ASCO 2019 Special

Episode 23:

Alan P. Lyss, MD, a medical oncologist in community practice at Missouri Baptist Medical Center in St. Louis, joins Blood & Cancer host David H. Henry, MD, of the University of Pennsylvania, Philadelphia, to break down the most interesting and practice-changing studies at the recent 2019 annual meeting of the American Society of Clinical Oncology.

Show notes

By Ronak H. Mistry, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia

Big Data:

• Impact of the Affordable Care Act (ACA) Medicaid expansion on racial disparities in time to cancer treatment (Abstract LBA1).
  • Evaluated 34,000 patients from January 2011 to December 2018 in states with Medicaid expansion. The time from diagnosis to treatment (receipt of first-line treatment within 30 days of diagnosis) was decreased for African American patients with cancer.
• Impact of the Affordable Care Act on early-stage diagnosis and treatment for women with ovarian cancer (Abstract LBA5563).
  • Evaluated 36,000 patients with ovarian cancer. Under the Affordable Care Act, women with ovarian cancer were more likely to be diagnosed and treated within 30 days of diagnosis.
• Real-world outcomes of patients with advanced non–small cell lung cancer and autoimmune disease receiving immune checkpoint inhibitors (Abstract 110)
  • Patients with autoimmune diseases were excluded from trials testing checkpoint inhibitors; authors report that 22% of patients with NSCLC have autoimmune disease.
  • Utilized data from ASCO CancerLinQ database.
  • Authors show that survival rates using checkpoint inhibitors in patients with autoimmune disease were similar to those in patients without autoimmune disease.

Colorectal Cancer

• Three versus six months adjuvant FOLFOX or CAPOX for high-risk stage II and stage III colon cancer patients: Efficacy results of Hellenic Oncology Research Group participation to the International Duration Evaluation of Adjuvant chemotherapy (IDEA) project (Abstract 3500).
  • IDEA trial previously presented at ASCO showed that if patients had grade T3N1 or less colorectal cancer, 3 months of treatment was as effective as 6 months with FOLFOX or CAPOX.
  • The current study shows that 3-year progression-free survival was similar for 3 months or 6 months of therapy.
• Prospective pooled analysis of four randomized trials investigating duration of adjuvant oxaliplatin-based therapy (3 months vs. 6 months) for patients with high-risk stage II colorectal cancer (Abstract 3501).
  • Data from four major international trials were assessed.
  • Patients included in this study were more high risk, as compared with the IDEA trial. Despite this, 5-year disease-free survival was 80.7% at 3 months vs. 83.9% at 6 months, showing noninferiority.

Pancreatic Cancer

• APACT: Phase 3 trial of adjuvant nab-paclitaxel plus gemcitabine for surgically resected pancreatic adenocarcinoma (Abstract 4000).
  • Use of nab-paclitaxel plus gemcitabine vs. gemcitabine alone was not significantly different at 18 months in terms of disease-free survival when assessed by independent reviewer; however,
  • Primary investigators, however, did find a difference in disease-free survival.
• POLO trial: Olaparib as maintenance treatment following first-line platinum-based chemotherapy in patients with a germline BRCA mutation and metastatic pancreatic cancer (Abstract LBA4).
  • About 5% of patients with pancreatic cancer (too locally advanced to be resectable or metastatic) in whom germline BRCA is checked are positive.
  • Use of olaparib maintenance after platinum-containing chemotherapy was associated with median progression-free survival of 7.4 months vs. 3.8 months in placebo.

Prostate Cancer

• Overall survival results of a phase 3 randomized trial of standard-of-care therapy with or without enzalutamide for metastatic hormone-sensitive prostate cancer: ENZAMET, an ANZUP-led International Cooperative Group Trial (Abstract LBA2).
  • Randomized 1,100 patients with metastatic prostate cancer to standard hormonal therapy plus enzalutamide, or standard therapy plus other nonsteroidal antiandrogens (NSAAs).
  • At 3 years, twice as many patients receiving enzalutamide had better disease-free survival and overall survival than did those with other NSAAs.

Lung Cancer

• Neoadjuvant nivolumab or nivolumab plus ipilimumab for resectable non–small cell lung cancer: Results from the NEOSTAR study (Abstract 8504).
  • Patients with stage I-IIIA resectable NSCLC were assigned to nivolumab or nivolumab plus ipilimumab.
  • Major pathologic response was 17% (single) vs. 33% (double)
  • There were also higher baseline PDL-1 levels in patients who had better response.

Breast Cancer

• Neoadjuvant trastuzumab, pertuzumab, and chemotherapy versus trastuzumab emtansine plus pertuzumab in human epidermal growth factor receptor 2 (HER2)-positive breast cancer: Final outcome results from the phase 3 KRISTINE study (Abstract 500).
  • Assessed chemotherapy vs. non–chemotherapy regimen for breast cancer. Event-free survival favors chemotherapy regimen because of locoregional progressive events.
  • When examined further, patients with locoregional progression had lower HER2 expression and more heterogeneity.
  • Consider the proportion of cells that are HER2/Neu positive when deciding about treatment, instead of just HER2-positive or negative.
• HER2 heterogeneity as a predictor of response to neoadjuvant T-DM1 plus pertuzumab (Abstract 502).
  • Highlights importance of assessing HER2 heterogeneity as a predictor of who will respond to targeted therapy without chemotherapy.
• Impact of clinical risk category on prognosis and prediction of chemotherapy benefit in early breast cancer by age and the 21-gene recurrence score in TAILORX (Abstract 503).
  • In women younger than 50 years old, there is value in looking at the recurrence score.
  • Women younger than age 50 years with RS 16-20 and low clinical risk get little benefit from adjuvant chemotherapy.

Health Informatics

• The impact of routine Edmonton Symptom Assessment System (ESAS) use on overall survival (Abstract 6509).
  • Using the Edmonton Scale results in a statically significant overall survival for adult cancer patients at 5 years and should be regularly integrated into clinical practice.

Phase 3 nonrandomized controlled trial of PROMPT-Care, an eHealth intervention utilizing patient- reported outcomes in routine clinical care (Abstract 6510).

• • Patients had monthly online assessments that then were analyzed by the care team.
  • Use of this technology resulted in a 26% decrease in emergency department visits, compared with patients who did not use this assessment.

Multiple Myeloma (https://ascopubs.org/jco/abstracts-multiple-myeloma-19)

• Smoldering Myeloma
  • Consider 2-20-20 rule for risk stratification (Abstract 8000):
    • Greater than 2g spike in monoclonal protein.
    • Kappa/lambda or lambda/kappa ratio greater than 20.
    • Bone marrow plasma cell greater than 20%.
      • Can add FISH testing.
    • Use of lenalidomide has no change in overall survival when given to patients with smoldering myeloma.
  • Myeloma – Exciting work is ongoing.
    • Carfilzomib- lenalidomide-dexamethasone (KRd) followed by autologous transplant is standard. One study showed that treatment with KRd-transplant vs. KRd alone was equally effective in achieving minimal residual disease. In high-risk patients, autologous stem cell transplant reduced the risk of early relapse (Abstract 8002).
    • Relapsed/Refractory setting:
      • Isatuximab (CD38 antibody) is showing promise when mixed with pamidronate and dexamethasone. Studies to come in this area.
      • Iberdomide is a novel cereblon E3 ubiquitin ligase modulator. Phase 1 study showing promise in patients who failed prior therapies.
      • Subcutaneous daratumumab shows no difference in outcomes, compared with standard intravenous administration, but without 1-2 days of infusion.
      • AMG420, anti-BCMA bispecific T-cell engager (BiTE) immunotherapy, resulted in a 70% response rate in a phase 1 trial (Abstract 8007).

Additional reading:

2018 at a glance: Recently approved therapies in oncology

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