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10
practice changes I will make after
attending ASCO 2016
By Jeffrey J. Kirshner
MD, FACP
1.
Avoid neurotoxic chemotherapy in diabetic and older patients,
when other options exist.
Dr Hershman et al examined the
SWOG database linked to Medicare claims (in the United States)
and determined that age and diabetes were predictors of the
development of neuropathy (Abstract 10001).
2.
Recommend an exercise program for patients starting potentially
neurotoxic chemotherapy treatment such as taxanes and
platinum drugs.
Greenlee et al presented data from the Pathways
Study (Abstract 10002) demonstrating a higher incidence of
taxane-induced neuropathy in breast cancer patients who were
obese and had a low level of physical activity. At the same session,
Dr Kleckner presented an analysis of a subset of 314 patients in
the URCC CCOP/NCORP EXCAP study (Abstract 10000). Those
randomised to the exercise program had a lower incidence of
early neuropathy, highly significant in older patients. Although
the majority of patients were women with breast cancer, there
were also men, and drugs included vinca alkaloids in addition
to taxanes and platinum.
3.
Consider the combination of daratumumab (D), bortezomib
(V), and dexamethasone (d) [DVd] as a treatment for relapsed
or refractory multiple myeloma.
Dr Palumbo presented the
results of the European CASTOR study at the Plenary Session,
which demonstrated superiority of DVd over Vd even in
patients previously treaded with V (Abstract LBA4). There was
a significant improvement in response rate, progression-free
survival, and time to progression, and responses were brisk,
which is important in these patients, many of whom are quite
symptomatic. Progression-free survival and time to progression
were approximately 7 to 8 months in the Vd group but have not
been reached in those who were treated with D as well.
4.
Offer short-course radiotherapy with temozolomide (TMZ) in
selected glioblastoma multiforme patients over the age of 65.
Dr Perry presented the results of a joint EORTC/NCIC study at the
Plenary Session (Abstract LBA2). The addition of TMZ to radiation
therapy resulted in an improvement in overall and progression-
free survival, most dramatic in patients with MGMT methylated
tumours. The regimen was well-tolerated, and there was an
impressive improvement in 2-year survival rates. Median survival
was increased from 3.9 to 5.3 months and in MGMT methylated
patients from 7.7 to 13.5 months.
5.
Use intermittent rather than continuous docetaxel in the
treatment of metastatic prostate cancer (Abstract 5005).
Although this German study, presented by Dr Cash did not
complete accrual, the intermittent regimen of docetaxel (12 weeks
of the drug either weekly or every 3 weeks, followed by a drug
holiday until progression) appears to be noninferior to the
continuous regimen. Another approach to decrease toxicity
in chemotherapy-treated patients in this population is to lower
the dose of cabazitaxel in the second line setting. DeBono et
al presented the results of their PROSELICA study (Abstract
5008), which demonstrated that the lower dose of 20 mg/m
2
was noninferior to the standard dose of 25 mg/m2, and there
was an improved overall safety profile!
6.
Add capecitabine (CAP) to gemcitabine for the adjuvant
treatment of resected pancreatic cancer
while we await
the results from ongoing studies of even more aggressive
combinations. The ESPAC-4 trial results were reported by
Neoptolemos et al (Abstract LBA4006), which demonstrated an
improvement in median survival from 25.5 to 28 months when
CAP was added to gemcitabine, with added but manageable
toxicity. These were very high-risk patients. Most impressively
the 5-year survival rates were increased by the addition of CAP
from 16% to 29%!
7.
Not use exemestane as adjuvant treatment for invasive lobular
breast cancer
in favour of one of the two nonsteroidal AIs,
anastrozole or letrozole (Abstract 521). There are increasing data
that exemestane is less effective in patients with this histology, which
was confirmed by this review of the MA.27 study by Strasser-Weippl
et al. Patients with invasive lobular carcinoma had improved overall
survival when treated with anastrozole as opposed to exemestane
(HR, 1.8; P = 0.55), consistent with the findings in the BIG 1-98 trial.
8.
Use more AC/T and less TC in patients with high-risk early breast
cancer
, based on the ABC analysis of three randomised trials
presented by Blum et al (Abstract 1000). In this initial report, the
non-anthracycline regimen did NOT demonstrate noninferiority
to the anthracycline regimens. TC may be noninferior for ER-
positive patients, however, but for receptor-negative patients, I
will use anthracyclines in most cases.
9.
Continue aromatase inhibitor (AI) therapy for at least an
additional 5 years in high-risk postmenopausal women with
early-stage breast cancer
. Many of these women have been
reluctant to stop their AI at 5 years; I have generally made
recommendations case by case, but mentioned that we will have
data to help guide our decisions, once we had the results from
the MA.17R and B42 studies. The initial results from MA17.R were
presented at the Plenary Session (Abstract LBA1) by Dr Goss. In
patients treated with 5 years of AI, as initial therapy or preceded
by up to 5 years of tamoxifen, extended AI treatment to 10 years
(as opposed to placebo) significantly improved disease-free
survival. The gains were modest, and there was an increased
risk of osteoporosis; so, I don’t plan on this approach in all of
these women, but I will have the discussion, considering the risks
and benefits, and probably recommend continuation in women
at high risk of late recurrence. Data presented in Abstract 505 by
Pan et al was an analysis of predictive factors for late recurrences
in ER-positive patients (over 46,000 British women followed for
up to 14 years), and its findings will help in advising our patients.
10.
Consider the use of checkpoint inhibitors for patients with
refractory cancers
as there is increasing evidence of efficacy
in a number of diseases, including metastatic colorectal, with
high microsatellite instability (Abstract 3501; Overman et al),
squamous cell anal (Abstract 3503; Morris et al), and even
metastatic bladder as first-line in cisplatin-ineligible patients
(Abstract LBA4500; Balar et al). I predict that these treatments
will become approved in the near future and may even be
available in some circumstances under compassionate use
programs.
ASCO 2016
7
DECEMBER 2016