3 ASCO Updates Tackle Treatment and Supportive Care Questions

Stage 1A

Robert Morreale/Visual Explanations, LLC © 2005-2011 American Society of Clinical Oncology (ASCO)

Breast Cancer

Canadian Agency’s Outlook on Ovarian Ablation Endorsed

In keeping with its policy of endorsing guidelines developed by other organizations deemed appropriate, an American Society of Clinical Oncology (ASCO) ad hoc panel has voiced agreement with clinical guidelines established by Cancer Care Ontario (CCO) on adjuvant ovarian ablation (OA) for premenopausal women with earlystage invasive breast cancer.

CCO, the agency that oversees cancer care in the province of Ontario, Canada, determined that OA should not be added routinely to systemic therapy with chemotherapy, tamoxifen, or the combination of tamoxifen and chemotherapy.

In addition, OA is not recommended as an alternative to any other form of systemic therapy, except in the specific case of patients who are candidates for other forms of systemic therapy but who for one reason or another will not receive any other systemic therapy.

Finally, monthly injection is the recommended mode of administration when the chosen method of OA is chemical suppression using luteinizing hormone-releasing hormone (LHRH) agonists.

The ASCO panel noted its overall agreement with the recommendations, with the caveat that ongoing studies involving dosing regiments for LHRH agonists and combination ovarian suppression and aromatase inhibitor therapies may change its outlook.

Additionally, the panel cited potential limits of ovarian suppression using LHRH agonists. “Ovarian suppression cannot be confirmed by cessation of menses alone,” the ASCO panel wrote, “and estradiol assays are not always reliable indicators of ovarian function.”

The panel also stated that there is no evidence that OA benefits premenopausal women with breast cancer who also have hormone receptor-negative disease or unknown hormone receptor status. (J Clin Oncol. 2011; doi:10.1200/JCO.2011.36.4950). http://tiny.cc/ca3rt

Lung Cancer

Chemotherapy Limits for Stage IV Patients Weighed

An ASCO update committee recommended that patients with stage IV non-small cell lung cancer who have received 4 cycles of first-line chemotherapy and whose disease has not progressed could be immediately switched to alternative, single-agent chemotherapy to extend progression-free survival and, potentially, overall survival.

The recommendations were based on a literature review of 162 publications that met the inclusion criteria. Randomized controlled trials of carboxyaminoimidazole, docetaxel, erlotinib, gefitinib, gemcitabine, and pemetrexed have evaluated outcomes in patients who received an immediate, non—cross resistant alternative therapy after first-line therapy.

“For those with stable disease or response after four cycles, immediate treatment with an alternative, single-agent chemotherapy such as pemetrexed in patients with nonsquamous histology, docetaxel in unselected patients, or erlotinib in unselected patients may be considered,” wrote the authors in a summary of the recommendations published on ASCO’s Website ahead of print.

“Limitations of this data are such that a break from cytotoxic chemotherapy after a fixed course is also acceptable, with initiation of second-line chemotherapy at disease progression,” the panel said. “Bevacizumab is recommended with carboplatin-paclitaxel, except for those with certain clinical characteristics.”

The committee recommended cetuximab with cisplatin-vinorelbine for patients whose tumors test positive by immunohistochemistry for epidermal growth factor receptor. Second-line treatments that the committee recommended were docetaxel, erlotinib, gefitinib, or pemetrexed. Erlotinib is recommended third-line therapy for patients who have not received prior erlotinib or gefitinib.

The committee did not have sufficient data to recommend the routine third-line use of cytotoxic drugs or molecular markers to select chemotherapy. (J Clin Oncol. 2011; doi:10.1200/JCO.2010.34.2774). http://tiny.cc/lf5s0

Supportive Care

Review of Antiemetic Therapies Yields New Recommendations

In its first review of antiemetic therapies since 2006, an ASCO committee tackled key clinical questions involving chemotherapyinduced and radiation-induced nausea and vomiting, clarifying language and refining guidelines in several areas.

The update panel performed a systematic literature review, examining reports on 37 trials, and 2 systematic reviews.

The committee reclassified combined anthracycline and cyclophosphamide regimens as highly emetic. The panel said patients who receive those regimens or any highly emetic agents should receive a 5-hydroxytryptamine-3 (5-HT3) antagonist, dexamethasone, and a neurokinin 1 (NK1) receptor antagonist.

Fosaprepitant, a single-day formulation, with aprepitant was validated for equivalency in a large trial, and the panel noted that either therapy is appropriate. For moderate emetic risk regimens, preferential use of palonosetron combined with dexamethasone is recommended.

The panel also recommended that for low-risk agents, patients can be offered dexamethasone before the first dose of chemotherapy.

Patients undergoing high emetic risk radiation therapy should receive a 5-HT3 antagonist before each fraction and for 24 hours after treatment. Additionally, those patients may receive a 5-day course of dexamethasone before fractions 1 to 5. (J Clin Oncol. 2011; doi:10.1200/ JCO.2010.34.4614). http://tiny.cc/cujza