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The American Society of Clinical Oncology (ASCO) along with other professional societies sponsors an annual symposium focused on GU cancers, with a day and a half devoted to prostate cancer. You can view all of the abstracts on screening, detection, and management of localized disease here. If you have an area of specific interest (for example, the use of MRI in detection) you can use the search function on your browser to find articles of interest. On the mac, it is “command+f” keys for both safari and chrome. You then type “MRI” into the box and use “command+g” to scroll through all of the abstracts. You come up with very interesting new information like an abstract on page 108, “MRI targeted biopsy dramatically increases detection of clinically significant prostate cancer while reducing the risk of indolent cancer detection.”
If your interest is more on the newest studies for advanced prostate cancer, you can go here, and do the same thing. What you will find, of course, is that the avalanche of information is pretty hard to digest. When we started ASCO OnLine in the early 90’s, the technology was limited, but now it overwhelms. We are left to hope that the experts who select the most important abstracts to be presented will have done a good job, but that presumes they know our individual interests, which of course they can’t. When tweeting became available, I decided I was too old. I did sign up for a handle, @ascotwit, that I used in a couple of meetings but in general, I haven’t found twitter to be very helpful, even though some of my younger colleagues tried to help me and we even wrote an an article about it. (…I certainly don’t think it is a good way to run a country…but I digress).
So to you, my loyal followers, and with no attempt to correct spelling (why should I if the leader of the free world doesn’t do it?), here are the tweets from the oral abstract presentations that I would have sent out if I was a twitter user:
Ipi + novolumab – “checkmate 650) therapy duration only 2.1 or 1.4 months. Only 1/3 reached maintenance phase with ~1/2 of patients dropping out for toxicity. compared to patients in melanoma trial getting about 4 doses.“if you can’t get the drug in, you can’t see a response” 25% of patients had a response in cohort 1. They tend to respond early The subsets are those who had PD-1 positivity or high tumor mutation burden.
- Scher assay. Getting to CTC 0 was useful in predicting better survival and was better than looking at a drop of 50% in PSA. The development of a show term outcome marker remains elusive. 46% of the patients who lived 13 weeks were not included because of not enough CTC’s
- #140 ARAMIS study – efficacy and safety of darolutamide in nmcrpc. Different structure than end and app and does not cross blood/brain barrier. men with no mets and psa dt <10 months. ADT + placebo vs dark. met free survival 18 months vs 40 months . overall survival 83% vs 73% placebo at 36 months. also improved time to pain, time to skeletal, time to cytotoxic chemo. Tolerance was excellent with no difference in AE rates. Fatigue 15.8% vs 11.4% (see nejm this week)
- Final analysis of Phase III Latitude study. High risk met castrate naive pca newly diagnosed
- High risk gleason >/= 8
- Abi vs placebo + ADT.
- Final analysis showed hazard ratio of 0.66. OS 36.5 months vs 53.3 months. Time to pain progression was much longer (see slide). High volume patients clearly benefited most
- #687 ARCHES trial ADT +/- Enz
- included both low and high volume CHAARTED criteria, as well as could have had prior docetaxel or not. 2/3 had gleason 8-10; 18% had prior doce in the hormone sensitive setting
- Primary endpoint was rPFS or death. secondary: time to spa progression, new rx, spa undetectable rate objective response rate
- rPFS HR =0.39 across all subgroups including those who had previous doce Time to spa progression was 91% at 12 mo vs 63%. 68% got 0 psa vs 18%.
- Fatigue and hot flashes were worse but mostly grade 1/2. 93% of patients still alive. at 14.4 months
- Is M0 crpc really important? New imaging techniques – does it even exist??. Inflection point of doubling time <6mo is important predictor (matt smith curve). Cost: for Enz 220k/year of life saved. PFS2 is the time to progression or death on the theft therapy. The Latitude trial suggests delay in time to next endpoint.
- Cost for abi/p is still 10k/mo but generic is now approved
- discussion of which one to use. not strictly comparable patient populations. need cost effectiveness randomized trial?
- # 2 Choline scan can replace conventional imaging, but has poor negative predictive value – identifies mets earlier but no way to say that the earlier management changes makes any difference.
- #144 – small. initiation of apalutamide early may result in prolonged effect looking at psa2 See screen shot. Earlier treatment for non-metastatic disease is likely better than waiting for mets. There are 3 potential agents (enz, apa, dur). Delaying time to symptoms is also very important. Suggests that anything you add later still does not make up for starting early.
- #365 – yu. Pembro + olaparib in doce pretreated patients with mCRPC. Needed disease progression after doce, randomized to cohort A Pembro + olap 68% had measurable disease. 41% with visceral disease. None of the patients had DDR mutations by biopsy or circ. dna. 12% response rate. 39% had some measurable disease response. they will expand from 42 to 100 patients. Continue randomizing to other cohorts.
- #146 Chen Genetic drivers of poor prognosis and enz resistance in mcrpc. 86% patients had ar gain. Complete biallelic loss of RB1 median OS 14.1 months vs 42 months (not looked at in association with enz resistance -they didn’t look). WNT btea catenin pathway was highest abn asso with resistance. CTNNB1 mutation found only in enz resistant patients and was also associated with poor prognosis similar to the RB1
- #147 – compared 3 arms. MDT upfront with SBRT. vs abi/ADT up front vs ADT up front. Assumed 10 years. Markov model. Looked at cost effectiveness. ADT upfront low cost/low effective. Abi/ADT is not cost effective compared to MDT. Willingness to pay threshold of $100,000/qaly. Costs would need to decline by 90% to be the dominant strategy. MDT is a cost effective treatment. Did not look at MDT + upfront ADT with or without abi. Model assumed 1-3 extracranial metastases using data from STOMP and M1 Stampede.
- #148 Doce +/- enz CHEIRON study. N=246. Combo arm more toxic with neutropenia. disease control 89% combo vs 73%. But no difference in overall survival but most patients did go on to receive 2nd gen adt.
Reading through them, with misspellings, poor wording, and probably containing some real errors (don’t rely on this “tweet” – go to the abstract to verify anything above) I realize how challenging it is to keep up these days. My best suggestion to ALL cancer patients is that they find a physician who is focused on their particular disease if at all possible. I fear the era of being a general medical oncologist is over (and certainly over for a 71-year-old like me). While any of us could use the NCCN guidelines (or other practice guidelines from organizations like ASCO or AUA) to care for patients, there is little that can replace the actual experience one gains by participating in the development of new agents that are rapidly coming into clinical use these days. If you can think of a solution, don’t tweet to me because I have no idea how to use it and don’t “follow” many people. However, I welcome your comments on this old fashioned blog, and can even throw in an emoji (of sorts): 😉 Have a great February and remember, the prostate is our only heart shaped organ.