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Just In... Meeting News
Key news updates from recent oncology and hematology meetings.

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Saturday, February 28, 2015

 

BY ROBERT H. CARLSON

 

MIAMI BEACH, Florida--It’s time to stop arguing about screening mammography and just do it, said one of its most well-known proponents, Daniel B. Kopans, MD, Professor of Radiology at Harvard Medical School and Senior Radiologist in the Breast Imaging Division of Massachusetts General Hospital, speaking at the Miami Breast Cancer Conference.

 

“It’s a never-ending controversy, and enough is enough,” he said, before launching into his rebuttal to every myth he says has been perpetrated about this imaging modality.

 

The controversy, he said, is not a case of "experts disagreeing." In fact, he maintained, the arguments against screening mammography come "from those who don't see breast cancer patients themselves"

 

“All the arguments against screening, most of which are not scientifically based, have been addressed by science,” he said. “Mammography is not the ultimate answer to breast cancer, it does not find all cancers and does not find all cancers early enough to result in a cure. But it does save thousands of lives each year.”

 

Kopans’ outrage on the topic is palpable and some of the myths that he says persist are truly outrageous, such as that “mammography squeezes cancer into the blood causing early death,” and “breast cancer would melt away if left undetected.”

 

But objections to mammography screening come from some usually reputable sources. In the 1960s, Kopans noted, some authorities held that since breast cancer is systemic from the outset, early detection thus has no benefit. In the 1970s, arguments were heard that “we can’t possibly screen all women,” and “radiation from mammograms will cause more cancers than are cured.”

 

Randomized clinical trials disproved those claims, he said. But some of the claims took hold and led to guidelines. Kopans said that in 1993, the U.S. National Cancer Institute, following results from what he said was a compromised trial from the Canadian National Breast Screening Study, dropped support for screening women ages 40 to 49, and said women ages 50 and over could be screened every two years.

 

“The fact is, randomized controlled trials have always shown a significant reduction in breast cancer from screening women age 40 to 49,” said Kopans, who points to flawed analyses for the misconception.

 

He said age 50 was made to look like a threshold by grouping and averaging data, but in fact none of the parameters of screening change abruptly at age 50, or at any other age: “The percentage of women who are recommended for biopsy is a fairly constant with no change at age 50 or any other age.”

 

Other canards he cited:

·    "Mammography leads to false-negative studies leading to biopsies;

·    “Breast tissue until age 50 is too dense to detect cancer”;

·    “Detecting cancer in women leads to premature death”; and

·    “Screening should be based on risk.”

 

“It seems like every week a new impediment is put in front of screening mammography,” he said. "As each new challenge to mammography is addressed, opponents dream up new challenges, most of which have no scientific basis.

 

“The medical oncology, radiation oncology, and surgical oncology communities have to stand up and say enough is enough. We need to support annual mammography beginning at age 40 as we continue to try and find better ways to treat breast cancer.”


Friday, February 27, 2015

 

BY ROBERT H. CARLSON

 

MIAMI BEACH, Florida--How to treat older women with breast cancer is becoming a critical question in the U.S., where the average age of a breast cancer patient is 61, and the vast majority of women who die of breast cancer are age 65 and older.

“That’s frequently not the public’s perception, though, or the perception of our colleagues,” said Hyman B. Muss, MD, Director of Geriatric Oncology at Lineberger Comprehensive Cancer Center and Professor of Oncology at the University of North Carolina at Chapel Hill, speaking at the Miami Breast Cancer Conference.

 

He called this the coming “tsunami” of older-age patients.

 

But age is not the key to choosing chemotherapy—rather it is the patient’s life expectancy and overall health, he said. “The real issue in older people is whether cancer is the patient’s most serious diagnosis, considering the common comorbid conditions in this population such as hypertension and diabetes. Even breast cancer patients with regional nodes usually die of non-cancer causes if they’re over age 70.”

 

The goal of adjuvant chemotherapy in elderly treatment is not always longevity, he explained.

 

“For the fit patient with good life expectancy, consider state-of-the-art chemotherapy. For the frail and very ill, consider endocrine therapy. For patients in the middle ground, the oncologist has to define the added value of chemotherapy, consider the expectations of the patient and family, and ask whether the potential toxicities are worth it.

 

Some patients may not consider therapy worth the toll on their bodies, Muss said, pointing to a survey of seriously ill patients asked to end the sentence: “I would rather die than have a treatment that causes…” The results:

·        11 percent said “high burden”;

·        74 percent said “severe functional impairment”; and

·        89 percent said “severe cognitive loss.”

 

Making the Chemotherapy Decision

Deciding whether to recommend chemotherapy to older patients is the most difficult decision, Muss said, since chemotherapy is associated with the greatest toxicity and the greatest potential for loss of function and adverse effects on quality of life.

 

Therefore, when considering whether to recommend chemotherapy, it is important to consider the life expectancy of the patient apart from the cancer. He said this can now be done accurately with available online models such as

ePrognosis.      

 

 

Based on life expectancy, the potential benefits of different chemotherapy regimens can be shown using programs such as Adjuvant! Online and PREDICTthese tools, though have not been verified in older patients, Muss cautioned.

 

He said chemotherapy is likely to be most beneficial in older women with triple-negative breast cancer, and those with hormone-receptor-negative, HER2-positive breast cancers. Such therapy is likely to increase survival in most patients with these breast cancer phenotypes, provided that the patient’s estimated survival is more than five years.

 

“The most difficult decision concerning chemotherapy use is in patients with hormone-receptor-positive, HER2-negative tumors,” Muss said. “For these patients, if they have node-negative disease, and even if they have one to three positive nodes, the use of genetically based tests such as the 21-gene panel can be most helpful in making a treatment decision.

 

“For those with higher-risk hormone-receptor-positive, HER2-negative tumors, especially those with high-grade tumors and extensive nodes, chemotherapy is a major consideration.”

 

Muss said the use of adjuvant radiation after breast-conserving surgery and for patients with mastectomy who have high-risk tumors is generally well tolerated. Breast radiation following breast conservation can be omitted without deleterious effects on survival in women with small hormone-receptor positive HER2-negative tumors, or those likely to be compliant with endocrine therapy. However, this does carry a small increased risk in local-regional recurrence, he said.

 

Adjuvant endocrine therapy is likely to be beneficial in reducing local-regional and distant recurrence in older women with hormone-receptor-positive breast cancers who have tumors larger than one centimeter and with estimated survival times exceeding five years, he said.

 

Triple-Negative Treatment Age Dependent

About 15 percent of elderly breast cancer patients have triple-negative breast cancer--“and it’s just as bad in older people as in younger people,” Muss said.

 

Most recurrences are within five years, so estimates of five-year survival are important. “More chemotherapy is better--usually with taxanes and anthracyclines--so estimating life expectancy and toxicity is key,” he said. But even patients with a shorter life expectancy can benefit from treatment if the patient has large tumors or many involved nodes.

 

Anti-HER2 therapy in elderly patients depends on estimated survival, he said. “When there is an estimated survival of more than five years, I treat older patients like younger patients. But if the patient has cardiac comorbidities, order a cardiology consult.”


Friday, February 27, 2015

 

BY ROBERT H. CARLSON

 

MIAMI BEACH, Florida--Early intervention in lymphedema can result in substantial savings for breast cancer patients after surgery, both financially and in quality of life. That was the word here at the Miami Breast Cancer Conference from Sarah McLaughlin, MD, Associate Professor of Surgery at Mayo Clinic, Jacksonville.

 

“Identification of lymphedema after breast cancer surgery is important because early interventions can reverse swelling,” she said.

 

“What we know about lymphedema is that it is a long-term, chronic side effect of surgery; it is common but under-reported, it is a fiscal burden, and it has a negative impact on patient quality of life.

 

“What we don’t know, though, is much more,” she continued. “We really don’t know what the mechanism of action is or the pathophysiology, or even have an accurate measure of the incidence of breast-cancer related lymphedema.

 

“Recent randomized controlled trials all use different follow-up and different definitions of lymphedema, so there is a wide variation in the reported incidence,” she said, noting, though, that a recent meta-analysis suggests that 21 percent of women will develop lymphedema after treatment for breast cancer.

 

Detecting Subclinical Lymphedema

Today there is a strong emphasis on detection of subclinical lymphedema, McLaughlin said. “It is only recently understood that mild, early swelling may be reversible, but when early swelling is left untreated there is a 50 percent risk that it will progress to more severe forms.”

 

There are several measuring techniques, she said, and they are all reasonable as long as the same method is used throughout treatment and follow-up.

 

But measurements do not take the place of an office exam, she stressed. “In an ideal world we would be able to identify which of our patients are at risk for developing lymphedema.”

 

In her own practice, she said, she stratifies patients with baseline, six-month, and one-year measurements, but this has only shown that it is not possible to predict who will develop the condition.

 

“Because we can’t identify who is at risk for progressing to lymphedema, it is our responsibility as clinicians to educate all of our patients. And we need to educate them because they really worry about developing lymphedema, and they start worrying early.”

 

Although women who have had sentinel lymph node dissection have a far lower risk than women who had axillary node dissection, they all seem to want to follow precautionary behaviors, McLaughlin said.

 

There are dozens of reported risk-reducing behaviors patients may want to follow, from not carrying children to avoiding racquet sports to not having their IV draws or blood pressure taken. “But studies show that the only real behavior to avoid is sauna use,” she said.

 

On the other hand there are good data on resistance exercise, and she said she tells patients to go back to their regular exercises after therapy. “Whatever they were doing beforehand, they can go back to after surgery.”

 

Cornerstone of Treatment

The cornerstone of treatment, McLaughlin said, remains CDT--complex decongestive therapy--which includes both reductive and maintenance phases.

 

CDT results in limb reductions of 25 to 75 percent, she said. But it is cumbersome and requires constant care, which is both expensive and time consuming on a daily basis.

 

“What is getting a lot of buzz now is whether surgery will correct the underlying pathophysiology of lymphedema,” McLaughlin said. Surgery is gaining renewed interest with the adoption of microvascular surgical techniques, and lymphovenous anastomosis and lymph node transfer are showing promising results.

 

But, McLaughlin concluded, educating patients about their individual risk is key to developing tailored risk-reducing strategies.


Thursday, February 26, 2015

 

By Robert H. Carlson

 

MIAMI, Florida--Cancer patients undergoing surgery benefit from a multimodality approach to anesthesia, when analgesics are used in combination with narcotics in place of high doses of narcotics alone.

 

Reet Lawhon, MD, Director of Regional Anesthesia at Maimonides Medical Center in Brooklyn, NY, a speaker at the Miami Breast Cancer Conference, discussed recent innovations in pain management.

 

In introducing him, Conference Chair Patrick Borgen, MD, said that in preparing this year’s meeting it became clear that there had never been anything on pain control in the entire 32-year history of the conference, so it was important to add it this year.

 

New Direction

“We have great data showing a new direction in pain relief, with longer-acting medications and the ability to give the patient a much better outcome from surgery in the long-term afterwards,” Lawhon said.

 

The number one cause for hospital re-administration after cancer surgery is pain management. But interestingly, he said, patients report that their number one concern when they are about to undergo anesthesia is that they will be sick to their stomach. Whether their pain will be controlled is the patient’s second concern.

 

Current Anesthesiology Research

Anesthesiology research today focuses on the reduction of narcotics for surgical patients, Lawhon said. In the preoperative phase, analgesia often includes a COX-2 inhibitor such as Celebrex, or tramadol. There is also increased interest in the potential role for low-dose morphine.

 

Patients with anxiety disorders are a concern, Lawhon said. They may self-medicate before surgery, which they may or may not tell the physician about. And their systems may have built up a tolerance to numerous central nervous system depressants. Anxiolytics may be necessary for these patients.

 

As a result of the surgical incision, cytokines and other inflammatory mediators play a role in the development of chronic pain. 

 

“Postoperative pain increases afferent stimulation and activity in both the peripheral and central nervous systems, both in the operating rooms and after surgery. This increases the likelihood of developing chronic pain.”

 

Lawhon said uncontrolled pain may have an impact on cancer recurrence, as adrenergic stimulation results in reduction in NK cells, humeral and cell mediated immunity, and angiogenesis.

 

Paravertebral Block

Lawhon discussed paravertebral block, which he said is not a new technique, having been first introduced in 1906. But until recently the optimal dosage, timing, and choice of location were not well understood.

 

The procedure is generally done for breast cancer surgery in two levels, T2-3 and T4-5. “Recent data show that if the paravertebral block is done before surgery, it blocks many of the responses the patient will have to a surgical incision,” he said.

 

A paravertebral block can be done in the holding room under mild sedation or in the operating room. A paravertebral block with bupivacaine can provide 18 to 24 hours of pain relief—“it is the longest-acting anesthetic we have,” Lawhon said.

 

Liposomal-encapsulated bupivacaine can average 55 to 60 hours of pain relief. “Within 15 to 20 minutes the patient should have a significant amount of pain relief; this allows us to give less narcotics in the operating room-- perhaps 25 percent of what it would be without the paravertebral block.”

 

Possible complications include a failed block, vascular puncture, pleural puncture, hypotension, and pneumothorax.

 

Paravertebral block for mastectomy patients may reduce the risk of metastases, he said, citing a retrospective study that demonstrated that regional anesthesia in combination with general anesthesia was associated with a longer cancer-free interval and a lower incidence of recurrence. (Exadaktylos et al: Anesthesiology 2006;105:660-664).

 

The authors—from Mater Misericordiae University Hospital, National Breast Screening Program-Eccles Unit, in Dublin, Ireland--speculated that regional anesthesia might help to maintain perioperative immune function by reducing general anesthesia requirements and by sparing postoperative opioids, and thus preventing the dissemination of malignant cells. The group that had paravertebral block had significantly less pain at four and at 24 hours, and at four years follow-up had reduced recurrence and metastasis.

 

“We’re not sure if it is actually the blocks themselves, or the enhanced pain relief from some of the newer agents, or the avoidance of narcotics, which can increase an increase in angiogenesis at the tumor site and an increased volume of tumor as a response to a narcotic,” they said.


Wednesday, February 25, 2015

 

BY SARAH DIGIULIO

 

Genetic susceptibility panel testing, neoadjuvant endocrine therapy, and immunotherapy strategies all make the agenda for this year’s Miami Breast Cancer Conference—the 32nd Annual. But unlike other meetings that focus on brand new research, most of the sessions in Miami will be short-format talks with speakers discussing instead how to use those new advances.

 

“It’s the practical lessons: How does this impact your practice? Does it? Is this ready for prime time? Is it too early for prime time?” Conference Chair Patrick Borgen, MD, Chair of the Department of Surgery at Maimonides Medical Center and Director of the Brooklyn Breast Cancer Center at the Maimonides Cancer Center in Brooklyn, New York, said in a phone interview. It’s the same model the meeting has followed for its more than three decade history, and according to Borgen, is one of the reasons behind the meeting’s longstanding success. Such sessions allow physicians and researchers to better understand how to integrate the new research in their fields in their work and use it to help their patients, he said.

 

PATRICK BORGEN, MD

 

“This field changes on a week-to-week, month-to-month basis. For example, with new agents, there are only very restricted clinical scenarios where some of these drugs are actually approved,” Borgen explained. “That’s where Miami plays a role. [The meeting includes] the people that did the research and the people who wrote the guidelines saying, ‘this is how I integrate this into my practice’—that’s the gem—our motto has always been ‘hear it on Friday, use it on Monday.’”

 

Fresh Perspectives

Though some topics get revisited year after year, the perspective from the podium is never the same two years in a row. Borgen along with the Conference’s three Program Directors select the faculty of speakers each year, based largely on feedback from meeting-goers, Borgen noted—but no one speaker is invited to speak two years in a row.

 

“There is always a fresh perspective and a fresh take on a problem,” he added. “We want to keep the meeting as practical as possible.”

 

The Conference Program Directors are: J. Michael Dixon, MD, OBE Professor of Surgery & Consultant Surgeon and Clinical Director of the Breakthrough Research Unit in the Edinburgh Breast Unit; Hyman B. Muss, MD, Professor of Oncology at the University of North Carolina and Director of Geriatric Oncology at the UNC Lineberger Comprehensive Cancer Center; and Debu Tripathy, MD, Professor of Medicine and Chair of the Department of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center.

 

Another update started at last year’s conference was to have a clinical case presented at the beginning of each lecture along with a question about that case, Borgen said. “The speaker will attempt to use his or her knowledge, along with the available data, to provide the best answer to the question.” 

 

Members of the audience are polled again after the lecture and can see how their answers compare to their colleagues’ answers.

 

New & Pertinent Topics

There are several new topics on the conference agenda this year, along with updates on recurring debates in the field, Borgen also noted. For the first time in the meeting’s history, there will be a series of lectures on pain and pain management, which include several specialists talking about pain after surgery, utilizing new agents that provide local anesthesia for days, and metastatic breast cancer pain (Thurs., Feb. 26, 3:15 pm; Fri., Feb. 27, 2:50 pm, 3:05 pm, 3:20 pm; Sat., Feb. 28, 3:35 pm; and Sun., Mar. 1, 8:30 am).

 

There is a session on new immunotherapies that will also focus on new, effective breast cancer vaccines, he noted (Sat., Feb. 28, noon: “Is Immunotherapy Ready for Prime Time in Breast Cancer? Update on All Immuno Strategies”). And there will be talks on: a new staging system for breast cancer (Fri., Feb. 27, 8:15 am: “Incorporating Tumor Biology Into an Improved Staging System for Breast Cancer”); emerging agents like Paclociclib and others (Sat., Feb. 28, 3:05 pm: “Late-Breaking News From the Breast Cancer Research Front”); the mammography debate (Fri., Feb. 27, 8 am: “The Never-Ending Controversy Over Screening Mammography: Enough is Enough”); and the overdiagnosis and overtreatment of ductal carcinoma in situ (Fri., Feb. 27, 2:05 pm: “DCIS: Predicting Local Recurrence After Local Excision Without Radiation Using Genomic Profiling”; and Sat., Feb. 28, 8 am: “Overdiagnosis and Overtreatment of Breast Cancer: What is the Reality”).

 

Sunrise Sessions

Also new on the Miami agenda this year are two Sunrise Sessions. These sessions are longer than the conference’s other short-format talks allowing more discussion, Borgen said.

 

The first is a video clinic, which includes video presentations of several unique surgical cases (Sat., Feb. 28, 6:45 am). Audience members are presented with the case and asked how they would tackle it—and then a video of the actual operation is shown.

 

The second Sunrise Session is a discussion of how to best use social media to build an oncology practice, grow a practice, and maintain contact with patients (Sun., Mar. 1, 7 am). The discussion will be led by Deanna Attai, MD, Assistant Clinical Professor of Surgery at the David Geffen School of Medicine at the University of California, Los Angeles, known in the social media world for her leadership in the Breast Cancer Social Media community (#BCSM, bcsmcommunity.org), including her role as co-moderator of the #bcsmchat every Monday evening (featured in OT’s award-winning Profiles in Oncology Social Media series: 12/25/13 issue).  

 

Breast Cancer Survivor Joan Lunden to Deliver Keynote

Finally, this year’s agenda features journalist and author Joan Lunden, a former host of Good Morning America and a breast cancer survivor, who will deliver the keynote address (Sat., Feb. 28, 10:45 am). She will be highlighting her journey and will stay for a question and answer session after the talk, Borgen said. [More on Lunden’s keynote.]