ASCO20 Virtual Scientific Program Research Round Up: Breast Cancer, Sarcoma, and Supportive Care

July 21, 2020
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In the annual Research Round Up podcast series, Cancer.Net Associate Editors answer the question, “What was the most exciting or practice-changing research in your field presented at the ASCO20 Virtual Scientific Program?” In this episode, 3 editors discuss new research in the fields of breast cancer, sarcoma, and palliative and supportive care.



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 who care for people with cancer.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses.

Every year, the ASCO Annual Meeting brings together attendees from around the globe to learn about the latest research in the treatment and care of people with cancer. This year, attendees from 138 countries worldwide gathered virtually for the ASCO20 Virtual Scientific Program, held Friday, May 29 through Sunday, May 31.

In the annual Research Round Up podcast series, Cancer.Net Associate Editors answer the question, “What was the most exciting or practice-changing research in your field presented at the ASCO20 Virtual Scientific Program?” In this episode, 3 editors discuss new research in the fields of breast cancer, sarcoma, and palliative and supportive care.

First, Dr. Norah Lynn Henry will discuss 3 studies that exploring treatment options for different types of breast cancer. Dr. Henry is an Associate Professor in the University of Michigan's Division of Hematology/Oncology in the Department of Internal Medicine and is the Breast Oncology Disease Lead at the Rogel Cancer Center. She is also the Cancer.Net Associate Editor for Breast Cancer.

View Dr. Henry’s disclosures at Cancer.Net.

Dr. Henry: I'm Dr. Lynn Henry, one of the breast cancer experts from the Rogel Cancer Center at the University of Michigan. I would like to share with you a few of the research highlights related to breast cancer from the ASCO 2020 Virtual Scientific Program. I do not have any relationships to disclose related to any of these studies. There were many exciting trials presented at this conference for all types of breast cancer. Today I will highlight 3 key studies that will likely change how we treat patients with breast cancer. Before I start talking about the trials themselves, I'm going to give a very brief overview of the types of breast cancer. Then I will talk about an important study that looked at the use of surgery and radiation in patients whose cancer is metastatic or has already spread to other sites of the body at the time they are diagnosed with breast cancer. Then I will highlight some research that was presented on triple negative and HER2-positive metastatic breast cancer.

As a brief review, there are multiple kinds of breast cancer. Some breast cancers are called hormone receptor positive or estrogen receptor positive and are stimulated to grow by estrogen. We treat those cancers with anti-estrogen treatments to block estrogen or to lower estrogen levels. Other breast cancers are called HER2-positive. These are often more aggressive cancers, but because they have extra copies of the HER2 receptor, they often respond to treatments that block HER2. Finally, there are breast cancers that don't have any hormone receptors or HER2 receptors. These are called triple-negative breast cancer and are also often very aggressive cancers.

The first clinical trial I'm going to discuss was a relatively large trial conducted by the ECOG-ACRIN cooperative group. Of patients newly diagnosed with breast cancer, about 6% are actually found to have cancer in other sites in their body such as in the bone, liver, or lung, as well as in the breast. This is called de novo metastatic breast cancer. The goal of this trial was to determine whether patients in this situation should have surgery and radiation to treat the cancer in their breast in addition to drug treatment, or whether they should just have drug treatment for their cancer. In this trial, patients with de novo metastatic breast cancer of any type were treated with appropriate drug therapy for 4 to 8 months. The approximately 250 patients whose cancers improved with treatment were randomized to either have breast surgery and, if appropriate, radiation therapy, and then resume drug therapy or to just continue drug therapy the entire time. Overall, there was no difference in how long patients survived whether they had removal of the breast mass or not. In addition, the quality of life in the 2 groups of patients also appeared to be similar. These results confirm studies that have been conducted in other countries around the world and importantly examined whether surgery is appropriate in patients who are treated with modern therapies. It appears that surgery is not needed in most patients. This is important information for patients with de novo metastatic breast cancer who are trying to decide whether or not to have breast surgery as part of their treatment.

The next trial is called KEYNOTE-355 and examined the use of an immunotherapy drug pembrolizumab, also called Keytruda, in patients with triple-negative metastatic breast cancer. Immunotherapy is a treatment type that allows a patient's own immune system to help treat her cancer. We already have the FDA approved option of using a similar immunotherapy medication called atezolizumab, also called Tecentriq, in combination with a specific chemotherapy drug for patients whose cancer express PDL1. In this new KEYNOTE trial, pembrolizumab was combined with 1 of 3 possible chemotherapy options in patients with previously untreated metastatic triple-negative breast cancer. In this trial, in patients whose tumors had an increased amount of PDL1 on the cells and in the surrounding tissue, the addition of pembrolizumab to chemotherapy made it less likely for the cancer to progress compared to chemotherapy alone. Although this treatment combination is not yet FDA approved, all the drugs that were tested are already approved for use in other situations. These results are exciting because they will likely lead to new treatment options for patients with this type of breast cancer which can be quite challenging to treat.

Finally, I will highlight new results from the clinical trial called HER2CLIMB. This is a large phase 3 trial examining a new drug called tucatinib that is a pill that is designed to turn off the HER2 receptor. Patients who enrolled on this trial had previously been treated with multiple different treatments for HER2-positive metastatic breast cancer. All enrolled patients were treated with the anti-HER2 antibody drug trastuzumab, also called Herceptin, as well as a chemotherapy drug called capecitabine or Xeloda. In addition, two-thirds received the new drug tucatinib and one-third receive placebo. We learned about 6 months ago that this drug combination was pretty well tolerated by patients. And what is exciting about this trial is the patients who were treated with tucatinib had a longer time until their cancer progressed and lived longer compared to those who took placebo. As a result of this trial, the drug was approved by the U.S. Food and Drug Administration in spring 2020.

Because of the type of drug that it is, tucatinib is thought to treat cancer both outside and inside of the brain. This is important because many patients with HER2-positive breast cancer have the cancer spread to their brain. In fact, almost half of the patients enrolled in the trial had a history of metastases in the brain and many had active growing cancer in their brain at the time of trial enrollment. Importantly those patients with cancer in their brain obtained a similar benefit from the drug compared to those who didn't. Over half of patients with active cancer in their brain had at least a partial shrinkage of the cancer in their brain as seen on brain MRI when treated with tucatinib in addition to the other drugs, which demonstrates that tucatinib can get into the brain to treat the cancer. On average, patients with active cancer in their brain were more likely to live an average of 8 months longer as a result of taking tucatinib. This represents an exciting new treatment option for patients with HER2-positive breast cancer whose cancer has spread to their brain, and importantly this treatment is already available for patients.

Overall, there's a lot of exciting research going on across all the different subsets of breast cancer. As you can see, the results of these and many other important clinical trials were reported at the recent ASCO Annual Meeting and there are many more clinical trials ongoing that will hopefully result in the approval of multiple new effective treatments for breast cancer. In addition, there's research going on that is examining the impact of treatment on patients with breast cancer and trying to improve the lives of those living with breast cancer. Clinical trials are critical to the development of these new treatments.

Well, that's it for this quick summary of this important research from the ASCO 2020 Virtual Scientific Meeting. Overall, we continue on a fast track in breast cancer with many new and exciting therapies being actively studied and research helping support our patients do better than ever before. Stay tuned to Cancer.Net for future updates from upcoming cancer conferences. Thank you very much.

ASCO: Thank you, Dr. Henry.

Next, Dr. Vicki Keedy will discuss an international study that compared different treatment options for Ewing sarcoma, as well as new research in using immunotherapy to treat sarcomas. Dr. Keedy is an Assistant Professor of Medicine in the Division of Hematology/Oncology and the Clinical Director of the Sarcoma Program at the Vanderbilt-Ingram Cancer Center at Vanderbilt University Medical Center. She is also the Cancer.Net Associate Editor for Sarcoma.

View Dr. Keedy’s disclosures at Cancer.Net.

Dr. Keedy: Hello, my name is Vicki Keedy, and I am the clinical director for Sarcoma at the Vanderbilt-Ingram Cancer Center at Vanderbilt University Medical Center. I am pleased to discuss with you some of the exciting research findings in the management of patients with sarcomas presented at this year's ASCO Annual Meeting. I have no direct conflict of interest, but my institution does participate in some of the trials using some of the immunotherapy agents discussed below. Sarcomas are a class of cancers made of many different types of connective tissue tumors. Thus, there is significant variety in the types of abstracts presented, making narrowing them down a difficult task. First, I will discuss a study that establishes the standard first-line treatment for patients with Ewing sarcoma. And then, I will finish by summarizing a few abstracts on the use of immunotherapy in various sarcomas.

Ewing sarcoma is a type of sarcoma that can start in either the bones or soft tissue, tends to occur in children and younger adults, but can present at any age. It is characterized by small, round blue cells and is considered sensitive to chemotherapy. Regimens using multiple chemotherapy agents are considered the standard first-line treatment. However, there's variation in the exact regimen with considerable differences between the treatments most commonly used in the United States versus that used in many European sarcoma centers. EURO EWING 2012, presented by Dr. Bernadette Brennan compared these 2 most common regimens to determine whether 1 is better in regards to improving survival but also to evaluate differences in toxicity. In this trial, 640 patients in 10 different European countries with newly-diagnosed localized or metastatic Ewing sarcoma were randomized to receive either the regimen called VIDE, most commonly used in Europe, or the regimen called interval-compressed VDC/IE, most commonly used in the United States.

VIDE consists of four drugs - vincristine, ifosfamide, doxorubicin, and etoposide - given together every 3 weeks prior to surgery. This is then followed by additional chemotherapy of a similar regimen post-surgery. VDC/IE consists of 2 different regimens alternating an every 2-week cycle. These are vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide, and these are received both before and after surgery. The results of this study showed an improved survival for patients who received VDC/IE that was both clinically and statistically significant. Its benefits seem to hold true for patients with both localized and metastatic disease regardless of age. Additionally, VDC/IE appeared to be less toxic with fewer episodes of neutropenic fever and fewer severe treatment-related toxic events, while also allowing patients to complete their treatment approximately 3 months earlier than patients receiving the VIDE regimen. This study demonstrates the importance of cytotoxic chemotherapy for patients with Ewing sarcoma and establishes interval-compressed VDC/IE as the standard of care.

Moving on to the next topic of immunotherapy and sarcoma, many of the abstracts presented this year related to use of those concepts in patients with various types of sarcoma. Due to the biology of sarcoma, the immune system is generally not able to recognize and attack sarcoma cells. Thus, this approach by itself has not shown much benefit in most sarcomas. However, as I mentioned, there are many types of sarcomas, and they do not all behave the same. We have seen signals of benefits in certain subtypes. Many of the abstracts presented this year evaluated immunotherapy in some of these specific subtypes or attempted to use it in combination with other treatments such as chemotherapy or radiation. Unfortunately, these studies were relatively small or did not compare the immunotherapy to a standard treatment, making it very difficult to make definitive statements about the results. But they do give us more insights into which types of sarcomas might benefit from this approach. These abstracts confirmed responses in undifferentiated pleomorphic sarcoma, synovial sarcoma, alveolar soft part sarcoma, in angiosarcoma, and Kaposi's sarcoma. There's still much work to be done to determine whether an immunotherapy approach is better than already approved treatments for these types of sarcomas, and it is essential to validate these results by treating patients with immunotherapy agents in the context of the clinical trial. I thank you for your time and hope you found this discussion helpful. I look forward to discussing more exciting results next year.

ASCO: Thank you, Dr. Keedy.

Next, Dr. Kavitha Ramchandran will discuss several aspects of research in supportive and palliative care that was presented at ASCO20. This type of care focuses on managing the symptoms and side effects of cancer and its treatment. It also includes support to help reduce the financial, emotional, and social effects of cancer.

Dr. Ramchandran is the Clinical Associate Professor of Medicine in the Division of Oncology at Stanford University, and the Medical Director of Palliative Medicine at the Stanford Cancer Institute. She is also the Cancer.Net Associate Editor for Palliative Care.

View Dr. Ramchandran’s disclosures at Cancer.Net.

Dr. Ramchandran: Hi. It's wonderful to be here with you all today. My name is Kavitha Ramchandran, and I'm a clinical associate professor at Stanford University in oncology and palliative medicine and also have the pleasure of being the Associate Editor for Palliative Care on ASCO's patient education website, Cancer.Net. And I do not have any conflicts of interest to disclose related to the research that we'll be discussing today.

ASCO 2020 was a wonderful year in terms of palliative care education and research, and I am excited to share some of the highlights from that meeting with you all. We'll be talking about a few key research studies, and we'll be discussing a couple of different things. One, what are some of the novel approaches to symptom management in palliative care? Two, how do we actually assess risk in terms of our patients and how can we better stratify patients in terms of what type of treatments are best for them, and are there novel tools we can use? Three, how can we improve care by integrating palliative care early and often, both through a primary palliative care approach as well as a specialist palliative care approach? With that, let's go ahead and get started.

So in terms of symptoms, we had a really great discussion by Dr. Roeland from Mass General on several abstracts. The couple of abstracts that we're going to focus on here, one looked at armodafinil, which is a stimulant that has been often used for cancer fatigue. And the second was looking at cannabis compounds that have been thought about in thinking about nausea and folks who are suffering from nausea due to chemotherapy.

So our investigators that looked at armodafinil looked at armodafinil in patients who had glioma, and they wanted to see that if they used armodafinil in these patients, whether or not they would have an improvement in their fatigue. Now in the past, we know that there have been a number of studies that have looked at different types of treatments for fatigue, everything from steroids, to stimulants, to herbs, and what we found is that, consistently, stimulants have not been shown to improve fatigue. The things that have been shown to improve fatigue in small studies include steroids as well as American ginseng. Unfortunately, this was yet another negative study, and what we see here is that armodafinil did not improve fatigue and in fact, at the dose of 250 milligrams, might have increased insomnia or trouble sleeping. And so with that, I think we would make the assumption that we probably need to rethink our approach with stimulants in cancer-related fatigue and, for the majority of our patients, would make the decision that stimulants may not be the best course to improve fatigue.

On a positive note, we did look at patients who were receiving chemotherapy, and, in an Australian study, what they looked at was whether the addition of a THC plus CBD compound - now, this was both THC and CBD 1-to-1 - could improve nausea. And what they found is that, for these patients who all received the normal prophylaxis-- so they got Zofran. They got a D2 receptor antagonist, such as Compazine. If you added the THC-CBD compound, those patients actually had better nausea control, which was fantastic. However, they did also have some side effects from the THC-CBD, including dizziness, sedation, and disorientation. Yet despite these side effects, the patients really felt better, and so they were likely to continue using the cannabis. And they would actually choose to continue using the cannabis.

Moving on to a different note, there were a variety of different studies that looked at risk assessment, and can we actually identify which patients would benefit most from which intervention? And there was a couple of different types of studies here. One looked at the utilization of patient-reported outcomes to see whether or not we can identify patients who may be at more at risk for poor outcomes. We know Ethan Basch published, a couple years ago, a landmark study that showed that if you integrated patient reported outcomes, also known as PROs, routinely into cancer care, you could improve survival. So basically, if you looked at symptoms, evaluated those symptoms, and treated those symptoms early and often, people lived longer and lived better.

Now, can we use this data that patients give us through questionnaires on a regular basis, can we use this data in other ways? And we actually had a few studies here that looked at patients who had metastatic disease. And Dr. Batra et al. from Calgary looked at 1,300-plus patients, and what they found was that patients who had fewer symptoms tended to do better. And it seems like a kind of obvious point. If you have more symptoms, you might do worse, but I think the routine assessment of symptoms in patients and utilizing those symptoms is not done. So if we know that patients who have fewer symptoms might do better, may be able to use that data to see whether or not those patients might need more support or to use that data to see if those patients may not be the best patients for a clinical trial. Maybe we need to do symptom control first. So it does help us to risk-stratify and understand that patients that have more symptoms tend to have a shorter survival. Patients that have fewer symptoms tend to have a better survival.

Additionally, we have some really interesting data from Dr. Supriya Mohile at the University of Rochester looking at the use of a different type of assessment called the geriatric assessment for patients who are older. Now, we know that the geriatric assessment can identify patients who are at high risk for things like falls or cognitive changes or dementia, but what we don't necessarily know is whether if we routinely use the geriatric assessment, it helps us with our cancer treatment. And what they did in the study is they actually randomized patients to do the geriatric assessment. And in 1 arm, they showed the geriatric assessment to the oncologist, and in the other arm, they did not. And what they found is when they showed the geriatric assessment to the oncologist, the patient actually received treatment that was probably better for them based on the findings of their geriatric assessment. So patients who were more frail or who had more findings that would require an assessment and treatment had those things done. So if they needed a fall assessment, that got done. If they needed some neuropsych testing for their dementia, that got done. And for those patients, the oncologist often would choose to give a slightly lower dose of treatment to prevent further adverse effects. So what they found is that if you did a geriatric assessment routinely for older patients, you could appropriately provide for those needs and actually give them the treatment that is correct for them, preventing adverse events, preventing higher-grade toxicities, and ensuring that those patients got the best care.

And then finally, coming to our last group of trials, we had a really great discussion from Amber Barnato from the Dartmouth Research Institute. So it looked at variety of clinical trials of early palliative care integration as well as integrating palliative care through primary palliative care intervention. Now, what's the difference here? So primary palliative care intervention is when you teach clinicians, like your oncologist, to do palliative care themselves. So that's when they prescribe an opioid for pain, or that's when they do a goals of care discussion as part of routine advance care planning. Now, specialist palliative care interventions look a little different, and that's often when you have someone who's board-certified in palliative care and hospice, and they come in and do another consultation. And this would be akin to having a cardiologist come help your primary care doctor take care of your hypertension. This would be pulling in another team. So that's the difference between primary and specialist palliative care. So what we saw here is that there were 2 different types of interventions that were both really interesting.

Now 1 was done in University of Pennsylvania, where they actually looked at several thousands of patients who had their oncologists get a little nudge through an email that said, "You know what? Your patients coming in this week might be at a little bit of a higher risk for a poor outcome, at a higher risk for mortality. And when that happens, it might be good to do some advance care planning." So that these oncologists that got this email nudge, they were more likely to do the right thing by their patients. They were more likely to do an advance directive, and they were more likely to ensure that these patients had their goals of care documented and their prognosis documents within their charts. So something as simple as a mortality prediction done through a computational tool and an email to those oncologists could really improve getting the basics done for patients, such as getting their advance directive done.

Additionally, when we think about, now, specialist palliative care intervention, Dr. Barnato actually made a really beautiful point. She actually looked at a couple of different studies, 1 done by Tom Smith looking at integrating palliative care in phase 1 populations and the other by Dr. Areej El-Jawahri looking at integrating palliative care into the acute leukemia patient population. And both of these studies were really excellent studies that showed quality of life improvement with early integration of palliative care. And that is fantastic, and it supports the work that was led by Jennifer Temel in 2010, where she saw that if you integrated palliative care early and often, those patients had better quality of life, those caregivers did better, and those patients live longer.

And these studies continue to support the fact that early integration of palliative care improves quality of life for patients from a variety of different walks, whether it's phase 1 or acute leukemia. But what Amber Barnato pointed out was that palliative care also does something really different. What palliative care does is it also improves the way that we communicate across systems, and what she said, and I think it's important to point out, is that we don't often account for that in our metrics. We don't often point out that when a palliative care doctor talks to an oncologist, it decreases the anxiety of the oncologist. It makes the oncologist deliver better care. It actually changes the infrastructure of how we deliver care in the system, and that improves quality in ways that goes beyond the biopsychosocial model of just quality of life for patients but really changes the paradigm of how we deliver care across the system. And that we not only need to measure quality of life for patients but really look at some of these system changes that palliative care really helps to propagate and think about how that could be measured ongoing.

So it's been another great year for research. We're really excited about what our colleagues are doing out there in palliative care and supportive care and both in improving systems, improving risk assessments, and improving symptoms. We look forward to another year of research in ASCO 2021. Thank you so much for having me here today to talk to you a little bit about what we learned from our colleagues and friends.

ASCO: Thank you, Dr. Ramchandran. Learn more about the research presented at the ASCO20 Virtual Scientific Program at, and subscribe to Cancer.Net podcasts on Apple Podcasts or Google Play for additional episodes in the Research Round Up series, released throughout the summer.

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