Barbara Brenner, Former Executive Director
I arrived at the San Antonio airport after an uneventful flight from Oakland via Phoenix. What greeted me as I walked to baggage claim were digital ads reading “Aromisin welcomes you to San Antonio.” Now, I’ve been welcomed in many places by many things, but I’ve never been welcomed anywhere before by an aromatase inhibitor. This promised to be another drug-dominated San Antonio Breast Cancer Symposium.
The introduction to the first day was given as always by Kent Osborne, Director of Breast Center at Baylor College of Medicine who chairs the meeting. Dr. Osborne delivered the usual good news about how much progress has been made in breast cancer since SABCS started 30 years ago and the future of targeted, individualized breast cancer treatment.
Changes Coming to SABCS
In addition, Osborne announced that, starting next year, the symposium would be a partnership between SABCS and the American Association for Cancer Research (AACR). It seems the intention is to create more dialogue between the clinicians (largely represented by SABCS-goers) and scientists (largely represented by AACR). This step is also likely to greatly expand the size of this meeting. I just hope it doesn’t lead to changes that would make it harder for activists and advocates to learn what is going on in research. Right now, the meeting is set up so that there are no “concurrent” sessions, so that we don’t have to choose between listening to a presentation on breast stem cells and one on adjuvant treatment. I would be very sorry to see this meeting turn into one where everyone who wants to can’t hear everything.
In terms of substantive information pertinent to breast cancer patients or those who care about them, there was not a lot of news in today’s meeting. In fact, I’ve been asking folks here—both clinicians and advocates—whether they expect any big news from this meeting, and the answer has been, “no.”
Adjuvant Treatment in General
Adjuvant treatment is defined by Wikipedia as “additional treatment, usually given after surgery where all detectable disease has been removed, but where there remains a statistical risk of relapse due to occult [hidden] disease.” This morning’s first plenary session was a presentation by Richard Peto of a worldwide overview of systemic adjuvant therapy.
The presentation reviewed data on over 300 randomized trials involving 350,000 women. Peto discussed the impact on patients of various systemic therapies:
- radiation treatment following mastectomy,
- tamoxifen treatment depending on estrogen and progesterone status,
- aromatase inhibitors compared to tamoxifen, and
- effects of chemotherapy by age, estrogen status, and chemo regimen
A lot of statistics were presented, but all in terms of what happens to lots of people when you give these treatments, not what any individual can expect if she undergoes any of these treatments. And the take home message was that systemic treatment (which, for Peto, includes screening) has cut mortality from breast cancer in middle-aged women in half. Unfortunately, this does not mean that an individual who undergoes any (or all) of these treatments will reduce her risk of dying from breast cancer by half.
The short answer on each of the treatment options Peto reviewed is:
- radiation treatment after breast cancer improves survival in patients with positive lymph nodes, though there are side effects to consider
- being ER positive means that tamoxifen is an appropriate treatment, but progesterone status is irrelevant, and the benefits of tamoxifen carry over for 5 to 10 years following the end of treatment
- aromatase inhibitors improve breast cancer mortality compared to tamoxifen
- while estrogen status is not a predictor of response to chemotherapy, chemotherapy helps some patients. How much chemo helps depends on the age of the patients, with younger patients benefiting more.
Peto also explained that prosperous countries have more breast cancer because the women in them have fewer kids and are more likely to be obese after menopause. Nice, simple, non-complicated explanation, with no mention of environmental toxins. Not surprising at this meeting, but disappointing nonetheless.
For the presentations discussed below, abstracts can be found online at www.sabcs.org, as can the slides from each presentation.
Genetic predictors of the need for treatment (Abstract 10)
The Oncotype DX test was evaluated in node-positive breast cancer patients to see whether the risk score (RS) that the test derives for patients will predict who will benefit from chemotherapy, or not. The researchers concluded that node positive patients with a high RS are likely to benefit from anthracycline-based chemotherapy, while those with low RS scores may not benefit.
Asked about the clinical implications of this study, Kathy Albain said that the information here is only helpful for women with a low RS who are ER positive. She would continue to recommend chemo to patients with a large number of positive nodes, no matter what the RS score showed. And it was clear from the questions posed that doctors are struggling with the treatment implications of an intermediate RS score.
Is HDC/ABMT finally dead as at treatment for breast cancer? (Abstract 11)
Donald Berry presented a meta-analysis of the use of high dose chemotherapy/autologous bone marrow treatment (HDC/ABMT) as adjuvant treatment for breast cancer. While we thought this issue was resolved in 2000, Dr. Berry essentially saw no benefit from this treatment in his review of the 15 randomized trials that have been done in the adjuvant setting. While he showed slides that appeared to show a small survival benefit in Her2 positive patients, Berry did not read the data as positive, and said he could not identify any subset of patients who benefited from this treatment.
BCA has recently heard that at the M.D. Anderson Cancer Center, where Dr. Berry works, a trial of HDC/ABMT is being offered to inflammatory breast cancer patients, who are required to pay $235,000 to participate. I asked Dr. Berry whether he had views of testing HDC/ABMT in this patient population at M.D. Anderson, but he was unaware of the trial.
Anthracyclines—Who Should Get Them? (Abstract 13)
Dennis Slamon gave what I thought was the most clinically significant presentation today, talking about who might benefit from, and therefore should get, anthracycline-based chemotherapy treatment.
Slamon reviewed the data showing that women whose breast cancers overexpress Her2/neu benefit from anthracycline treatments but, women whose cancers don’t over-express Her2 do not. His research shows that this result in Her2 positive patients is due to the presence of another enzyme called Topoisomerase IIα, or Topo IIα. Slamon also showed results of his recent research showing that Topo IIα doesn’t seem to occur unless Her2 over-expression is also present. Slamon concluded that since Topo IIα only occurs in 30% of the 25% of breast cancer patients who over-express Her2/neu, he wondered what justifies using anthracyclines in other patients.
No questions were taken after this presentation, supposedly because of time considerations, but I also know that the doctors chairing the session give a lot of chemotherapy to patients. Had I been able to ask a question, I would have asked Dr. Slamon two questions:
- Should patients who don’t over express Her2 get anthracyclines?
- Is there an available test for topo IIα over-expression?
Unable to ask these questions of Dr. Slamon at the time, I asked another scientist here whether Slamon’s research meant that women who don’t over-express Her2 should not get anthracyclines. When she answered that that is what Dr. Slamon would say, I asked if she agreed. Her response was that “Dennis is usually right.”
At an advocate briefing session this evening, Dr. Slamon said that we would not give an anthracycline to a woman whose breast cancer does not over-express Her2/neu, but Dr. Peter Radvin disagreed with this conclusion.
Rethinking Clinical Trial Structure (Abstract 14)
In the latter part of this presentation, Dr. Ragaz suggested ways to restructure clinical trials to get to meaningful results in the adjuvant setting sooner. His suggested changes to the clinical trial process to reduce the time to move things from the bench to the clinic to 5 years include some ideas I found intriguing:
- International coordination
- Distinguishing levels of benefit in the Stage IV setting, and only moving into the adjuvant setting substances that show high benefit in metastatic disease
- Paying more attention to neo-adjuvant treatments, using needle biopsies to test efficacy
Aromatase Inhibitors and Bone Mineral Density (Abstracts 26, 27, 28)
We heard several presentations on this subject, the take home message of which was that giving a bisphosphonate drug at the same time as an AI reduces the adverse bone mineral density impact of aromatase inhibitors, and can actually increase bone mineral density. Once again, one pill makes you smaller…
Notably, one of these studies was in the “prevention” setting of using Arimidex in European women without breast cancer, a type of trial that BCA was instrumental in stopping in the U.S.
The day closed with the Komen Award presentations to outstanding scientists. This year’s winners are Joe Gray of University of California San Francisco and Leslie Bernstein of City Of Hope (and BCA’s Scientific Advisory Board). It was great to see two Californians honored at this meeting.
Heard in the halls
I’ve been coming to this meeting for so long, and know (and am known by) so many of the prominent researchers here, that I’m sometimes told things that researchers or doctors can’t comfortably say in front of a large meeting. Today, I heard this after a presentation on taxanes in breast cancer treatment, “taxotere has done better in every industry sponsored trial, and worse in every government sponsored trial.” When I asked the person who told me this what he made of it, he told me he just noted it.
Follow the money.