The fifth seminar of our eight-part online, integrated educational course on issues relevant to the current and future treatment of several different solid tumors and hematologic cancers features Drs Charles S Fuchs, David H Ilson and Laura H Tang. Part V (originally held July 12, 2011) features discussion of the latest clinical research data sets in gastric cancer. (Webinar)
CE Disclosures and Faculty Information
TARGET AUDIENCE
This activity is intended for medical oncologists, hematology-oncology fellows and other healthcare providers involved in the treatment of gastrointestinal cancer.
OVERVIEW OF ACTIVITY
Although significantly less prevalent than its colon and rectal gastrointestinal cancer counterparts, gastric cancer currently ranks second in global cancer mortality. Until recently, the systemic management of metastatic gastric and gastroesophageal junction (GEJ) cancer has undergone only minor incremental enhancements, but this paradigm has now undertaken a dramatic shift for the minority (~20 percent) of patients with cancer of the stomach or GEJ whose tumors overexpress the HER2 receptor and rely on this growth pathway. To this end, an epidemiologic and molecular understanding of gastric and GEJ cancer has become paramount to the research and development of new therapies. This program uses a review of recent ASCO papers and other relevant publications, faculty case presentations, Q&A and discussion of community practice patterns to assist practicing clinicians in the formulation of up-to-date and appropriate treatment strategies.
LEARNING OBJECTIVES- Educate patients with locally advanced and metastatic gastric cancer about the risks and benefits of available treatment options.
- Foster enhanced communication between pathologists and medical oncologists related to HER2 testing.
- Counsel patients with HER2-positive disease about the potential benefits and risks of trastuzumab when added to first-line chemotherapy.
- Offer clinical trial participation to patients with advanced disease.
ACCREDITATION STATEMENT
Research To Practice is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
CME credit is no longer available for this issue
CREDIT DESIGNATION STATEMENT
CME credit is no longer available for this issue
HOW TO USE THIS CME ACTIVITY
CME credit is no longer available for this issue
This CME activity consists of a video component. The participant should watch the video.
CONTENT VALIDATION AND DISCLOSURES
Research To Practice (RTP) is committed to providing its participants with high-quality, unbiased and state-of-the-art education. We assess potential conflicts of interest with faculty, planners and managers of CME activities. Real or apparent conflicts of interest are identified and resolved through a conflict of interest resolution process. In addition, all activity content is reviewed by both a member of the RTP scientific staff and an external, independent physician reviewer for fair balance, scientific objectivity of studies referenced and patient care recommendations.
FACULTY — The following faculty (and their spouses/partners) reported real or apparent conflicts of interest, which have been resolved through a conflict of interest resolution process:
Charles S Fuchs, MD, MPH
Director, Center for Gastrointestinal Cancer
Dana-Farber/Harvard Cancer Center
Professor of Medicine
Harvard Medical School
Boston, Massachusetts
Advisory Committee and Consulting Agreements: AstraZeneca Pharmaceuticals LP, Bristol-Myers Squibb Company, Genentech BioOncology, Genomic Health Inc, ImClone Systems, a wholly owned subsidiary of Eli Lilly and Company, Roche Laboratories Inc.
David H Ilson, MD, PhD
Professor of Medicine, Weill Cornell Medical College
Attending Physician, Memorial Hospital
Memorial Sloan-Kettering Cancer Center
New York, New York
Paid Research: Bayer HealthCare Pharmaceuticals, Genentech BioOncology, Pfizer Inc.
Laura H Tang, MD, PhD
Assistant Attending Pathologist
Memorial Sloan-Kettering Cancer Center
New York, New York
No real or apparent conflicts of interest to disclose.
MODERATOR — Dr Love is president and CEO of Research To Practice, which receives funds in the form of educational grants to develop CME activities from the following commercial interests: Allos Therapeutics, Amgen Inc, AstraZeneca Pharmaceuticals LP, Aureon Laboratories Inc, Bayer HealthCare Pharmaceuticals/Onyx Pharmaceuticals Inc, Biogen Idec, Boehringer Ingelheim Pharmaceuticals Inc, Bristol-Myers Squibb Company, Celgene Corporation, Cephalon Inc, Daiichi Sankyo Inc, Dendreon Corporation, Eisai Inc, EMD Serono Inc, Genentech BioOncology, Genomic Health Inc, ImClone Systems, a wholly owned subsidiary of Eli Lilly and Company, Lilly USA LLC, Millennium: The Takeda Oncology Company, Mundipharma International Limited, Myriad Genetics Inc, Novartis Pharmaceuticals Corporation, OSI Oncology, Sanofi and Seattle Genetics.
RESEARCH TO PRACTICE STAFF AND EXTERNAL REVIEWERS — The scientific staff and reviewers for Research To Practice have no real or apparent conflicts of interest to disclose.
This educational activity contains discussion of published and/or investigational uses of agents that are not indicated by the Food and Drug Administration. Research To Practice does not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings. The opinions expressed are those of the presenters and are not to be construed as those of the publisher or grantors.
This activity is supported by educational grants from Genentech BioOncology and ImClone Systems, a wholly owned subsidiary of Eli Lilly and Company.
Hardware/Software Requirements:
An Internet connection that is at least 28.8 Kbps
A monitor set to 1280 x 1024 pixels or more
Internet Explorer 6.x or newer, Firefox 2.x or newer, or Safari 2.x or newer
Macromedia Flash plug-in 6.0 or greater
Adobe Acrobat Reader
(Optional) Sound card and speakers for audio
Last review date: July 2011
Expiration date: July 2012
Acknowledge and close
(WiFi is recommended for best performance):
Case 1 (Dr Ilson): A 53-year-old executive with HER2-negative adenocarcinoma at the GE junction and multiple liver mets
This patient was fortunate to have a CR on first-line treatment (DCF), but we reflected on the likelihood that progression may loom not far in the future. Although a recent ASCO paper demonstrated that second-line chemo yields modest benefit, perhaps the greatest hope for such patients is the panoply of exciting new targeted therapies that are rapidly emerging. This led to a discussion of a spectacular recent review article by Janice Reichert on the “top 25” antibodies in clinical development (click here for the paper). Interestingly, the only agent on the list that is currently in Phase III evaluation in GC is the novel anti-angiogenic monoclonal antibody ramucirumab, and Charlie commented on a study he heads at Dana-Farber, as well as other trials looking at it in combination with chemo. Unlike bevacizumab (that binds to VEGF) and the fused protein aflibercept (that
Case 2 (Dr Fuchs): A 54-year-old father of three presenting with GC and mets, similar to Patient 1, who sought a second opinion after receiving irinotecan/cisplatin from a community-based oncologist
This case really fried my egg and is still bothering me because first-line treatment without knowledge of HER2 status was started in January 2010, more than six months after Eric Van Cutsem’s ASCO presentation of the ToGA trial results. Well aware that these epic data demonstrated a progression-free and overall survival advantage with the addition of trastuzumab to chemo for patients with HER2-positive gastric cancer, Charlie ordered a HER2 assay, which was positive, and the patient went on to have a significant antitumor response to FOLFOX/trastuzumab.
Dr Tang then reviewed the not-so-simple difference between HER2 testing in breast cancer and GC, particularly the heterogeneity of tumor involvement that often occurs in the latter. However, she explained that in terms of interpreting HER2 results, GC follows a basic breast-like algorithm — accepting IHC3+ as positive with reflex FISH testing on 2+ and probably 1+. We also noted several papers from ASCO confirming the surprising ToGA finding that, as in breast cancer, about 20 percent of patients have HER2-positive tumors.
Case 3 (Dr Ilson): A 67-year-old attorney with HER2-positive GC responding to FOLFIRI/trastuzumab
We used this case to explore secondary issues that have been the subject of extensive discussion in HER2-positive breast cancer but are just now being considered for GC. In this regard, we talked about the use of adjuvant anti-HER2 treatment off study (neither faculty member would endorse), the continuation of anti-HER2 treatment after progression (thumbs down here also until there are data) and the use of trastuzumab monotherapy or postchemo maintenance (another no vote even though patients in the ToGA trial received six cycles of trastuzumab/chemo followed by trastuzumab alone until progression, à la breast cancer). We also touched on the use of newer anti-HER2 treatments — lapatinib, T-DM1, pertuzumab and more — that are being tested in GC.
Case 4 (Dr Fuchs): A 63-year-old Eastern European immigrant s/p R0 resection of a T1N1 GC with two of 17 positive nodes
This patient actually entered the CALGB trial Charlie presented at ASCO demonstrating no difference between two chemo/radiation regimens. However, David said he would have used chemo alone. This sparked a modest Memorial versus Dana-Farber showdown that must have warmed the hearts of audience members who also struggle with this and other related difficult decisions.
Neil Love, MD
Research To Practice
Miami, Florida