In this podcast, Dr. Charles Loprinzi discusses some of the research on improving the quality of life for people living with cancer, including new treatments for common side effects and the importance of honest discussions with medical providers.
ASCO: You're listening to a podcast from cancer.net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world's leading professional organization for doctors that care for people with cancer.
In today's podcast, we'll discuss some of the research on improving the quality of life for people living with cancer, including new treatments for common side effects and the importance of honest discussions with medical providers. This podcast will be led by Dr. Charles Loprinzi, who is a medical oncologist and the Regis Professor of Breast Cancer Research at the Mayo Clinic. Dr. Loprinzi is also an Associate Editor for Cancer.Net.
The ASCO Annual Meeting is the premiere educational and scientific event where physicians, researchers and other healthcare professionals gather to discuss the latest in cancer care and treatment. This Cancer.Net podcast helps put new research findings into context, and explains what they mean for patients. ASCO would like to thank Dr. Loprinzi for summarizing this research.
Dr. Loprinzi: Hello, this is Charles Loprinzi. I'm a medical oncologist at the Mayo Clinic in Rochester, Minnesota. I'm going to talk about 4 different items that deal with symptoms related to patients who have cancer or are receiving cancer therapy. These are items that came up at the recent meetings that we had in late May and early June, 2015. The first item I'm going to talk about has to do with zoledronate, otherwise called zoledronic acid or Zometa, as a drug to help patients who have breast cancer or other sorts of cancers that have metastasized—that means spread—to bones. And there have been data for some time available to demonstrate that given these bone strengthening agents, in patients who have cancer spread to bones, can actually help those patients and decrease the need for radiation, and decrease the chance of fractures, and decrease the amount of pain that people have. In past years it was recommended to give this medication, zoledronate, once every month, and do that indefinitely. Some people have suggested stopping that after 2 years of treatment.
Last year there were a couple of trials that came out that suggested that if a person had this treatment once a month for a year, then at the second year they were randomized to get it once a month or once every 3 months, and it was found out that once every 3 months was just as good as once a month. So that changed practice. The current trial that was presented this year actually took patients who had the boney metastasis—the cancer spread to bone—and randomized the patients to get this zoledronate once every month for two years versus to get it once every three months for two years. 1,822 patients were entered on this clinical trial, and they were randomized to the two different arms, so it was a play of chance as to which arm patients got. It turns out that if you looked over time with these patients, there were similar numbers of bone related problems in both groups. There were 29 patients in each group who had these problems, with no difference between the 2 arms. If you looked at the time to when these bone problems came on in these patients they were quite similar also, and if you looked at the amount of pain that patients had over time on the 2 arms they were quite similar, and if you looked at what we call the performance status—how active a patient is versus how much time they need to spend in a chair or in bed—they were quite similar between the 2 arms.
And if you look at the toxicities of this medication—and there are some where it can cause some trouble with the jaw bone or some kidney troubles—there were similar amounts of toxicities on both arms. A little bit less—actually, it was half as much in the patients who received once every 3 months as opposed to every 1 month—but from a statistical stand point they were close enough that it wasn't what we call statistically significantly different. So the bottom line with this particular study is that this information suggests that giving this medication once every 3 months works as well as giving it once a month; that it's cheaper, of course, when you give it less often; and it appears to be that there are less side effects from this medication when given less frequently.
The second topic I'm going to talk about deals with chemotherapy induced nausea and vomiting. And it is well known that lots of the chemotherapy drugs can cause nausea and vomiting. We're much better at treating this problem than we were 10, 20 years ago, but we haven't solved it completely. So this particular trial looked at a drug called olanzapine which is a drug that's used for people that have psychiatric troubles—used chronically there—but looked at this medication for just four days instead of another medication called fosaprepitant which is a standard medication used to try to prevent nausea and vomiting in patients, and it randomized patients to get one of the two different medications. Now, the standard medication that's around has been around for many years. It's quite an expensive medication, and it can cost hundreds of dollars for each course of therapy, and the olanzapine medication is a generic medication, and it can be obtained for just a few dollars for each course of therapy.
So patients who were set to receive what we call highly emetogenic chemotherapy, or chemotherapy that can cause a lot of nausea and vomiting, with a drug called cisplatin. They also got 5-Fluorouracil in there but that doesn't cause as much nausea and vomiting. But they were randomized to get the anti-emetic, or the anti-nausea or anti-vomiting regimen, with fosaprepitant versus this one with olanzapine. In both arms people got another medication called palonosetron and they both got some dexamethasone, which is a corticosteroid medication. It turns out that there were about 100 patients on this study and they were randomized equally. One arm had 51 patients on it and the other arm had 49 patients on it. If you look at the complete response, and that means that the patients did not have any vomiting and they did not have to take any rescue medications because of nausea or vomiting, that they were statistically similar between olanzapine and fosaprepitant, although numerically they were a little bit better in the patients getting olanzapine. So, in the first 24 hours, 88% of patients had a complete response—no vomiting and not taking rescue medications—with olanzapine versus 84% with the fosaprepitant. And if you looked at the whole 5 days after treatment, those numbers were 76% and 73%. So a little bit better, but not statistically different in terms of that complete response.
However, the other thing that they looked at in detail was whether the patients had no nausea over the 5 days, and patients every day were supposed to fill out a questionnaire that said, "How much nausea do you have from none to very bad?" and this was on a scale of zero to 10, so they have 10 numbers where they can grade how much trouble they had. And if you look at the numbers of patients—the percentage of patients—who had no nausea with the standard medication, it was 41%, and that was improved to 71% in the patients who received the olanzapine medication. So bottom line is the olanzapine medication appears to be better for nausea, it's quite cheap compared to the cost of the other medication, and it may well be a new standard. There's a little bit of debate as to whether this is enough information to make this the new standard of therapy, with some people saying, yes, they think it is, and other people thinking, “Maybe we need another study or so to help improve that process.”
The next trial to talk about is one that dealt with a treatment for patients who had advanced cancer, and were having trouble with poor appetite and weight loss. There are some medications that have been shown in the past to be able to help that—a drug called magestrol acetate and corticosteroid-type medications that can help increase appetite in patients, and help patient's gain a little bit of weight. It turns out that they have some side-effects with them, and they don't improve survival overall or quality of life, and so they haven't been widely endorsed. So this medication that they studied here is a new one called anamorelin, A-N-A-M-O-R-E-L-I-N. It was done in an international study design, and they actually did two studies, and the put all of the data together from these two studies. And the bottom line that they noted was that the patients who received the anamorelin versus a placebo, they had an improvement in their weight by several pounds; they increased their lean body mass, which is basically their muscle-type mass as opposed to fat or fluids; they increased their appetite; and their family members were less worried about how much they were eating. So those are all the good things related to the results of this study. On the other hand, they looked at hand grip strength—how well a person could squeeze a tool to see what their strength is in their hand—and there was no change in that over the duration of the study. The survivals were quite similar on both groups of patients, and it didn't appear to help fatigue in those patients. So this drug does seem to be helpful. The drug is not yet approved, and there will be a discussion as to whether or not it's worth giving this medication to people who have trouble with appetite and loss of weight. There'll be a judgment from the patient and the doctors as to whether or not this is enough information to suggest that it's beneficial to utilize or not.
So, last thing I want to briefly discuss, deals with discussions of difficult issues with patients—survival probabilities in patients with advanced cancer; resuscitation wishes, whether or not a patient would want to be resuscitated or be put on a breathing machine if their heart were to stop or their lungs were to stop working—hospice sort of discussions. And the bottom line from a series of abstracts this year is that most patients do benefit from having these discussions with their physicians; that these discussions help provide an appropriate balance of hope and reality, both important things in patients who have advanced cancer; that these discussions help to facilitate appropriate medical decisions—whether to take more chemotherapy or not, whether to be hospitalized again or not, and whether to spend more time at home or not in the advanced stages of cancer process. And most patients and families do appreciate having these discussions in a compassionate manner. It's difficult to have these discussions at times, and physicians have been afraid of having these discussions because they're afraid that they might be taking away hope, but the information that's coming out from clinical trials, or actually it's showing, that most patients and families do appreciate this. And so, bottom line, I call this compassionate honesty—try to be honest with the patient to try to help provide appropriate decision-making processes. Thank you for your attention. Bye-bye.
ASCO: Thank you, Dr. Loprinzi. To find all of the science presented at ASCO's 2015 Annual Meeting, visit www.cancer.net. If you have questions about whether new research may affect your care, be sure to talk with your doctor.
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