Josep Tabernero, MD; Martine J. Piccart, MD, PhD


October 08, 2012

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What's Practice-Changing at ESMO 2012?

Josep Tabernero, MD: Hello. I am Josep Tabernero, Head of Medical Oncology at Vall d'Hebron University Hospital in Barcelona, Spain, and the Scientific Chair of the European Society for Medical Oncology (ESMO) 2012 meeting. Welcome to the Medscape wrap-up of the annual ESMO meeting being held here in Vienna. Joining me today is Dr. Martine Piccart, Head of the Department of Medicine at the Institut Jules Bordet in Brussels, Belgium, and President of ESMO. Welcome, Martine. As ESMO 2012 comes to a close, what do you consider to be practice-changing studies presented in this year's congress?

Martine J. Piccart, MD, PhD: There was at least 1 very important practice-changing study in lung cancer,[1] in which the use of the targeted drug crizotinib turned out to be better than conventional chemotherapy as a second-line treatment in patients with non-small cell lung cancer. On the other hand, there were many reports on important large phase 3 trials that are the focus of the 2 presidential symposia. In particular, the 2 breast cancer phase 3 trials that looked at the optimal duration of trastuzumab in early HER2-positive breast cancer are worth mentioning because, as you know, trastuzumab is a real breakthrough in personalized medicine for breast cancer.

This drug works very efficiently in advanced breast cancer and in early breast cancer, provided that there is HER2 overexpression, but in early disease we have empirically fixed the duration of treatment at 1 year, without any strong rationale. Many of us have been wondering for a long time whether it would be better to give it for longer than a year, but perhaps the more important question, given the cost of the drug, is whether we could give it for less than a year. This ESMO meeting featured the presentation of the results of the HERA trial,[2] comparing 2 years with 1 year, essentially demonstrating that there does not seem to be a gain when you give longer treatment.

The results of the PHARE study,[3]which is a French trial initiated by the National Cancer Institute in France, compared 12 months to 6 months, trying to demonstrate the noninferiority of the shorter treatment duration. That is very difficult in oncology, to show noninferiority, so this was a relatively large study with more than 3300 patients involved. The study essentially failed to demonstrate noninferiority, which means that according to this trial, at least the recommended duration for adjuvant trastuzumab will remain at 1 year. Nevertheless, the follow-up on this trial is still a bit short -- only 4 years. It is 8 years for the HERA trial, and there are other trials ongoing in Europe also looking at the question of a shorter duration of trastuzumab. Some of these trials have a completely different design, such as the study run by Dr. Joensuu, where trastuzumab is given up front with a taxane, which is a very innovative way of giving the drug. This combination strategy at the beginning might still turn out to be a very effective treatment where you perhaps don't need to give a very long trastuzumab therapy.

Medical Oncology Is About to Change

Dr. Tabernero: One of the main topics of the ESMO meeting has been personalized medicine -- not only the fact that new drugs are being introduced in this field but also that we have to review the duration. Duration is going to be important, especially for these 3 drugs. Is there any other aspect of breast cancer and the spectrum of cancer research that you would like to highlight?

Dr. Piccart: Today we had a very exciting American Society of Clinical Oncology-ESMO joint symposium that focused on the genomics of breast cancer. We have learned essentially in the last 2 years about the complexity of the disease, and fantastic papers were published in the last 2 months in Nature[4,5] dealing with the complexity of solid tumors and breast cancer in particular. When you consider DNA analysis of the tumors using DNA sequencing technologies, medical oncology could change dramatically in the next 2 years if we are clever enough to collaborate and to try now to link this very complex information to what is happening to the patient. What is going to be very important in the coming years is collaboration efforts at applying this technology in the context of the clinic, and not picking at random some tumors and metastases and looking at the genomic landscape of the tumor, but trying to understand whether the genomic landscape is linked to prognosis and to response to treatment or to absence of response to treatment. There is huge work ahead of us but it is very exciting.

Putting Science to Work in the Clinic

Dr. Tabernero: One of the major challenges that we have is how we compile all this information, not only the clinical information but also information of the molecular profiling and how we determine the best treatment for our patients. What other challenges do we have, particularly in ESMO?

Dr. Piccart: In my introductory speech to the symposium, I tried to explain that although personalized treatment is a dream for oncologists and patients, we are not there yet. There are a few striking examples of situations in which you identify a driver mutation in a tumor, you have the right drug to match the mutation, and you see fabulous responses, but I consider that these are still a minority of examples. We still have to work very hard, so a message is that clinical translational research is crucially important, even more so than in the past.

Dr. Tabernero: As you mentioned, we have had the data on vemurafenib in melanoma and we have been able to define a population of patients that have a driver, an oncogene addictive mutation for BRAF. Also, we have the population of patients with non-small cell lung cancer adenocarcinoma. We have been able to target this population in different subtypes, EGFR-mutations and now the ALK translocation. So, as you mentioned, we are moving forward in this field, and there is hope for the future.

Thank you, Martine. It has been a pleasure speaking with you today as always, and thank you for joining us for this edition of Medscape Oncology Insights. This is Josep Tabernero, signing off from ESMO 2012 here in Vienna. Thank you.