The theme of the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting is Caring for Every Patient, Learning from Every Patient. For the past year, ASCO President Monica M. Bertagnolli, MD, FACS, FASCO, has visited local groups across the United States to learn what patients and doctors truly experience when receiving and providing cancer care. As she writes in this year’s Clinical Cancer Advances report, “Cancer treatment advances are only as good as patients’ ability to access them.” This year’s ASCO Annual Meeting strikes the balance in Dr. Bertagnolli’s theme, bringing late-breaking research news to the public and exploring the ways that access to cancer care can be improved for patients. 

More than 32,000 oncology professionals from around the world are at the ASCO Annual Meeting in Chicago, presenting and discussing the latest research in cancer treatment and patient care. Learn about the research released today:

• Enzalutamide lengthens lives of men with metastatic prostate cancer

• Maintenance therapy with olaparib slows the growth of metastatic pancreatic cancer with BRCA mutations

• Income, health insurance, and place of treatment affect how long people with multiple myeloma live

• ACA has led to earlier diagnosis and treatment of ovarian cancer

• Medicaid expansion allowed timely cancer treatment and improved racial equality in care

Watch a patient education video with Dr. Bertagnolli explaining how the ASCO Annual Meeting changes patients’ lives.

Enzalutamide lengthens lives of men with metastatic prostate cancer

A phase III clinical trial called ENZAMET found that the combination of enzalutamide (Xtandi) and standard initial treatment for metastatic hormone-sensitive prostate cancer may help men live longer than other similar treatments. Enzalutamide is a type of medication called a nonsteroidal anti-androgen (NSAA) currently approved by the U.S. Food and Drug Administration (FDA) as a treatment for prostate cancer.  

The initial standard treatment for metastatic hormone-sensitive prostate cancer is a type of hormonal therapy called androgen deprivation therapy (ADT). This type of prostate cancer uses male sex hormones called androgens to grow. The most common androgen is testosterone. Lowering levels of androgens with ADT can help slow cancer growth. ADT may involve surgery to remove the testicles or an injection that lowers androgen levels. Some men may receive an additional treatment, such as chemotherapy with docetaxel (Taxotere) or another type of hormonal therapy called abiraterone acetate (Zytiga).

As part of this clinical trial, the 1,125 participants received an injection that lowers testosterone levels plus either enzalutamide or 1 of 3 other NSAAs as a pill every day. These other NSAAs included bicalutamide (Casodex), nilutamide (Nilandron), and flutamide (Eulexin). In addition, 503 men received docetaxel.

Overall, researchers found that 80% of men who received enzalutamide were alive after 3 years, compared with 72% of men who received another NSAA. They also found the following after 3 years:

• Among the men whose imaging scans showed higher amounts of cancer, 71% of those who received enzalutamide were alive compared with 64% of those who received another NSAA.

• Among the men whose scans showed a low amount of disease, 90% of those who received enzalutamide were alive compared with 82% of those who received another NSAA.

• Men who received enzalutamide without docetaxel were more likely to be alive than those who received any other treatment in the study. For example, 83% of these men were alive after 3 years compared with 70% of those who received another NSAA without docetaxel.

• 64% of men were still taking enzalutamide, while only 36% were still taking another NSAA.

More men taking enzalutamide experienced serious side effects compared with those taking another NSAA (42% compared with 34%). The side effects of NSAAs may include headaches, confusion, loss of vision, and seizures.

What does this mean? Adding enzalutamide to standard treatment is a new and effective alternative to chemotherapy with docetaxel for many men with metastatic hormone-sensitive prostate cancer.

“Physicians and patients with prostate cancer now have a new treatment option with enzalutamide, and this is especially relevant for men who cannot tolerate chemotherapy and have a lower burden of disease seen on scans.”

—   study co-chair Christopher Sweeney, MBBS
Dana-Farber Cancer Institute
Boston, Massachusetts

Maintenance therapy with olaparib slows the growth of metastatic pancreatic cancer with BRCA mutations

A phase III clinical trial called POLO showed that using olaparib (Lynparza) after initial chemotherapy kept metastatic pancreatic cancer linked with a BRCA gene mutation (change) from worsening for a longer time. BRCA gene mutations are inherited and increase the risk of developing several other types of cancer, including ovarian, breast, and prostate cancers. About 5% to 6% of pancreatic cancers are caused by a BRCA gene mutation.

Olaparib is a type of targeted therapy called a PARP inhibitor. PARP inhibitors block an enzyme that repairs damaged DNA inside cancer cells, leading to cell death and slowing or stopping tumor growth. Olaparib is approved by the FDA as a treatment for breast and ovarian cancer related to a BRCA gene mutation.  

This study included 154 people with metastatic pancreatic cancer who had already received chemotherapy. Four to 8 weeks after chemotherapy ended, all participants received either olaparib or a placebo. A placebo is an inactive drug.

Researchers found that maintenance therapy with olaparib kept the cancer from worsening for almost 4 months longer than a placebo. Maintenance therapy is the treatment of cancer with medication, typically following an initial round of treatment. After 1 year, almost 34% of people taking olaparib had no signs that the disease was growing compared with about 15% of those taking a placebo. More people taking olaparib had their cancer stop growing after 2 years as well (about 22% compared with about 10%). Overall, olaparib lowered the risk of the disease worsening by 47%.

Olaparib was linked with more serious side effects: 40% of people taking the drug experienced side effects, compared with 23% of those taking the placebo. About 6% of participants stopped taking olaparib due to these side effects, compared with just under 2% of those who received the placebo.

What does this mean? Using olaparib as a maintenance therapy can slow the growth of metastatic pancreatic cancer in people with a BRCA gene mutation, and it may become a new treatment option in the future for some patients with this cancer.

“POLO is the first phase III randomized study to establish a biomarker-driven approach in the treatment of metastatic pancreatic cancer, and it opens the door to a new era of personalized care for this difficult-to-treat cancer. Roughly 1 in 5 patients responded to olaparib for a median of 2 years, which is truly remarkable for metastatic pancreatic cancer. For patients with BRCA-driven metastatic pancreatic cancer, we may be seeing a change in patients’ disease trajectory.”

—   lead study author Hedy L. Kindler, MD, FASCO
University of Chicago Medicine
Chicago, Illinois 

Income, health insurance, and place of treatment affect how long people with multiple myeloma live

A recent study analyzing information from the National Cancer Database found that certain socioeconomic factors, especially living in an area of higher incomes, having private health insurance, and receiving treatment at an academic institute, are linked with how long people with multiple myeloma live after diagnosis.

For this study, researchers gathered information on 117,926 people living with multiple myeloma between 2005 and 2014. They found that the following socioeconomic factors contributed to how long people survived:

• Treatment center. People who received treatment in an academic institution had a 49% higher chance of survival.

• Regional income. People living in areas where the median income is $46,000 or more per year had a 16% higher chance of surviving compared with those who earned less. The median is the mid-point, which means that half of the incomes in these regions were higher and half were lower.

• Insurance. People with private health insurance had a 59% higher chance of surviving than those who had Medicaid and a 62% higher chance than those who had no insurance. People age 65 and older who had private insurance lived longer than those who only had Medicare.

• Overall health. The researchers used the Charlson Comorbidity Index, which predicts risk of death within 1 year of being hospitalized for people with multiple chronic illnesses. A lower score was linked to a higher chance of survival.

• Distance traveled. More people with private insurance traveled over 120 miles to a treatment center compared with people who had Medicare or Medicaid.

According to researchers, these findings suggest that it may be harder for people with lower incomes to afford the medications used to treat multiple myeloma, which can be very expensive. In addition, people often need to continue taking these drugs over the long term to keep the cancer from coming back. People who have difficulty paying for their medications may be more likely to stop treatment or take a break from treatment, which can reduce its effectiveness.

What does this mean? Long-term treatment and costly medications can be a significant financial burden for many patients with multiple myeloma. Patients should talk with their health care team about any available resources that can help them cope, including travel and medication assistance programs and other types of support.

“With the continuously increasing cost of health care, it is important to highlight the presence of a survival disadvantage for people who cannot afford their treatment costs. Prices of oral cancer drugs have been rapidly escalating, especially for patients and survivors of multiple myeloma, and we need to take action to limit and reverse the disparity for those who cannot afford private insurance or have lower incomes.”

—   lead study author Kamal Chamoun, MD
University Hospitals Seidman Cancer Center
Cleveland, Ohio 

Two studies show Affordable Care Act has had a positive impact on cancer care

The Affordable Care Act (ACA) is a U.S. health care law that was passed in 2010 and has since expanded access to insurance and care for many people. In 2010, about 16% of Americans were uninsured, but by 2016, the number dropped to 12%. Two new and separate studies suggest that the ACA helps people receive treatment earlier and improves equality in care.

ACA has led to earlier diagnosis and treatment of ovarian cancer

An analysis of information from the National Cancer Database found that more women with ovarian cancer were more likely to be diagnosed earlier and start treatment sooner after the ACA went into effect.

For this study, researchers first collected information from 35,842 women who were diagnosed with ovarian cancer and received treatment between 2004 and 2009, which was before the ACA went into effect (pre-ACA). Then, they compared this information with information collected from 37,145 women who were diagnosed with ovarian cancer and received treatment between 2011 and 2014, which was after the ACA went into effect (post-ACA).

To analyze this information, the researchers looked at the cancer’s stage when diagnosed and how long it took for treatment to start. Then, they compared the information from women ages 21 to 64 with women older than 65, who had access to Medicare and were more likely to have health insurance both before and after the ACA was implemented.

Researchers found that early-stage diagnoses were almost 2% higher post-ACA in women ages 21 to 64 compared with those older than 65. Women in this age range were also about 2% more likely to start treatment within 30 days of diagnosis post-ACA. They also found that women ages 21 to 64 with public insurance benefitted the most, with about a 3% increase in early-stage diagnoses and timely treatment. In addition, these improvements were seen regardless of race, income, or education level.

Though the post-ACA improvement percentages seen in this study are small, the researchers note that it means nearly 400 more women were diagnosed earlier, at a more treatable stage of ovarian cancer.

In general, more than 75% of women diagnosed with early-stage ovarian cancer live 5 years or more compared with less than 30% of women diagnosed at an advanced stage, which highlights the importance of early diagnosis.

What does this mean? This study shows that access to health insurance affects how soon some women are diagnosed and how quickly they can start treatment for ovarian cancer.

“Detecting and treating ovarian cancer at an early stage saves lives and lowers health care costs compared to treatment of cancer at a more advanced, incurable stage. Having health insurance plays a major role in whether or not a woman has access to care providers who can monitor symptoms and act on those symptoms if necessary.”

—   lead study author Anna Jo Smith, MD, MPH
Johns Hopkins Medicine
Baltimore, Maryland

Medicaid expansion allowed timely cancer treatment and improved racial equality in care

In a different study, information from 30,386 electronic health records of people with cancer throughout the United States showed that black people were more likely to receive treatment within 30 days of a cancer diagnosis in states that increased Medicaid access due to the ACA. Previous studies have shown that black people in the United States face the most racial health disparities. And the results of this study show a major step in improving access to care and reducing disparities. Health disparities refers to inequalities in care among racial and ethnic minorities.

Starting in 2014, the ACA allowed U.S. states to expand their Medicaid programs to make health insurance available to more people. In participating states, Medicaid provides health care coverage for people with very low incomes.   

The goal of this study was to look at whether the ACA-related Medicaid expansion impacted how soon people with advanced or metastatic cancer started treatment after a diagnosis and compare the differences among racial groups. The researchers analyzed information from people ages 18 to 64 who were diagnosed between 2011 and 2019 and divided those records based on whether the state where they lived had expanded Medicaid. The information came from the Flatiron electronic health record-derived database of records from 280 cancer clinics nationwide.

The researchers found that before the Medicaid expansion, black people were almost 5% less likely than white people to start treatment within 30 days of a cancer diagnosis. After the Medicaid expansion, there was a 6% increase in the number of black people who started treatment within 30 days of diagnosis compared with a 2% increase for white people.

What does this mean? The ACA has allowed more people access to health insurance and may have helped equalize care for many who were at a disadvantage.  This makes it possible for more people with cancer to be diagnosed and receive treatment at an earlier stage, which can improve their chance of living longer.

“Many studies have described racial disparities that exist in cancer, but few have shown what types of interventions improve health equity -- we now have evidence that Medicaid expansion can mitigate certain health disparities. We also know that uncertainty about having health insurance, especially for someone newly diagnosed with cancer, can make a big difference in getting appropriate care in a timely manner.”

—   study author Amy J. Davidoff, PhD, MS
Yale School of Public Health
New Haven, Connecticut