Gastrointestinal Cancers Symposium

GI 2018 Daily News Friday

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Managing Metastatic Pancreatic Cancer Davendra P. S. Sohal, MD, MPH M etastatic pancreatic cancer continues to carry a dismal prognosis and is predicted to be the second leading cause of cancer-related death in the United States by 2020. 1 ASCO issued guidelines in 2016 for management of meta- static pancreatic cancer 2 ; recommendations therein, advances since then, and future directions are discussed here. A quick note on stag- ing: this discussion applies to metastatic disease. Although locally advanced (unresectable) cancer is also incurable, treatment impli- cations are somewhat different. Frontline Therapy The two frontline options for management remain FOLFIRI- NOX (5-fluorouracil, irinotecan, oxaliplatin) and gem/nab-P (gem- citabine/nab-paclitaxel). 3,4 Since there is no head-to-head compari- son of these two regimens, we have to evaluate the nuances of each trial to determine which regimen may be best for a given patient, albeit with the caveat that a formal comparison across two different trials is not feasible. The first step is study design and eligibility criteria. The FOLFIRI- NOX trial was conducted in France from 2005 to 2009; the gem/ nab-P study was global and conducted from 2009 to 2012. Both used gemcitabine—the previous de facto standard of care—as the control arm. Eligibility criteria for both trials were very similar: no- table items include ECOG Performance Status (ECOG PS) greater than or equal to 1 for FOLFIRINOX and Karnofsky Performance Status greater than or equal to 70 for gem/nab-P; upper age limit of 75 years for FOLFIRINOX but none for gem/nab-P; bilirubin up to 1.5 times upper limit of normal for FOLFIRINOX but no greater than upper limit of normal for gem/nab-P. The primary outcome for each study was overall survival (OS). The FOLFIRINOX study enrolled 342 patients; the gem/nab-P study had 861 patients. The next step is evaluating the actual enrolled population. The median age in the FOLFIRINOX trial was 61 years, with the imposed upper limit of 75 years; the median was 63 years for the gem/nab-P study, with patients up to age 88. In the FOLFIRINOX trial, 99% had ECOG PS greater than or equal to 1; in the gem/nab-P trial, 92% had a Karnofsky Performance Status greater than or equal to 80, which is equivalent to ECOG PS greater than or equal to 1. The rest of the characteristics were remarkably similar as well. For the FOLFIRINOX and gem/nab-P studies: biliary stents were present in 14% and 17% of patients, 88% and 84% had liver metastases, and 42% and 52% had CA19.9 values greater than or equal to 5X ULN, ESMO 2017 Congress: Gastrointestinal Cancer Highlights T he European Society for Medical Oncology (ESMO) 2017 World Con- gress featured an array of new research and important discussions of clinical practice considerations for gastrointes- tinal (GI) malignancies. Here are some of the GI highlights of the conference, which was held from September 8-12, 2017, in Madrid, Spain. Gastric Cancer Treatment Advances The phase II KEYNOTE-059 trial found that the immune checkpoint inhibitor pembroli- zumab demonstrated relatively strong response rates among heavily pretreated patients with metastatic or recurrent gastric cancer. The study (Abstract LBA28) included a cohort of 259 pa- tients with metastatic disease and at least two previous lines of chemotherapy who were treated with the PD-1 inhibitor pembrolizumab alone, as well as two smaller cohorts of patients with newly diagnosed disease treated with either pembroli- zumab in combination with chemotherapy (25 patients) or first-line pembrolizumab alone (31 patients). In the pretreated group of pa- tients, after a follow-up period of 6 months, there was an objec- tive response rate of 12% with pembrolizumab monotherapy. Patients who expressed PD-L1 fared better, with a response rate of 16%, compared with 6% in those who did not. The me- dian duration of response was 14.2 months, and some experi- enced durable responses of 19.0 months or longer. The two newly diagnosed cohorts had objective response rates of 60% (combination ther- apy) and 26% (monotherapy). The therapy was generally well tolerated across the cohorts. Co-chair of the session on GI tumors and the noncolorec- tal GI tumors Congress chair, Eric Van Cutsem, MD, PhD, of See Metastatic Pancreatic Cancer, Page 4 See ESMO 2017 Congress, Page 3 Annals of Surgical Oncology Advances Surgical Oncology 3 ASCO Guideline: Sexual Problems in People With Cancer 5 Radiation Therapy in Resected Biliary Tract Cancer 11 SSO Membership Supports Early-Career Surgeons 11 Liver-Directed Therapy for Advanced ICC 12 Quality Training Program 14 Exploring Innovation With Data-Driven Dialogue 14 Why I Attend: A Surgical Oncologist's Perspective 15 Symposium Essentials 15, 22, 25 Gefitinib in Patients With EGFR–FISH-Positive Esophageal Cancer 16 Pressing Research Questions From ASTRO Members 21 Restaurant Recommendations 21 National Cancer Groups Chart the Future of Health Disparities Research 22 ASCO Guideline on Clinician- Patient Communication 23 ASCO University ® Essentials 24 QOPI ® , QCP Participants Eligible to Claim MOC Points 25 INSIDE See Early-Onset CRC, Page 4 Early-Onset Colorectal Cancer Increases Globally T he growing incidence of early-onset colorectal can- cer is the topic of several presentations to be pre- sented during the General Ses- sion, "Early-Onset Colorectal Cancer" on January 20.* Session Co-Chair Andrew T. Chan, MD, MPH, of Massachusetts General Hospital and Harvard Medical School, said that a large body of data have emerged indicating that the rate of colorectal cancer is rapidly increasing in people younger than age 50 in the Unit- ed States, even as the overall rate in the population as a whole is declining. Session speakers will highlight issues related to the epidemiolo- gy of early-onset disease, poten- tial strategies for prevention and screening, and clinical manage- ment and survivorship concerns of younger patients. Session Co-Chair Rodrigo Jo- ver, MD, PhD, of Hospital Gen- eral Universitario de Alicante, DAILY NEWS FRIDAY · JA N UA RY 1 9 · SA N F RA N C I SCO Gastrointestinal Cancers Symposium 2018 ■ ■ The two frontline options for metastatic pancreatic cancer management remain FOLFIRINOX and gemcitabine/nab- paclitaxel. ■ ■ Second-line therapy options are extrapolated from studies conducted in patients who received gemcitabine as first-line therapy, including the NAPOLI-1 and the CONKO-003 trials. ■ ■ An important addition to our armamentarium has been the evaluation and approval of pembrolizumab for tumors with MSI-H or dMMR. ■ ■ Integrated genomic analyses have identified distinct molecular subtypes of pancreatic cancer, which will hopefully allow precision oncology trials in this arena. ARTICLE HIGHLIGHTS T A R G E T I N G C A N C E R C A R E Attendee Tip of the Day Use Interact, powered by Touch, to: ■ ■ View speaker slides on your personal device in real time ■ ■ Take notes on slides during sessions ■ ■ Pose questions to session faculty ■ ■ Use audience response technology Experts discuss the clinical implications of the IDEA collaboration, which compared 3 and 6 months of chemotherapy in colorectal cancer. David Levitan

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