Something New, Something Old: More From ASCO

We are now into the third day of the annual meeting of the American Society of Clinical Oncology here in Chicago.


Trying to determine what research and which issues are going to become most relevant to cancer treatment are becoming a bit clearer.  There is even a little bit of controversy to go along with the scientific presentations.


For example, at a presentation earlier today, a researcher from Germany made a comment that received a considerable amount of interest from those in attendance, including members of the media.


The study, which examined the value of MRI compared to standard screening mammography in the detection of non-invasive breast cancer (called ductal carcinoma in situ, or more commonly known as DCIS), concluded that MRI was more likely than mammography to identify high grade DCIS lesions.  This is important, since high grade DCIS is more likely than its low grade counterpart to progress to true invasive breast cancer.


The modest controversy occurred because the researcher was quoted as saying something to the effect that MRI was a better screening tool than mammography, and that the reasons we don’t recommend MRI for routine breast cancer screening are based on politics and finances.


This created a bit of a stir, especially since in another quote the researcher stated what I consider the more appropriate observation, namely, “More research is necessary before we can make any specific recommendations about the use of breast MRI for DCIS in clinical practice.”


In fact, the study performed at the University of Bonn, Germany, demonstrated that when women were screened with both MRI and mammograms, 40% of DCIS lesions were seen only on MRI, and 78% of these were high grade—the type more likely to progress to breast cancer, according to the research report.


In contrast, 8% of DCIS lesions were seen only on mammograms, and of these all but one were low grade, implying a lower risk of advancing to breast cancer.


In a sense, these results are not unexpected. 


We know that MRI is a more sensitive test than mammograms.   But it also finds many lesions that are not cancerous.


For example, a recent report on the use of MRI in women recently diagnosed with breast cancer but prior to surgery showed the value of MRI in finding previously unexpected DCIS and other breast cancer lesions in the breast opposite from the one where the primary breast cancer was discovered.


More importantly, in a recently released guideline from the American Cancer Society on the use of MRI as a screening tool for breast cancer, the experts who reviewed the evidence concluded that MRI was only definitely valuable in women at particularly high risk of breast cancer, such as those women who are BRCA positive, or who may have had radiation therapy in the past to treat a disease such as Hodgkins disease.


Those experts concluded that the routine use of MRI in screening  women at average risk for breast cancer was not justified based on the evidence.


In addition, the Society report highlighted the concerns of the expert panel that the technology for quality breast MRI is not generally available.  Also, that article noted that it is very important that even in those situations where its use is justified, MRI studies should be performed in centers of excellence that are fully equipped to provide the best images and appropriate follow-up for suspicious lesions seen on MRI.


For now, I suspect that this study—although important and certain to raise interesting questions and stimulate further study—is not going to change the standard of care in the United States or elsewhere.


Another study highlighted for me the fact that what is new is sometimes very old.


The disease in question is acute promyelocytic leukemia (APL). 


When I started my oncology training in 1972, we saw occasional patients with this form of leukemia.  It was a devastating disease, and we had very little to offer these patients.


Over time, the situation changed and subsequent advances made this form of leukemia one of the most successfully treated acute leukemias in adults.


What is interesting about this particular story is that several years ago, a medicine emerged from the far rural reaches of China that was found to be effective in the treatment of this disease.  The medicine, called arsenic trioxide, was a traditional Chinese medicine that was discovered by someone who was doing a Cultural Revolution related sojourn in a rural part of China.


The story behind this discovery is a fascinating one, and was recounted in detail in a 2001 article in the Sunday magazine of the New York Times.


Currently, APL is treated with a combination of chemotherapy.  Arsenic trioxide is used to treat patients who relapse after failing the initial therapy.


In the new study, the researchers reported that by using the arsenic compound as part of the primary treatment, they were able to increase survival significantly at three years, and also significantly increase the time to relapse in patients who received the arsenic treatment immediately after the primary treatment was administered, instead of waiting until the cancer recurred which is the current practice in the treatment of this leukemia.


From my perspective, this particular study points out two major themes:


The first is that you can never tell where the next advance in cancer treatment will be found.  Adapting a traditional Chinese medicine to effective cancer treatment was certainly an unexpected advance, but one that has proven very effective—albeit only for a small number of cancer patients.


The second is that even compounds which at first glance would be assumed to be very toxic—in the case of arsenic, obviously lethal—may in different forms or different doses prove to be very helpful.


Which leads me to the final thought for this blog, namely that you can never make absolute assumptions about anything.  One must always keep an open mind and always keep searching, for you never know where the next new drug or new treatment may come from.



3 thoughts on “Something New, Something Old: More From ASCO

  1. Hello Dr. L.,

    I just discovered your blog. I’m an ovarian cancer patient anxiously awaiting something new to be discovered for my type of cancer. Unfortunately, ov-ca is always on the back burner when it comes to research and new treatments. It seems like all the attention is being given to breast, prostate, colon cancers. While I am so happy that those patients are given hope, I am disheartened that there seems to be so little effort for ovarian cancer.

    My oncologist, from Cedars Sinai Medical Center in Los Angeles, is at the ASCO conference right now. I told him to look very hard for any new information that might help me and all the other ov-ca patients. I hope he comes back with good news.

    Thanks for sharing your knowledge.

  2. Thanks for this interesting summary. The number of drugs presented at the ASCO meeting and the complexity of trials presented is increasingly difficult to comprehend. I would like to make you aware of a new information system on new treatments in oncology that is not listed in your list of links:
    I found the free information available at the site quite helpful.

  3. I stumbled onto your blog looking for what is the current “standard of care” when is comes to breat cancer – which I unfortunately have. I was at a very high risk – sibling with breast cancer, no children before age 19, very dense breasts – and nothing caught the very large cancers growing in both breasts until it was too late.
    I was scheduled for a lumpectomy until I insisted on a MRI of the other breast. Lo and behold another tumor not caught by ultrasound or mammography! MRIs rather than the ineffectual mammograms and ultrasounds would have saved my life.

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