ASCO 2013 Cancer Update

Over 26,000 cancer scientists and clinicians attended the American Society of Clinical Oncology (ASCO) annual meeting in Chicago last week. At this critical international meeting the latest research findings are presented and because ASCO is the world’s dominant oncology specialty group, the discussions and recommendations set the standard for cancer care.  Thousands of studies, small and large were reviewed, so here we will just brush the surface.

The increasing financial ramifications of the federal sequestration on access to cancer therapy were a major topic of concern.  According to presenters, the loss in reimbursement is having a growing affect on the ability to pay for therapy and to continue vital research. In addition, a survey found that 83% of oncologists saw drug shortages in recent months and 94% reported that shortages were affecting patients.  It is expected that these problems will get worse.  Presenters urged Congress to quickly address these potentially fatal issues.

Paradoxically, a remarkable presentation, which received enthusiastic applause, was a very low cost technique to screen for cervical cancer.   In India the dollars, technology and expertise to perform routine PAP smears is not available. Therefore, researchers used acetic acid (vinegar), which is swabbed on the cervix during a pelvic exam.  If a precancer or cancer is present, the surface turns white. The vinegar method reduced cervical cancer deaths by 31%, saving tens of thousands of lives.

Following the theme of saving dollars, several studies looked at the need for routine monitoring of cancer survivors. While many guidelines recommend regular surveillance, research often shows limited benefit of repeated scans, labs or even exams. For many cancers, the earliest sign of cancer recurrence is the patient’s symptoms.  For example, most breast cancer patients do not require any x-rays or even tumor marker tests to be followed safely.  ASCO presenters reviewed data indicating that excess testing increased the risk from radiation exposure, increased false positive results which can lead to unneeded extra testing and can cause severe anxiety about test results, which has a profound affect on patient’s lives.

There were a significant number of new therapies for cancer treatment.  It is important to note that most are not classic chemotherapy agents, that is they are not toxins, but rather are biologics. These drugs change or block the natural physiology, genetics or microanatomy of cancer.  This represents a major change from even just a few years ago, when the whole focus was on poisoning the malignant cells. Now we try to find each cancer cell’s particular biologic weakness.

Thyroid cancer is a slow growing, but common malignancy, which is resistant to most therapy. Therefore, data that a pill, Sorafenib (Nexavar), can treat this disease generated enough excitement that it was announced at a plenary session. The results of the DECISION Trial showed that in patients with metastatic thyroid cancer, Sorafenib stopped cancer growth for almost a year. This is a stunning result, considering the lack of treatment options for this disease and opens the way for new therapy and research.

Monoclonal antibodies are proteins manufactured artificially which can alert a patient’s immune system that there is a target to attack.  Anticancer antibodies are increasingly used in oncology. Treatment of Stage IV melanoma with the investigational antibody Nivolumab, was presented at ASCO.  With few side effects, Nivolumab killed melanoma three to six times better than other therapies, so that 30% of patients with that cancer had reduction in tumor masses.  Another biologic agent against melanoma was presented in a study that added a bone marrow stimulating agent (GM-CSF) to a recently created anti-melanoma drug (Ipilimumab, also an antibody). The combination extended the survival of patients with stage IV melanoma

Anti-angiogenesis agents continue to score breakthroughs against cancer.  These drugs destroy microscopic blood vessels, which feed the disease. The dominant drug of this type continues to be Bevacizumab (Avastin).  In two studies, it demonstrated activity against two very different cancers.  In the first, Bevacizumab added to chemotherapy improved length of survival in women with advanced cervical cancer. In the second study, the combination of Bevacizumab, radiation and an oral chemo agent, Temozolomide (Temodar), slowed disease progression in very aggressive brain cancer (glioblastoma).  Both of these findings will likely change standard of care.

Another drug, with similar anti-blood vessel effects, Pazopanib, was given to women after they had received initial surgery and chemotherapy for advanced ovarian cancer. It was tested as a maintenance therapy to delay or prevent the cancer’s return.  This oral medication, sold as Votrient, succeeded in delaying relapse, compared to a placebo.  Oral medicines of this type, which are called tyrosine kinase inhibitors, block growth stimulating substances, as well as stopping angiogenesis.

About 80% of breast cancer is “estrogen receptor positive,” meaning that estrogen made by a woman’s body stimulates the cancer’s growth.  Like fertilizer, estrogen does not start the cancer, but helps it grow.  For this reason, premenopausal women with early breast cancer, after initial treatment with surgery, radiation and/or chemotherapy, are usually placed on tamoxifen for five years. Now several large studies, the aTTom and ATLAS trials, have shown that fewer recurrences of breast cancer occur if the tamoxifen is continued for 10 years.  While there is still some debate regarding this issue, because of potential long-term side effects, it is likely that in the future oncologists will recommend a decade of therapy.

In the spirit that the best way to fight cancer is never get it in the first place, the Cooper Center Longitudinal Study was revealed. This 20-year study of 17,049 men with an average age of 50 years, showed that men who maintained increased levels of cardiovascular fitness had lower risk of developing colon or lung cancer.  The researchers were able to focus on fitness (measured yearly by a treadmill test), even if a man smoked, drank or was overweight.  Fit men had a 68% lower risk for lung cancer and a 38% lower risk for colon cancer.  If a fit man does get colon, lung or prostate cancer, he is more likely to survive.

Finally, there is increasing excitement with the area of “Personalized Medicine.”  This is the concept that by understanding a patient’s genes, we can better predict cancer, prevent cancer, attack cancer and by matching treatment to patient, reduce side effects. For example, a study was presented that genetic changes in breast cancer can predict whether the drug Everolimus will work.  Research on the Veristat test, which analyses serum proteins to see if the mutation-targeting drug Erlotinib will work, was presented.  Advanced New Generation DNA sequencing techniques (NGS) were discussed, which will likely make it possible to identify gene targets for personalized treatment. As every person who attended ASCO knows, cancer is a disease of mutated growth genes and the future, the cure, will come from the science of genetics.

In the last 12 months, over 40,000 articles on cancer research and therapy were published.  Despite cuts in cancer research (deeper in the United States than any other major Country), we continue in the war to defeat this disease.  Step-by-step we move forward, toward a tomorrow when the dread disease will be no more.



  • Thanks for the summary of the conference. Helpful overview.
    • James Salwitz, MD
      My pleasure. After my piece on "Aliens" it was time to get back to basics. jcs
  • Thanks for sharing the ASCO findings. A huge Amen! to "When the dreaded disease will be no more". Will you write a book about your years as an oncologist at that point? If so, it will without a doubt become a best seller.
    • James Salwitz, MD
      Thank you very much for your support. I wonder about a larger piece of work (i.e. a book) about the stories of those who have fought and suffered in the cancer war, just before it was cured. jcs
  • Kathleen Denny
    Thanks. I'm glad to hear that ASCO gave prominence to the vinegar swab screen for cervical cancer and to the value of survivor symptoms, rather than routine radiation images, in followup. More on survivorship later... I've been following the new alternatives to mass poisoning - sound promising and certainly a better way to go. My concern is our vulnerability to the priorities of insurance and pharmaceutical companies, and that is backed by other parts of your report, in which you refer to drug shortages. A drug may be effective and life-saving to a given percentage with one form of cancer, while another is just right for another percentage, and yet another for the other third, all of whom survive with less toxicity, but if those drugs don't generate the block-buster profits pharmaceutical companies demand, they don't necessarily keep up production. The story of Avastin is instructive.
  • IBS
    I am just a patient, so if someone can help me understand something what was written, I would appreciate it. Are monoclonal antibodies the same as MGUS? "They are proteins that can alert a patients immune system to attack a target." I also use TBL-12. I have a lot of autoimmune problems. My systemic lupus went to sleep..or is too busy killing things in my body.I still have neuropathy, Raynauds and Fibro. My MGUS, although not normal, never advanced to MM. My Palliative LC IV is still stable <no coughing, not out of breath, still drive, no blood and I'm gaining weight Two or 3 years ago, My Rheum told me to see a Thyroid doc. He saw two lumps. I I had biopsies and no cancer. Both docs were amazed...............When one has to constantly go to doctors, one gets confused which doctor I'm going to....To Dr. S as to why patients are late. I always go to the wrong doctor. Monoclonal antibodies are the only words I know, so please just answer yes or no. Anyone want tainted blood? I could use the money. The economy is so bad. :)
    • James Salwitz, MD
      Great comments. Monoclonal antibodies are a form of medicine; MGUS is a medical condition. Monoclonals are created by a pharmaceutical company and are designed to attack a specific target, such as cancer. They are generally given by IV. The most commmon and most successful monoclonal antibody drug is Rituximab, which is used to suppress the immune system in certain medical conditions or to attack lymphoma. MGUS = Monoclonal Gammapathy of Unknown Significance: This is when a person's body makes an exceess of one antibody which does not seem to have a function. This occurs commonly in people as they age and occassionally in patients with autoimmune disorders. By itself, MGUS, is not harmful. The concern, as you hint in your comment, is that in some people the presence of a MGUS indicates the presence of a bone marrow cancer, known as Multiple Myeloma. In general, the best way to make certain that Myeloma is not present, is to do a bone marrow biopsy. jcs
      • Debbie
        My husband in currently on an immune suppressant called Sirolimus and he receives this with Gemzar chemotherapy as an oral medication every night, we have just had our CT results and his scans showed noticeable shrinkage his primary was Cardiac Angioscaroma with mets to his liver. The heart tumour was removes December 2011 with clear margins and his heart has done wonderfully well ever since he stayed NED for 10 months until they found 2 spots in his liver which he is being treated for at present.
        • James Salwitz, MD
          Fantastic!!!! While Gemzar is a standard chemotherapy in sarcomas, the use of Sirolimus (Rapamune) is a fairly new and exciting idea. While the original use of Sirolimus was to prevent rejection in renal transplant patients, the drug was found to block a critical target in cancer cells. This activity, actting as an mTOR inhibitor, stops the cancer cell from making new protein. The cell, especially when also attacked by a conventional chemotherapy agent, falls apart. I recently met a patient who has been in complete remission for several years with a story similar to your husband's. Congratulations! Keep up the great work! jcs
  • Lizabeth Santomauro
    Any thoughts on AHCC? I've read this is wonderful for individuals with cancer undergoing treatment, and as a preventative. Thank you! Liz
    • James Salwitz, MD
      AHCC - active hexose correlated compound: This is a mushroom extract which has some anti-oxidant studies. In mouse studies it seemed to slightly increase the activity of chemotherapy. In a human study there was a suggestion it might extend the survival of patients with advanced liver cancer, but this was not seen in patients with prostate cancer. Not enough is known about it as yet. jcs
  • IBS
    Thank you, Dr. S. Is Rituximab just like cyclosporine? I was put on that a long time ago, but my IgG kept on going up, and I quit. I have very bad genes on both sides of my family including heart, which my first cousins had, and my beloved infant passed from, MM, Lupus and Waldenstrums. I need time for peace. My last BMB was 3 years ago...8% And now Lung cancer. 2/12 Thus, palliative care. I thought perhaps the article from Chicago might have helped. Now my kids have hired an "elder care" person for me. I'm extremely independent and that's hard for me. I don't even know what to do with her. It's okay, I am still doing well. Are there any other patients on here that their kids are trying to control their life? I still live alone. I do know cancer programs need more money, and I did give a generous donation to research for lymphoma. I know that a lot of people send flowers for their beloved that have passed, but instead, it would be wonderful to please give to cancer research in lieu of flowers. It will help all of the patients and researchers that can find cures.
    • James Salwitz, MD
      It is tough sometimes to find a balance between being independent and getting the care you may need, especially when loving children are involved. The best solution, though not easy, is to keep communicating. You need your freedom, but also children need to support you ... it is a natural need and urge. Make sure they know what you need and listen to what they need. Rituxan is an artificial antibody which boosts the immune system's response to cancer. Cytoxan is a chemical which poisons cancer cells directly. Both have their place, sometimes together, in treating cancer. jcs
      • IBS
        Dr. Salwitz, I appreciate your kindness and patience with me. Sometimes their love is just too overbearing. Although I just wanted a few buttons to wear for help, I'll swear I'll give it a chance. Thank you....100% for you 0% for me.
  • Wondering why Sirolimus hasn't made the nightly news and front page headlines. Found to block a critical target in cancer cells, stopping the cancer cell from making new protein, and the cell when also attacked by a conventional chemotherapy agent, falls apart. And you recently met a patient who has been in complete remission for several years having received this treatment. Several years . . . so this is not a new drug. WOW! Why aren't we hearing more about this miraculous finding? What is known about which cancer patients may benefit?
    • James Salwitz, MD
      Sirolimus has so far found benefit only in a narrow spectrum of uncommon cancers and its use is experimental. For many patients the improvement is small. Researchers are still trying to figure out how and when to use it. jcs

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