The 2018 American Society of Clinical Oncology Annual Meeting Highlights Major Cancer Research Advances
Adding Atezolizumab Immunotherapy to Chemotherapy Slows Growth of Advanced Squamous Lung Cancer
Initial findings from a randomized phase III clinical trial show that people with advanced squamous non-small cell lung cancer benefit more from initial treatment with PD-L1 targeted immunotherapy atezolizumab (Tecentriq) and chemotherapy than from chemotherapy alone – 29 percent had a reduced risk of disease worsening or death compared with those who received chemotherapy alone. At 12 months, cancer had not worsened in twice as many people who received Tecentriq plus chemotherapy compared to those who only received chemotherapy. This benefit was observed across all PD-L1 expressing sub-groups.
“We used to think that chemotherapy just knocked down the patient’s immune system and that it would be irrational to combine it with immunotherapy, but growing research, including this study, shows that chemotherapy can help trigger the immune response to the tumor, helping the immunotherapy treatment work better,” says lead study author Robert M. Jotte, md, phd, medical director and cochair of the USON Thoracic Committee at Rocky Mountain Cancer Centers in Denver, CO.
Phase III Trial Finds Many People with Advanced Kidney Cancer Do Not Need Surgery
A randomized phase III clinical trial showed that many people with advanced kidney cancer can avoid surgery to remove the kidney, called nephrectomy, without compromising survival. The median overall survival for people who received only the targeted therapy sunitinib (Sutent) was 18.4 months, compared to 13.9 months for those who received surgery followed by Sutent, the current standard of care.
In addition to putting patients at risk for complications, including blood loss, infection, pulmonary embolism, and heart problems, nephrectomy delays medical treatment for people with advanced kidney cancer for weeks. In some cases, the cancer worsens so rapidly during this delay that there is no time to start systemic treatment.
“Thanks to this research, many patients with advanced kidney cancer can be spared unnecessary surgery and a host of severe side effects that often accompany it. These findings will likely lead to a dramatic change in treatment for people who are diagnosed with metastatic kidney cancer,” says ASCO Expert Sumanta K. Pal, MD.
Chemotherapy Regimen Extends Life by Nearly Twenty Months for People with Pancreatic Cancer
In a randomized phase III trial, people with surgically removed pancreatic cancer who received mFOLFIRINOX, a chemotherapy regimen containing four different medicines, lived a median of 20 months longer and were cancer-free 9 months longer than those who received the current standard of care, gemcitabine (Gemzar). Gemcitabine has been the standard adjuvant therapy for the past 10 years.
The mFOLFIRINOX regimen combines four chemotherapy medicines: oxaliplatin (Eloxatin), leucovorin (folinic acid), irinotecan (Camptosar), and 5-fluorouracil (Adrucil). A very similar regimen is already used as an initial treatment for metastatic pancreatic cancer, and this study shows FOLFIRINOX can also benefit people with earlier-stage disease.
Heated Abdominal Chemotherapy Not Beneficial in People with Advanced Colorectal Cancer
A randomized phase III clinical trial shows that people with advanced colorectal cancer may not need a frequently considered component of treatment – heated chemotherapy delivered to the abdomen during surgery. There was no difference in survival between people with metastases in the abdomen who received heated chemotherapy during surgery and those who received surgery alone. Long-term side effects were more common with chemotherapy.
“This study is an example where less is more. It suggests we can spare many people with colorectal cancer from unnecessary chemotherapy that often comes with harsh side effects,” says ASCO Expert Andrew Epstein, md.
Immunotherapy Pembrolizumab Works Better Than Chemotherapy Alone as Initial Treatment for Most Advanced Lung Cancers
A large, randomized phase III trial shows that the immunotherapy pembrolizumab (Keytruda) is a more effective initial treatment than chemotherapy (the current standard of care) for the majority of people with the most common type of lung cancer. People with advanced non-small cell lung cancer with a PD-L1 expression of one percent or more who were first treated with immunotherapy pembrolizumab lived a median of four to eight months longer than those who received chemotherapy. In addition, severe side effects occurred in fewer people receiving pembrolizumab than chemotherapy (18 percent vs. 41 percent).
Based on findings from a previous, smaller clinical trial, the U.S. Food and Drug Administration approved pembrolizumab, under the brand name Keytruda, for initial treatment of non-small cell lung cancer with high PD-L1 expression, which accounts for about one-third of these cancers. Pembrolizumab is currently the only approved immunotherapy for initial treatment of lung cancer. It is approved for use as a standalone treatment and in combination with chemotherapy.
Use of Mobile and Sensor Technology Lowers Symptom Severity for People with Head and Neck Cancer
A federally funded, randomized clinical trial of people receiving radiation for head and neck cancer, using mobile and sensor technology to remotely monitor their symptoms, resulted in less severe symptoms related to both the cancer and its treatment.
Trial participants who used the technology – which included a Bluetooth-enabled weight scale, Bluetooth-enabled blood pressure cuff, and mobile tablet with a symptom-tracking app that sent information directly to their physician each weekday – had lower symptom severity than those who had standard weekly visits with their doctors. In addition, daily remote tracking of patient wellbeing, according to the researchers, enabled physicians to detect concerning symptoms early and respond more rapidly, compared to usual care.
More Choices for Treating Insomnia in Cancer Survivors: Acupuncture and Cognitive Behavioral Therapy
A Patient-Centered Outcomes Research Institute (PCORI)–supported randomized clinical trial of cancer survivors showed that eight weeks of either acupuncture or cognitive behavioral therapy for insomnia, called CBT-I, decreased the severity of insomnia among cancer survivors, though improvements were greatest among those receiving cognitive behavioral therapy.
“Up to 60 percent of cancer survivors have some form of insomnia, but it is often underdiagnosed and undertreated,” says lead study author Jun J. Mao, MD, Chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center in New York, NY. “Our trial showed that both CBT-I and acupuncture were effective in treating moderate to severe insomnia, although CBT-I was more effective for those with mild symptoms of insomnia. Now patients have more choices to manage their insomnia.”
CBT-I is a newer form of psychotherapy that attempts to modify emotions, behaviors, and thoughts related to sleep. CBT-I has been the gold standard for treatment of insomnia, says Dr. Mao. Acupuncture was deemed a reasonable comparison to be used in this trial.
All trial participants had been clinically diagnosed with insomnia by research staff through structured clinical interviews and were randomly assigned to receive either CBT-I or acupuncture for eight weeks.
The participants who received CBT-I worked with a therapist to re-establish a restorative sleep schedule by:
• Reducing the amount of time spent in bed
• Limiting activities performed in bed to only sleep and sexual activity
• Modifying unhelpful beliefs about sleep
• Promoting good sleep hygiene (avoiding activities that included light from tablets and cellphones, eating too late, and performing vigorous activities; they also set a regular sleep schedule)
Researchers found that CBT-I was the more effective treatment overall. Among people with mild insomnia at the start of the trial, far more had an improvement with CBT-I than with acupuncture (85 percent vs. 18 percent). Participants who started the trial with moderate to severe insomnia had somewhat similar response rates to CBT-I vs. acupuncture (75 percent vs. 66 percent). All survivors maintained improvement in insomnia up to 20 weeks after the start of the trial.
Shorter Trastuzumab Treatment for HER2+ Breast Cancer Can Be as Effective, with Fewer Cardiac Side Effects
A phase III randomized clinical trial of women with HER2-positive, early-stage breast cancer found that taking trastuzumab (Herceptin) for 6 months was non-inferior to the current standard of 12 months. The disease-free survival rate at four years was 89.4 percent with 6 months of therapy and 89.8 percent with 12 months of therapy. In addition, only 4 percent of women in the 6-month arm stopped trastuzumab early because of cardiac problems, compared with 8 percent in the 12-month arm.
“The use of trastuzumab has been a major advance for women with HER2-positive breast cancer by increasing the cure rate, but no treatment is free of side effects, and heart damage has always been a concern with this treatment. This new trial shows that a shorter length of treatment can benefit patients just as much as a longer treatment, with less risk of cardiac side effects,” says ASCO President Bruce E. Johnson, md, fasco.
Pre-Operative Chemotherapy with Radiation May Help People with Pancreatic Cancer Live Longer
A randomized, phase III trial found that people who received chemotherapy with radiation (chemoradiotherapy) before pancreatic cancer surgery had better disease-free survival than those who started their treatment with surgery, which is the current standard of care. In addition, the two-year survival rate was higher for those who received chemoradiotherapy before surgery (42 percent vs. 30 percent). The preliminary findings of this trial show that chemoradiotherapy before surgery may be beneficial for people with pancreatic cancer.
New Regimens Improve Survival for Children and Young Adults with T-Cell Cancers
In a federally funded, randomized phase III clinical trial performed by the Children’s Oncology Group, 90 percent of children and young adults with T-cell acute lymphoblastic leukemia (T-ALL) or T-cell lymphoblastic lymphoma (T-LL) were alive four years after starting treatment regimens on this trial, and 84 percent were cancer-free. These are the highest survival rates for these T-cell malignancies reported to date, according to the authors.
In addition to receiving the standard, complex, multi-drug chemotherapy regimen known as COG augmented Berlin-Frankfurt-Munster chemotherapy, trial participants were randomly assigned to also receive either high-dose methotrexate (a chemotherapy) in a hospital or escalating dose methotrexate (a regimen that starts with low doses of methotrexate, gradually increased over time) in an outpatient setting. The group of patients with moderate or high risk of cancer recurrence were also randomly assigned to receive or not receive nelarabine (Arranon), in addition to chemotherapy, and cranial radiation. The addition of nelarabine to standard chemotherapy provided further benefit for the group with moderate or high risk of T-ALL recurrence – at four years 89 percent of those who received nelarabine were leukemia-free vs. 83 percent of those who did not.
Nelarabine was approved in 2005 by the FDA for the treatment of people with T-ALL and T-LL that had progressed after at least two chemotherapy regimens. Unlike the trials that led to the FDA approval, nelarabine was tested in newly diagnosed patients in this trial.
Visit the American Society of Clinical Oncology’s patient education website – Cancer.Net – for more research highlights from the 2018 Annual Meeting, as well as more information and resources for cancer survivors and their caregivers.
This article was published in Coping® with Cancer magazine, July/August 2018.