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Ten practice changes I will make after attending
ASCO 2017
By Jeffrey J. Kirshner
MD, FACP
Dr Kirshner is a partner of Hematology Oncology Associates of Central New York (HOACNY), and Director
of Research and serves as the Principal Investigator of the HOACNY Community Clinical Oncology
Program, East Syracuse, New York.
1.
I will treat selected stage III colon cancer patients
with 6 rather than 12 courses of FOLFOX adjuvant
chemotherapy.
As presented by Shi et al in LBA1 at
the Plenary Session, IDEA, the prospective pooled
analysis of six phase 3 trials investigating the duration
of adjuvant therapy, demonstrated noninferiority in
“lower-risk” stage 3 patients (T1–3, N1).
1
There appears
to be a slight improvement in DFS in patients with more
advanced stage 3 disease. As expected, the longer
duration was associated with more neurotoxicity and
certain T4 and N2 patients (especially those at risk for
neurotoxicity) might want to consider the 6 courses,
after a discussion of the risks and benefits of the longer
regimen.
2.
I will add abiraterone/prednisone to androgen
deprivation therapy in newly diagnosed high-
risk hormone-naive patients with metastatic prostate
cancer.
As presented by Fizazi et al in LBA3 at the Ple-
nary Session, LATITUDE, the phase III, double-blind
randomized trial of close to 1200 patients, clearly
demonstrated an improvement in overall survival
with the early initiation of abiraterone in this group of
patients.
2
Toxicity was manageable. Median relapse-
free survival was doubled to 33 months, and median
overall survival has not been reached yet (34.7 months
in the control group). This approach may replace the
addition of docetaxel in this group of patients, reserving
chemotherapy for patients with progressive disease.
3.
I will offer patients with refractory triple-negative
metastatic breast cancer (TNBC) pembroli-
zumab.
As presented by Adams et al in abstract
1008, Keynote-086, a phase 2 study of 170 patients
with previously treated TNBC, demonstrated only a
5% response rate; however, 21% of patients had sta-
ble disease, averaging 6 months, with some patients
without progression at over 10 months.
3
In the same
study, another cohort of patients was treated with pem-
brolizumab as first-line treatment for metastatic TNBC
(Abstract 1088).
4
Early results of the first 52 patients
demonstrate a response rate of 23%, with stable dis-
ease in 17%. Follow-up is short, but the estimated
6-month PFS is 29%. Note that, currently, pembroli-
zumab is not FDA-approved for this indication but can
often be obtained on compassionate release, and I
look forward to approval within the year.
4.
I will discuss with very high-risk patients who
have resected HER2-positive stage 2 and 3
breast cancer the addition of pertuzumab to tras-
tuzumab in the adjuvant setting for up to 1 year.
As
presented by von Minckwitz et al in abstract LBA500,
the randomized placebo-controlled APHINITY trial
of over 4800 patients demonstrated that the addi-
tion of pertuzumab to trastuzumab improved invasive
disease-free survival by a little over 1%, which was sta-
tistically significant.
5
Patients with nodal involvement,
particularly those with hormone receptor-negative dis-
ease achieved the most benefit and merit a discussion
of the risk/benefit and cost of adding pertuzumab to
trastuzumab.
5.
I will offer patients with refractory upper gastroin-
testinal adenocarcinomas checkpoint inhibitors
.
Two abstracts were presented at the Oral Session
which confirm the activity seen in earlier studies. Fuchs
et al reported the results of KEYNOTE-059 (abstract
4003), a global study of 259 heavily pretreated patients
with gastric and gastroesophageal junction cancer.
6
Overall response rate was 11.2%, with 17% stable dis-
ease. Median duration of follow-up is only 5.4 months;
but, so far, median duration of response is 8.1 months,
with some patients still responding at over 15 months.
Responses correlated with less prior treatment, with
PDL-1 positivity, and, especially, with MSI status. Jan-
jigian et al reported updated results of CheckMate 032
(abstract 4014), a global study of 160 similar patients
who were treated with one of three nivolumab reg-
imens (two in combination with ipilimumab).
7
Overall
response rate was 12% with nivolumab alone but
increased to 24% when combined with ipilimumab at
3 mg/kg every 3 weeks (nivolumab was decreased
to 1 mg/kg every 3 weeks). Median survival has not
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