The annual meeting of the American Society of Clinical Oncology, ASCO, held each year in Chicago, has wrapped yet again, with a staggering array of new scientific insights for cancer patients, caregivers and clinicians.
De-escalation of cancer treatment proved an effective strategy in several studies involving solid tumors, including a randomized clinical trial of rectal cancer patients that found radiation was unnecessary for those with locally advanced disease who’d received a chemotherapy cocktail known as FOLFOX before surgery. Safely foregoing radiation means these patients will suffer fewer toxic side effects (think bowel changes, infertility and menopause) while achieving better survival outcomes.
Another trial, involving early-stage low-risk cervical cancer patients, found that simple hysterectomy was a better option for patients than radical hysterectomy, marking a new standard of care. A new study of patients with brain cancers driven by IDH1 and IDH2 mutations found that replacing the current standard of care — chemotherapy and radiation — with a new oral-targeted drug provided patients with significantly improved progression-free survival.
In addition to de-escalation, researchers presented data on the expanded use of some cancer drugs like Enhertu, an effective HER2-targeted therapy currently used in breast, lung and gastric cancers. The antibody-drug conjugate may have potential in bladder, cervical, endometrial, ovarian, pancreatic and other cancers as well, according to data shared by the drugmakers.
Fred Hutchinson Cancer Center scientists attended the meeting en force, sharing findings on everything from acupuncture pain relief to genomic testing deficits in pancreatic cancers to the impact of low income on cancer clinical trial participation and more. Below, a few highlights from the five-day meeting.
Missed opportunities with regard to molecular testing — a backbone of precision oncology — were highlighted in two studies by the Hutchinson Institute for Cancer Outcomes Research, or HICOR.
Veena Shankaran, MD, presented data from a study led by hematology/oncology fellow and first author Lauren Shih, MD, on the use of molecular testing in patients with metastatic non-small cell lung cancer within Washington state.
“Therapies targeted at driver mutations such as EGFR and ALK in non-small cell lung cancers, or NSCLCs, have contributed to improved patient survival,” Shih and colleagues wrote in the abstract. “While current guidelines recommend all patients diagnosed with stage 4 NSCLCs undergo molecular testing to determine eligibility for targeted therapies, real-world testing patterns have not been well described.”
To evaluate these patterns, the HICOR team used patient data from a regional cancer registry covering 2017 through 2019, coupled with insurance claims from Medicare, Medicaid and two large commercial insurers, to evaluate the rates of molecular testing.
The researchers then compared those who did and those who didn’t receive molecular testing.
Their analysis showed that around 90% of all patients had molecular testing, but testing rates were significantly lower among Hispanic patients than non-Hispanic patients (77.8% versus 90.7%). Testing was also lower in older patients, male patients and patients using Medicaid insurance.
Shankaran, co-director of HICOR, also presented on the use of germline genetic testing in patients with prostate, pancreatic, or ovarian cancer in Washington state.
Inherited or germline genetic mutations are seen in 10 to 15% of all patients with these three cancers. Accordingly, universal germline testing is recommended to choose the best therapy and inform other family members of a potential risk.
But not all patients are routinely tested.
Lead author Qin Sun, PhD, Shankaran and other HICOR researchers dug into cancer registry data and insurance claims records (again, from Medicare, Medicaid and two large commercial insurers) to identify who was and who wasn’t receiving this type of testing during the first two years following their cancer diagnosis.
Out of 2,077 eligible prostate, pancreatic and ovarian cancer patients, the researchers found only 20% received germline testing with the median time to test between two months and nearly six months.
“Despite guideline recommendations, germline testing rates are low among cancer patients in Washington state with the lowest rates in prostate cancer patients, in Asian patients and in those with higher comorbidities,” the researchers wrote. “Underutilization of germline testing may not only adversely affect treatment, but also represents a missed opportunity for the testing of high-risk families.”
Another study, conducted by Fred Hutch researchers working with the SWOG Cancer Research Network, found that older patients enrolled in cancer clinical trials have a higher risk of unplanned emergency room visits if they live in areas with higher deprivation. The research team found the same risk in cancer patients with Medicare plus Medicaid insurance.
“These findings suggest that neighborhood deprivation and economic disadvantage may increase emergency room visits for socioeconomically vulnerable older patients with cancer,” the researchers concluded.
Cancer treatment does not come without side effects and Fred Hutch researchers presented a handful of studies regarding potential interventions during ASCO’s meeting.
Treatment for certain invasive bladder cancers can cause pain, urinary urgency and other symptoms which might be helped by acupuncture, a noninvasive integrative medicine technique that’s proven to help breast cancer patients with treatment-related muscle and joint pain.
Fred Hutch and University of Washington investigators, including lead author Sarah P. Psutka, MD, Heather Greenlee, PhD, ND, and Daniel Lin, MD, holder of the Pritt Family Endowed Chair in Prostate Cancer Research at UW Medicine, investigated whether weekly pre-procedure acupuncture could do the same for patients with non-muscle-invasive bladder cancer.
Eligible high-risk patients were randomized to either receive or not receive acupuncture before their weekly intravesical Bacillus Calmette-Guerin (BCG) treatments. All told, 28 received acupuncture and 15 did not. Most patients were male. Six patients withdrew from the study due to cancer progression or other reasons.
Results show patients who received acupuncture had improved urinary symptoms, including the easing of pain. And nearly all of the patients who received acupuncture reported that it was “very/extremely helpful.”
“Acupuncture prior to induction BCG treatments is feasible and safe,” said Greenlee, medical director of Fred Hutch’s Integrative Medicine program. “We observed reductions in pain and a trend towards improved urinary function scores over successive treatments among patients undergoing in-clinic pre-BCG instillation acupuncture.”
Eric Chow, MD, MPH, director of the Fred Hutch Prevention Center, presented data from the Children’s Oncology Group, or COG, on the need for better surveillance for cancer therapy-related cardiomyopathy among survivors of childhood cancers.
Chow compared echocardiograms (used to screen for cardiac dysfunction) and other data from young cancer patients with and without cardiomyopathy, eventually generating two-year and five-year prediction models to identify childhood cancer patients at high risk for the condition. Identifying these patients earlier provides a window of opportunity for interventions to slow or stop this late effect of treatment.
“Heart failure and other serious cardiovascular diseases are major complications of otherwise successful anti-cancer treatments,” Chow said in his oral abstract presentation, adding that children who receive certain chemotherapies and chest radiation need to be surveilled regularly for cardiovascular disease.
“Identification of high-risk patients will facilitate secondary prevention,” he said.
Hematology/Oncology Fellow Chipo Natasha Kwendakwema, MD, led and presented a HICOR study regarding financial toxicity at end of life.
The researchers linked cancer registry data to credit reports from TransUnion as well as Medicare and commercial payer insurance claims data, selecting patients with stage 1 through stage 4 solid tumors (such as breast, bladder, colorectal, lung, prostate cancers, etc.) who died between January 2013 and December 2019.
They then compared the number of emergency department visits, the number of inpatient visits, the place of death and the mean health care cost per patient (paid by the insurer) between patients who had adverse financial events (such as charge-offs, third-party collections, tax liens, delinquent mortgage payments, foreclosures or repossessions) and those who did not.
Results showed that patients with adverse financial events, or AFEs, were more likely to have multiple emergency department or inpatient visits in the last three months of life and were also more likely to die in a hospital. Health care costs were also higher in patients with AFEs than those without in the last six months of life.
“We demonstrated an independent association between adverse financial events as measured in credit records, increased end of life health care utilization and greater per-patient costs in the months before death,” the researchers concluded, suggesting that “addressing patient financial hardship could improve their end-of-life experience and decrease healthcare costs.”
Previous research by HICOR has shown that about 3% of cancer patients go bankrupt — and those patients are much more likely to die. HICOR researcher Hiba Khan, MD, MPH, dug deeper into the data to determine if patients with cancer who are experiencing less severe AFEs than bankruptcy are also at an increased risk of death.
The team used SEER cancer registry data from 2013 to 2018, linked to quarterly credit reports from TransUnion, to identify patients who’d survived at least two years following their diagnosis. Patients dealing with financial pressures — third-party collections, charge-offs, delinquent mortgage payments, tax liens, foreclosures and repossessions — within that two-year period were compared with those who weren’t.
All told, nearly 65,000 patients survived two years, with roughly 12,700 experiencing some kind of severe financial event. Analysis showed that patients dealing with any kind of debt were also more likely to die.
Prostate cancer patients with adverse financial events had the highest risk of death. Increased mortality was also associated with patients older than 65; patients who were Asian/Pacific Islander; patients from greater areas of deprivation and those with a higher stage of cancer.
“Further research should investigate mechanisms for this increased mortality risk,” Khan and colleagues concluded, “to inform potential interventions and policy solutions, especially among the prostate cancer population.”
Funding for the studies came from a variety of sources, including the National Institutes of Health; the National Cancer Institute; the NCI’s Cancer Center Support Grant; the Kathryn Butler Memorial Foundation; Texas 4000 for Cancer; Rally Foundation for Childhood Cancer Research and Fred Hutchinson Cancer Center.
Diane Mapes is a staff writer at Fred Hutchinson Cancer Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at dmapes@fredhutch.org. Just diagnosed and need information and resources? Visit our Patient Care page.
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