2011 ASCO Meeting Theme Reflected in All Aspects of the Program

The theme of the 2011 ASCO Annual Meeting, “Patients. Pathways. Progress.” was borne out in the scientific sessions at McCormick Place in Chicago in both the news that came out of the meeting and in the attitudes and philosophies espoused by this year’s presenters and honorees. It is impossible to summarize all of the new science and clinical updates presented at the Meeting — the largest oncology meeting in the world — but this article highlights a few of the presentations that particularly illuminate the collective theme of the meeting.

Care Begins with Patients

Patients, of course, come first. 2010- 2011 ASCO President George W. Sledge, Jr., MD, emphasized this in his Presidential Address, noting that maintaining humane standards is vital even in the current era of genomic research. He said clinicians must not forget “our compassion for our fellow beings, and our belief in their essential dignity.” Patients must be the primary focus and the source of inspiration for clinicians devoted to oncology, he said.

The primacy of the patient was also emphasized by Jamie H. Von Roenn, MD, Northwestern University, recipient of this year’s ASCO/American Cancer Society (ACS) Award, in her ASCO/ACS Lecture and in her ASCO Daily News Expert Editorial. Dr. Von Roenn, a pioneer in the development of palliative medicine, said that for optimum oncology care, palliative care must be integrated into the continuum of care for all patients with cancer. In particular, she emphasized that palliative care is not limited to end-of-life care, but has a key role during active treatment and survivorship.

“Palliative medicine has come of age,” she said in an interview with ASCO Daily News. “Palliative care has only recently become a recognized subspecialty in the United States, and its recognition by multiple medical specialties has made the concepts and the unique medical knowledge central to palliative care more visible.”

As advances in cancer treatment leave more people living with cancer as a chronic illness, the effects of the disease on patients’ quality of life are increasingly being recognized, and interest in survivorship care is growing. In Dr. Von Roenn’s Expert Editorial, she called for more integration of palliative care and survivorship care into oncology education.

“I will suggest that when we talk about ‘personalized medicine,’ we need to focus on the ‘person,’” she told ASCO Daily News.

Proper survivorship care. Because of the increasing number of cancer survivors, one of the focuses of this year’s Annual Meeting was the need for survivorship care plans. Survivorship care includes monitoring patients for recurrences, for second primary malignancies, and for the long-term effects of cancer and its treatment, such as pain, depression, and sexual dysfunction.

Julie H. Rowland, PhD, of the National Cancer Institute (NCI) and Chair of the Education Session “Survivorship Care: Whose Job Is It?” said many patients feel that they “fall into an abyss” after their definitive cancer treatment ends. “It is not clear to them who should be following them, where they should go for care, or how their care will be coordinated,” she told ASCO Daily News in an interview.

Recent data from the NCI’s Surveillance, Epidemiology, and End Results (SEER) program showed that as of 2007 approximately 65% of cancer survivors were still alive 5 or more years after diagnosis, Dr. Rowland said.

As oncologists must continue to see new patients, they cannot practically continue following all of the surviving patients they have cared for, she said. Therefore, provision for proper survivorship care must be taken into consideration as part of each patient’s care.

There is some confusion, however, between medical oncologists and primary care physicians (PCPs) regarding how that care is to be accomplished. Results of a nationwide survey of the barriers perceived by PCPs and oncologists regarding breast and colorectal cancer survivorship care, sponsored jointly by the NCI and the ACS, were announced at the meeting (Abstract CRA9006). The Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) results were presented by Katherine S. Virgo, PhD, MBA, of the ACS.

With 1,130 medical oncologists and 1,072 PCPs responding to the survey, results showed that PCPs were more likely than oncologists to report ordering treatments for protection against malpractice litigation (p < 0.0001) and more likely to be concerned about the possibility of missed care (p = 0.0047). PCPs were also more likely than oncologists to be concerned about lacking adequate training (p < 0.0001). This difference was the most striking found in the survey, Dr. Virgo said. Oncologists were more likely than PCPs to report concerns about duplicating care (p = 0.0035) and about which physician is responsible for providing general preventive care in the follow-up period (p = 0.0007).

Inaugural Humanitarian Award. Palliation of symptoms for patients with cancer is one of the research interests of Mark G. Kris, MD, of Memorial Sloan-Kettering Cancer Center, the recipient of the inaugural ASCO Humanitarian Award. Dr. Kris has explored the prevention of emesis, one of the most dreaded side effects of cancer and cancer treatment.

The ASCO Humanitarian Award honors an oncologist who personifies ASCO’s mission and values by providing outstanding patient care through innovative means or exceptional service and leadership in voluntary, uncompensated endeavors in the United States and abroad.

Dr. Kris has demonstrated exceptional patient care, making house calls when a visit to the hospital would be too taxing for a patient, and touching the lives of thousands of individuals with cancer. He has also dedicated countless hours to humanitarian organizations and has traveled to the sites of disasters.

“There is a tremendous need for others to get involved,” he told ASCO Daily News regarding his disaster relief work. “There is a need for all kinds of skills, from drivers to cooks to good listeners.”

Pathways and Progress

	2010-2011 ASCO President George W. Sledge, Jr., MD, spoke about compassion for patients and the focus on pathways — both the tangible pathways and those representing the bench-to-bedside transition of research — that has led to progress in oncology.

In Dr. Sledge’s ASCO Daily News article “The ASCO Annual Meeting: Value for All Cancer Professionals,” he notes the interrelationship between pathways and progress.

“Pathways can have multiple meanings: the molecular pathways dominating invasion, growth, and metastasis; the pathways patients follow during the course of their care; and the clinical research pathways new treatments traverse on their way to the clinic,” he wrote. “Progress follows from our mastery of those pathways and from our commitment to research and clinical excellence.”

Pathways, correctly navigated, lead to progress. Because “pathways” can be interpreted in genetic terms or as a metaphor for the transition of research from the laboratory to the clinic, a large number of abstracts presented at this year’s Meeting were relevant to this aspect of theme; just a few are discussed here.

• DNA repair pathways were the focus of an Educational Session, “PARP Inhibitors, DNA Repair, and Beyond: Theory Meets Reality in the Clinic.” Michael B. Kastan, MD, PhD, of St. Jude Children’s Research Hospital, Chair of the Session, said many tumors exhibit mutations of one or more DNA repair genes, and it is likely that those mutations are the source of the development of the tumor itself. Also, tumors with a defect in one repair pathway are sensitive to inhibition of a different repair pathway. These mutations, therefore, may be an Achilles’ heel. Investigators are working to develop compounds that can exploit these pathways for clinical benefit.
   
• Regarding the pathway from the bench to the bedside, one of the topics from the Meeting that received the most coverage in the mainstream media was the encouraging results with two new drugs for treatment of melanoma. Clinical trials of both ipilimumab and vemurafenib, demonstrating improved survival in patients with melanoma, were widely reported.
  
  Ipilimumab, a monoclonal antibody approved by the U. S. Food and Drug Administration earlier this year, conferred an overall survival (OS) benefit in patients with metastatic melanoma, as reported by Jedd D. Wolchok, MD, of Memorial Sloan- Kettering Cancer Center (Abstract LBA5). These results, from the second phase III trial to show an OS benefit for the drug, may change the treatment landscape for metastatic melanoma, establishing ipilimumab as the first-line therapy of choice in place of dacarbazine. See the article on page 8 for details.
  
  At the same session, Paul B. Chapman, MD, of Memorial Sloan-Kettering Cancer Center, reported that vemurafenib improved OS in patients with previously untreated melanoma with the BRAFV600E gene mutation (Abstract LBA4). Approximately half of patients with melanoma have this mutation in the BRAF gene. This was the first study to demonstrate that the drug significantly improves OS compared with the current standard, dacarbazine chemotherapy.
• Also widely reported in the mainstream media was the news that the aromatase inhibitor exemestane can reduce the risk of breast cancer occurrence with a more acceptable side-effect profile than other drugs currently approved for that indication. With a median 35 months follow-up, in postmenopausal women at increased risk of developing breast cancer, exemestane reduced the risk by 65% compared with placebo in a phase III clinical trial. “In our opinion, exemestane offers a new option for consideration of breast cancer prevention for postmenopausal women,” said Paul E. Goss, MD, PhD, of the Massachusetts General Hospital Cancer Center, who presented the study results (Abstract LBA504).
   
• Adding regional node irradiation (RNI) to breast-conserving surgery plus whole-breast irradiation improved disease-free survival (DFS; hazard ratio [HR]: 0.67; 95% CI [0.52, 0.87]; p = 0.003, stratified) and showed a trend toward better OS in women with early breast cancer (LBA1003). Timothy Whelan, BM, BCh, MSc, of the Juravinski Cancer Centre at Hamilton Health Sciences, Canada, said, adding that RNI reduced the risk of locoregional and distant recurrence without greatly increasing toxicity. He suggested that the findings of this study may be practice changing.
   
• For high-risk patients with gastrointestinal stromal tumors (GIST), extension of imatinib treatment for 3 years after surgery improved recurrence-free survival (RFS) and OS compared with standard 1-year adjuvant therapy with imatinib (LBA1). Patients who received 400 mg of imatinib orally for 36 months were 54% less likely to experience recurrence (HR: 0.46; 95% CI [0.32, 0.65]; p < 0.0001) compared with patients who received the drug for 12 months, said Heikki Joensuu, MD, of the Helsinki University Central Hospital, Finland.
   
• In patients with newly diagnosed diffuse large B-cell non-Hodgkin lymphoma, a reduced 14-day regimen of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) did not improve OS or PFS compared with standard 21-day treatment (R-CHOP 21; Abstract 8000). David Cunningham, MD, of The Royal Marsden Hospital, England, said that with a median follow-up of 37 months, HRs were 0.96 (p = 0.75) for OS and 1.0 (p = 0.98) for PFS, and other measures were virtually identical between the two cohorts.
   
• Another study in non-Hodgkin lymphoma (Abstract 8001) found that autologous stem-cell transplantation after cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP)-based induction therapy appears to improve PFS. Patrick J. Stiff, MD, of Loyola University Medical Center, the estimated 2-year PFS rate was 69% with autologous transplant compared with 56% with induction therapy alone, a 72% improvement (HR: 1.72; 95% CI [1.18, 2.51]; p = 0.005).