Barbara Brenner, Former Executive Director
I haven’t attended an ASCO meeting in a few years, but it doesn’t seem that much has changed since I was last there. There are still thousands of oncologists who attend, many of them from countries other than the U.S. The conference still takes place in a very large convention center that requires those in attendance to walk a long way between sessions. (Goddess help you if you’re on chemotherapy and trying to attend this meting.)
The sessions are still run concurrently, so it’s often necessary to miss a presentation that seems important while attending something else that also seems important. The exhibit hall—which I heard aptly referred to as the industry showroom—still takes up an enormous amount of space, and is mostly filled with drug detail reps on the one hand, and folks searching for free goodies on the other. Almost all of the sessions focus on drugs for cancer treatment. And almost all involve preliminary, unpublished results from small trials of new therapies.
A couple of things have changed at ASCO. This year there was a very well run Patient Advocate Center, that wasn’t hard to get to or to locate. On the other hand, many more of the presentations were made in sessions that required tickets, and therefore, greater expense, so that advocates were much less likely to attend those presentations
What I learned in 6 days in Atlanta falls into two categories: the tone of the meeting and the information presented.
Meeting tone: a true broader vision?
Since part of the focus of this conference was cancer survivorship, we heard presentations on the long-term consequences of some cancer treatments, such as the cardio-toxic effects of radiation therapy or chemotherapy for breast cancer, and the effects of cognitive function of chemo-induced ovarian failure (“chemo brain”).
Interestingly, one of the people who was asked to put this information in perspective was not an oncologist, but a cardiologist. It was very refreshing for me to hear someone put the risk of heart disease from cancer treatments in the context of the underlying risk for heart disease of older people.
Another presentation by a gerontologist raised important considerations for the appropriate treatment of older patients with breast cancer, pointing out the need to evaluate functional age in approaching the treatment of older patients, since not everyone is frail at 70 years old.
While these presentation stand out as pointing to a broader view of the responsibility of the oncology community, much of what was presented indicated to me that most of the focus of ASCO is so narrowly on cancer that other health issues are ignored. So, while there was concern expressed in some sessions about the long-term effects of treatments on patients, the potential adverse affects of “prevention” strategies such as aromatase inhibitors for healthy women were completely ignored.
The other thing that was sorely missing at this meeting was an engaged advocacy presence during the scientific presentations. After sitting through days and days of presentations on a variety of topics, I can’t remember that any (non-doctor) advocate other than me asked a question of a presenter.
I couldn’t help but notice that when I posed was about the risks of osteonecrosis of the jaw from bisphosphonates, I received a “brush off” answer from a scientist who discussed the use of bisphosphonates to reduce the risk of osteoporosis in women taking aromatase inhibitors. Interestingly, the next presenter also talked about bisphosphonates and responded much more thoroughly and respectfully to a question from a doctor about this side effect. Maybe it was a difference in presenters, but maybe it had to do with the fact that I always introduce myself by where I work when I ask a question.
And I was appalled that there was an oral presentation that was framed in terms of “patients failing” treatment. Is this really 2006?
New Information on Breast Cancer
Unlikely last year when Herceptin (trastuzumab) took the ASCO meeting and the media by storm, there was very little at this meeting that could be called new information for breast cancer patients.
The one exception was the announcement of the early results of a trial lapatinib (Tykerb®) in patients whose breast cancer was resistant to Herceptin. While there was a great deal of news coverage of this new therapy, all of it suggesting another great breakthrough in treatment, the numbers tell a slightly different story:
- Phase III trial, evaluating TTP (time to progression) among women with refractory (i.e, progressing) locally advanced or metastatic breast cancer treated with EITHER lapatinib plus capecitabine (Xeloda), or lapatinib alone.
- Total number of women for whom data available: 321. All had already been treated with chemo and Herceptin
- Trial was ended early because of positive results.
- Median TTP for combination = 36.9 weeks
Median TTP for Xeloda alone = 19.7 weeks
Highly statistically significant difference
No survival data yet from this trial. 29 deaths on each arm to date
- Events requiring discontinuation: 22 (14%) in combined arm and 16 (11%) in Xeloda alone arm.
- In combination arm, more than 20% had decrease in left ventricular eject on fraction (LVEF)—note, that this is a problem we also see with Herceptin. Less than 1% of women on Xeloda alone had this problem
I did hear Eric Winer, a prominent breast oncologist at the Dana Farber Institute in Boston tell folks who were crowding a room to hear about future directions for the treatment of Her2 positive patients that in the next 10 years women who have Her2 positive breast cancer will not die of their disease. He did wonder aloud how we would pay for the treatments that would make this possible. I hope that pretty soon, everyone will be asking this very important question.
There were presentations on per-operative chemotherapy, usually referred to as neo-adjuvant therapy. Oncologists are very excited about this approach to treatment because, in the appropriate setting, it can tell you whether a chosen chemotherapy works. Whether neo-adjuvant treatment will lead to improved survival is still an open question, but one that scientists hope to answer by finding “surrogate” measures of survival, such as pathological complete response (pcr), in which the chemo results in eradicating the tumor from the breast. Of course, only by following patients for long periods of time will we be able to know whether pcr is truly a surrogate for overall survival.
Aromatase inhibitors were discussed by a number of presenters. One study that looked at bone mineral density after 5 years of anastrozole (Arimidex®) found that only patients who had below-normal baseline bone mineral density developed osteoporosis while on the drug. And the first mature results from a study of switching patients from tamoxifen (Nolvadex®) to examestane (Aromasin®) after 2 or 3 years showed—as did other abstracts presented at ASCO—that switching to the AI improved overall survival over tamoxifen.
On the last day of the meeting, after almost everyone had headed home, there was a session on what may have been the most important study presented at the meeting. This study showed that young African-American women are far more likely than other women to develop the most aggressive form of breast cancer, characterized by ER/PR/Her2 negative (triple negative) status. This important study helps explain why young African-American are far more likely to die of breast cancer than other women. Research needs to focus on finding more effective treatments for this extremely dangerous form of breast cancer.