Latest Blogs

Meal Train

dear all

Meal Train..this looks a great new website that creates a meal roster for someone ill, that family and friends can contribute to.

   Step 1

Identify a friend who could use a little support and enter their name, email address, and where to drop off meals.

   Step 2

Enter the dates meals would be helpful.

   Step 3

Enter your friend’s food likes, dislikes, allergies, and the best time to drop off a meal.

   Invite Others

Invite friends, family, congregation members via email, facebook, twitter, newsletters, and more.

new PBAC approvals pertuzumab and trastuzumab emtasine

POEMS study

Hi all. 

It has been a while since last comments. San Antonio was a bust with me recovering from flu. Anyway, one of the best recent study outcomes was the POEMS study (http://www.nejm.org/doi/full/10.1056/NEJMoa1413204). This randomised study demonstrated conclusively that the hormonal implant goserelin can protect the ovarian function and therefore fertility during chemotherapy. This has huge ramifications for women receiving chemotherapy who still want to bear children or those wanting to avoid an early menopause. It is not government funded and will cost about between 700-1800$ depending on the length of the chemotherapy course.

It generates a temporary  menopause or hibernation of the ovaries if you prefer. Side effects may include hot flushes, mood disturbance and loss of libido.

Spring thought of the day ..apps

dear all, it occurred to me how useful the smartphone would be  as  a patient management tool. That statement  may be a no-brainer but  i think it is well known how under utilised our IT systems are. Having a quick trawl through the Apple App Store (I am sure there is an Android equivalent for pretty much well everything!), there are some  free apps that can track medication lists/doses and provide reminders when scripts are due. Apps such as Evernote are great;  recordings of consultations can be kept (I hate my voice on tape but never  mind) and results can be photographed and stored. This apps can be connected to similar computer-based applications that are password protected.

Finally, the good old calendar with alarms can be used for appointments. I must say I love the Week Cal app as it nicely shows the whole week which the Apple Cal isn’t so brilliant at.

Over time , the various patient or consumer resources will become app friendly. I note with interest that there is a BreaCan Navigator app.

Happy Spring. Shane

new immunotherapy

The oncology world appears to be on the verge of revolution, not simply evolution. The notion of immunotherapy as a means of cancer therapy has been one of the oncological “holy grails” for years. Major developments have been seen in melanoma first with ipilimumab which targets CTLA-4 and augments the immune attack on cancer. The inhibitors against PD1 and PDl1 have a different mechanism blocking immune tolerance to cancer, or as I like to think of it, removing the cancer camouflage, exposing it to attack. The Austin and other institutions are now in the throes of Phase I-III studies testing these new agents. This was as a result of data such as http://www.nejm.org/doi/full/10.1056/NEJMoa1200690 where an efficacy signal was seen for the first time.

clinical trials

For those who are interested we have a whole host of studies in lung cancer at the Austin hospital testing agents targeting EGFR, ALK and PD1/PDL1. The breast cancer portfolio was a wee bit quiet  for a year but this is expanding including studies in triple negative breast cancer. Phase I studies run by A/P Hui Gan include a novel PARP inhibitor (attractive in breast and ovarian cancer  partic in the BRCA +ve patients).

We are very collaborative in Melbourne and I work closely with colleagues at Peter Mac , Royal Melbourne Hospital (only to name a few centres) to give patients the option to participate in studies that suit their particular circumstances better. This is often under the auspices of Cancer Trials Australia (see introduction).  We strongly encourage patients to consider trials. Ultimately as their clinician, I want them to personally  benefit from such participation. It is  true that altruism is maybe  an important part of developing  new and better treatments and improved outcomes in cancer medicine, and in health in general. SW Aug 2014

SOFT/TEXT ASCO presentation/publication in NEJM

This was a combination of 2  trials (SOFT/TEXT) for a total of  4690 premenopausal  pts with hormone drive early breast ca (ER+)

All were treated  with ovarian suppression (injections or ovarian surgery /radiation)  for 5 yrs and either tamoxifen or exemestane. Exemestane is an aromatase inhibitor  (AI)(like anastrozole and letrozole) which is superior to tamoxifen in the ppost menopausal setting. Thus, the SOFT/TEXT study aimed to emulate these results in premenopausal patients.

Overall 5yr DFS (prim endpt) was 91.1% for exe vs 87.3% tam. So there was a 4% improvement in freedom from breast cancer recurrence (helping an extra 1/25 patients). Some criticisms or concerns would include the lack of long  term followup and assessment of implications for bone  thinning (osteoporosis) and cardiovascular disease. The AIs can be challenging with higher rates of joint aches, mood disturbance and libido issues.

My sense is that this may suit the right premenopausal patient with higher risk disease who wants to maximise theie therapeutic gain and has maybe through chemotherapy not found the hormonal disruption troubling in the leadup to this discussion and consideration. A quirk of the PBS is that exemestane can only be used after prior TAM for 2-3 years but I don’ t regard its action as  having a therapeutic advantage over the other AIs which are PBS listed ‘up front’. http://www.nejm.org/doi/full/10.1056/NEJMoa1404037

ZOOM 1 study 2013

At EBCC , the ZOOM data was highlighted http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(13)70297-3/fulltext.  For years clinicians have remained concerned that we are overusing anti-resorptive agents in advanced breast cancer with bone metastases. This data showed no detriment in outcome with a reduction in the use of zoledronic acid (ZA) to 12 weekly in year 2 of treatment. At the least, this new approach will improve patient convenience , and may impact somewhat on the incidence of  osteonecrosis of the jaw (BONJ).

It is speculative as to how to apply this new data to  denosumab, which  was not assessed in this study. Nevertheless, it is intriguing and not unreasonable to think that a similar result would be seen with denosumab, particularly as it is slightly more effective than ZA in the first instance.

EBCC Glasgow 2014 Bisphosphonate debate

one of the  highlights was the debate between Robert Coleman (Sheffield UK) who has led this area and Gabriel Hortobagyi (MD Anderson, Tx,US). Robert reiterated data presented at SABCS 2013 , a metaanalysis of 36 studies and > 18000 patients showing an  reduction in the development of bone metastases and a 3% improvement in overall mortality for post menopausal women with ER+ve breast cancers.

Hortobagyi’s concerns were statistical, but relevant. There was tremendous heterogeneity amongst the studies, none of the studies met their individual primary endpoint (let alone the metaanalysis), the study outcome  was inversely proportional to size, and there was no interaction between schedule type of agent.

Certainly on the basis of no real data Coleman was recommending a 6 monthly schedule of zoledronic acid as per the Austrian study 12 and also the later part of the schedule of ZA in Coleman’s own AZURE study.

(SW) This is contentious and no bisphosphonate is TGA approved for this indication, nor funded on the PBS. Its use would  need to be case by case and i think logically, related to the absolute  risk of relapse of the individual patient. The toxicities of osteonecrosis of the jaw (albeit low 1-2%) need to be considered also.

carboplatin increases responses in NAC in women with triple negative breast cancer

it seems clear through multiple studies that carboplatin improves the pCR (pathological complete response rate) in women having NAC (neoadjuvant or preoperative chemotherapy) in the setting of triple negative breast cancer.

It clearly adds toxicity through low white cells, and it remains unclear whether the benefit increases the chance of cure. The jury is still out but certainly could be considered in circumstances where the cancer is not initally responding well to standard therapy.