUS) are found, relatives are not tested. This is a more efficient and less costly way to determine whether relatives have inherited risk than to assess their whole genetic sequence.

The session on managing side effects of breast cancer treatment was moderated by Laura Esserman, a physician at the University of California, San Francisco (UCSF). It included very interesting and potentially useful information on lymphedema, herbal treatments, managing chronic pain, and preventing hair loss during chemotherapy.

Hair loss during chemotherapy is traumatic for many women, and some (as many as 8 percent) avoid it by refusing treatment. Michelle Melisco, a UCSF physician and researcher, reported on “Hair to Stay,” a study on the feasibility of chemotherapy patients using a “cold cap” during treatment to preserve their hair. Cooling the scalp to very low temperatures causes vasoconstriction, which reduces biochemical activity and minimizes chemical action on the hair follicles.

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Kim Irish:
The conference atmosphere was expectant at the start of the conference as BCA staff, board members, and volunteers planned schedules and set up a table displaying BCA materials in the exhibition hall. Topics covered during the educational sessions included advances in neurosurgery related to central nervous system (CNS) metastases and a discussion of the standards for radiation therapy for CNS metastases. The educational sessions were well attended and spurred some interesting questions for audience members to consider.

One fascinating talk, “NeuroSurgical Management of CNS Breast Metastases,” was given by Elizabeth B. Claus of Yale University. An estimated 20 percent of breast cancer patients will develop CNS metastases. Risk factors include young age, ER negative breast tumors, and HER2-positive breast cancer. Claus argued in favor of neurosurgery for patients with CNS metastases for several reasons, including relief of symptoms and improvement in quality of life. She concluded that in the appropriate setting, surgery can be a valuable treatment for CNS metastases but that more data is needed from patients with breast cancer who may benefit from neurosurgery as a treatment for CNS metastases.

The next session was titled “Radiation Therapy for CNS Metastases: What Should the Standard Be?” given by Minesh P. Mehta, a physician at Northwestern University. Mehta is a consultant for a huge array of pharmaceutical companies — Adnexus, Bayer, Merck, Schering, Genentech, and Tomotherapy. Mehta recommends that surgical resection followed by whole brain radiation therapy (WBRT) is a better treatment option for improving tumor control at the original site of the metastasis and in the brain overall when compared to surgical resection alone. Stereotactic radiosurgery (SRS) alone may provide an equivalent survival advantage for patients with brain metastases compared with SRS combined with WBRT.

From a patient perspective, some important questions were raised during the presentation titled “Systemic Therapy for CNS Metastases,” by Nancy U. Lin, a physician at the Dana-Farber Cancer Institute. Lin noted that FDA-approved drugs are currently not available for systemic treatment of brain metastases. Her presentation discussed the many unresolved issues related to systemic therapy, including determining the meaningful endpoints and how should they be defined, how much data is required before doing a trial in untreated patients, and what is the appropriate follow-up for treated patients. Lin concluded with the observation that systemic therapy for CNS disease is an area of increasing research interest, so more data may be forthcoming.

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Lindsey Collins:
While sitting in Friday morning’s panel, BCA’s executive director, Barbara Brenner, forwarded us a press release from Genentech on NEOSPHERE, its phase II trial on the combined use of Herceptin (trastuzumab) and pertuzumab with chemotherapy for early-stage HER2-positive breast cancers. The press release celebrated the results and cited the presentation at San Antonio. Not quite — the Genentech/Roche people hadn’t presented yet. Neil Spector, a physician from Duke University, was still talking about therapies that target HER2-positive breast cancers and the problem of women developing resistance to HER2 drugs such as trastuzumab. Spector suggested that adding lapatinib (Tykerb) and pertuzumab to Herceptin could have good effects even after women become Herceptin resistant, which often happens after 12 months. If women become resistant to trastuzumab (Herceptin), he asked, how can we block HER2 and make it affordable and accessible to women? To paraphrase, Spector asked, “If only four women can afford this therapy, then we have to ask what the hell we’re doing.” What the hell, indeed. Herceptin can cost patients anywhere between $42,000 and $65,000 a year.

That was an interesting transition into Luca Gianni’s presentation for Genentech. Gianni, the director of medical oncology at the National Cancer Institute in Milan, Italy, and principal investigator for the NEOSPHERE trial, neglected to mention the cost of a combined trastuzumab and pertuzumab therapy, which could easily top $100,000 a year (given that Herceptin alone can cost that much). The study recommends that the trial proceed to phase III due to findings in animal models that pertuzumab enhances the antitumor activity of trastuzumab in early inflammatory, locally advanced, or HER2-positive cancer. The study’s endpoint is pathological complete response (pCR), or complete tumor disappearance at the time of surgery, and found that the addition of pertuzumab and docetaxel (chemotherapy) achieved a pCR rate of 45.8 percent. The pCR for just Herceptin (trastuzumab) and pertuzumab was 16.8 percent. The study asserted that “a proportion” of HER2-positive tumors can be eradicated without chemotherapy with the trastuzumab-pertuzumab therapy. The study also found that there is no added toxicity and that “tolerability is good” for this combination. In other words, you’ll still probably have a reduced white blood cell count, diarrhea, and some frightening heart problems, but not a whole lot more. It’s important to also note that the study didn’t look at long-term outcomes, only tumor reduction until the time of surgery. There’s no data on whether this therapy works 12 months after surgery and beyond. The press release identifies side effects for Herceptin, which include diarrhea, fever, vomiting, heart problems, reduced blood cell counts, and infusion reactions, but neglects to elaborate on side effects of the Herceptin-pertuzumab combination or this combination and chemotherapy, other than the brief explanation in Gianni’s presentation about “no significant additional toxicity.” Unfortunately, lack of detail doesn’t mean lack of side effects.

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The Source—Winter 2011 | 1.19.11

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