June 9, 2012 at 3:13 pm #61718
I will just do that.
God bless.June 9, 2012 at 3:07 pm #61717
Nice job Percy and very understandable, this one is a keeper to be used over again. Now that I think back, Teddy was in #6. Time now to rest for you and to spend the weekend with your family!June 9, 2012 at 2:42 pm #61716
BTW, before I forget, here are the key points for those who are interested .
1. There Is no definitive evidence of adjuvant therapy benefit; differential effects and benefits depend on location or site of the primary.
2. For hand foot and skin side effect,apply 10% urea cream at the beginning of the therapy,but not when symptoms occur,will delay the occurrence and severity of the problem.
3. For liver tumor< 3 cm,RFA Or microwave treatment and/or combine with TACE will provide the same benefit of resection. Remember heat kills all cancer (>60C).
4. For liver tumor>5cm or multiple tumors, the standard treatment is chemoembolization (TACE). Alternative will be bead elute TACE or radioembolization .For RFA,TACE,and other interventional radiation,the choice of local expertise are highly adviced.
5. For systemic therapy, Sorafenib is the only approval targeted agent to treat liver cancer and the single agent use of it has modest benefit at best.
due to the disappointed result of the BINGO trial,(GEMOX+cetuximab vs GEMOX alone) and the result of another trial using panitumumab foe treating colon cancer has failed the study; safety use of those 2 agents had been in question. It may do more harm than good according to one presenter.
6. The difficulty in using the targeted agents for treatment of diseases is that,they can be effective at first, but during the course of treatment, the agents may start to mutate , the original pathway the agents intend to use for is no longer works to inhibit the growth of the tumor; or because of the pathway is effectively block by the targeted agents and stop the growth of the tumor, the tumor may reprogram itself and opens up another new pathway or developes new steps in the same pathway to bypass and continue to grow.( it just like when you are in traffic and when you notice trouble ahead of the highway,you will find another ways to get around the road block and keep going.) and therefore render the targeted agent ineffective.
7. The use of combined agents therapy is better than single agent mono therapy (ie:GEM/CIS is better than Gemzar alone.) in general.
8. Quality of life for older cancer patient should always be considered especially when patient has other kinds of medical problem pre-existed.
God blessJune 9, 2012 at 2:51 am #61715EliSpectator
Thank you for your excellent summaries. I appreciate the effort you put into keeping us updated.
Just a friendly reminder if I may: please remember to take a break and relax once in a while. Your own health is the most important thing of all.
EliJune 9, 2012 at 2:27 am #61714
Here is what I get from the presentation title ” Treatment of biliary tract and Gallbladder Cancer” by Dr. Jordan Berlin MD.
There are about 7,500-8,000 new cases per year. ( I believed he means in the States,but I am not 100% sure.)
Currently Gemzar+the platins(cisplatin,Oxaliplatin and Carpoplatin) provide the highest response rate(RR=22-48%);time to disease progress(TTP 7-13months) and overall survival(OS=7-13months).
A 5FU pooled analysis shown RR=22.6%;TTP=4.1 months & OS=8.2months.
Other chemo agents like irinotecan and the Taxanes (ie: docetaxel, Paclitaxel) ;the RR=20%;TTP=6months and OS=8months for a study done for docetaxel involved 25 patients; and there were no RR in a study done for Paclitaxel which involved only 15 patients.
He indicated that there may be biological and pathological differences in biliary cancers; and we are near the limit of where the cytoxic agents can do(ie: traditional chemo agents. );therefore we have look beyond the cytoxics and into the targeted therapies.
For target therapies,we have to look at the pathways first in order to determine where to start ;biliary cancer is a rare cancer and therefore it may be impossible to test every pathways to find new drugs;so we have to choose the pathways wisely. Currently there are overexpression in biliary cancer in MAP kinase pathways like EGFR;C-met(ICC=20% overpressed and ECC=16%);Kras mutation is about 50% in ECC and less in other sites.
Erlotinib(single agent study,42patients,RR=7%,17% of patients is PFS=6months ,benefit is modest at best) , cetuximab and panitumumab are EGFR inhibitor examples under study too.
MEK pathway is another pathway. In a study involved 28 patients ,using Selumetinib as a SINGLE agent in the 28 pts study;RR=12% PFS=3.7month and OS=9.8months; another MEK inhibitor under study is MEK 162 in phase I.
Other pathways are BRAF,PI3kinase;TGF beta etc. currently studies are in development to explore these pathways in order to search for new drugs to combat the biliary cancer;but due to the fact that there are biological and pathological differences in biliary cancer(ie:ICC vs ECC);we should approach the problems by targeting on different tumor sites, the disease as well as targeting the mutations.
Cell cycling is another pathway since our body cells are cycling all the time,and that is why it is dangerous since the cells keep growing.Examples of the cell cycling factors are p27,BcI2.p53 etc. the abnormality are different by site(ie: ICC,distal,Hilar). the agents that potentially useful are WEE1,CHK1etc.
The site of recurrence of biliary cancer in ICC patients : intrahepatic =54%; extrahepatic=24% and Intra+Extra =22%. Overall the recurrence rate is >75%.
Conclusions: The future belong to targeted therapy;currently chemotherapy is still the standard of biliary treatment . The Level 1 evidence standard treatment is GEM/CIS. In treating biliary cancer,we have to target the disease as well as the mutations in research and treatment of biliary disease.
Adjuvant therapies provide NO definitive evidence that will benefit the patients.It depends on the site of the Primary(ie:ICC,Hilar or distal).
It is possible that adjuvant treatment like radiation will have differential effect depending on site of the primary
God blessJune 8, 2012 at 5:30 pm #61713
BTW,No problem, Gavin, do whatever you want to do to help all us ,you have a big heart indeed.
Dr. Jennifer J Knox from Toronto discussed the three posters that are most related to biliary cancer.(there were I think just 5-6 posters in total that is related to biliary cancer and only this three are of great interest.)
The first one is the BRIDGE study of the management of HCC.(not biliary CC due to it may be of benefit to the intrahepatic patients )
It is a large population study(17,230 pt.) looking at the treatment of HCC around the world.(2,956pt ,17% from Europe and 2,262pt, 13% from North America,the rest is from Asia-China, Japan and Korea.)
The population selected are mostly child-Pugh A patients or Stage up to C in the Barcelona staging system. The therapies offer to the patients in order are TACE, surgery resection or RFA/PEI and last is the systemic use of sorafenib (Nexavar).
Diagnosis to time of treatment is less than 2 months.(0.2-1.8mo.)
Summary: This will be a bench mark study once they completed because of the large patient population in different region . But there is “low uptake” of systemic therapy to date given the stages of the patients diagnosed ;data is helpful to launch new products in the future.
God blessJune 7, 2012 at 7:37 pm #61712gavinModerator
Thanks for this Percy. I hope you won’t mind if I take some of the links that you post here and I’ll repost some of them over on our Facebook page so that people over there can read them as well.
Now go and put your feet up, relax and have a cold drink! Well deserved after all of your hard work at ASCO!!!
GavinJune 7, 2012 at 4:59 pm #61711
with regard to the study of Tivantinib(ARQ 197);As far as I know this study is a phase II study,randomized 2:1; for MET POSITIVE patient only and this targeted agent will have no effect if MET is negative.And the presenter never mention its use on CCA.
According to the presenter,there will be a phase III study to follow.
This study started at high dose 360mg twice daily and there were Grade4-5 adverse effects of neutropenia and so they decrease the dose to dose at 220mg twice daily for advanced HCC who failed one systemic therapy(ie:mostly sorafenib) before .
This study shown Tivantinib will extend overall survival(OS) and less side effects(ie:neutropenia etc.)at dose level 220mg twice daily for patients who are met positive only. Phase III study is planned for further investigation.
God bless.June 6, 2012 at 2:40 am #61710
This is about chemo or targeted agents taken by mouth.(oral) but if you want to do it as the article sugggested;make sure you consult with the doctor first: My guest is that the oncologists will say no more than they will say yes.
God bless.June 5, 2012 at 6:20 pm #61709
I attended2 seesions one is immunotherapy- whose times has come and the other is translating biological discoveries into clinical trials.
The future according to the presenters is that there will be a lot of new targeted agents as well as antibody-guided chemotherapy and antibody-guided targeted agents coming out in the near feature and FDA will response with a faster pace to approve drugs if presented materials are completed and relevant at first submitting .(see link below)
It looks like immunotherapy ( the one that I am talking about is attached an antibody to either a chemo or targeted agent to increase the immune cells likeT cells’ ability to fight cancer cells);(ie;immunohistochemistry analysis showed the addition of nab-paclitaxel alters the collagen structure surrounding pancreatic tumors;weaken the cancer cell’s outer structure for chemo or targeted agent to penetrate the cancer cell easier and kill it) : It is promising and will be part of the new guided “miracle missile ” to help us defend our body.
the other one is: check the link below
God bless.June 5, 2012 at 4:25 am #61708
Before I forget :
1. For tumor < 3 cm, RFA is as effective as resection if location of the tumor permit to do so.
2. If everything are equal,the effectiveness of radioembolization and chemoembolization are similar in general. Most likely will be determined by the institution which the procedure is the practice of that institution.
3. There are no FDA approval of targeted therapy for biliary cancer as of now.Most of the targeted agents are for ” off label use” or in clinical trials.
4. Be sure to choose a multidisciplinary team to treat CCA.(that means before treat plans started, it shall include medical,radiation oncologists as well as GI doctor specialized in liver surgery and interventional oncologists.
5. The PET SCAN result suggested by the presenter indicated that besides to have intra and inter institutional cross calibration to standardize the PET imaging technique so every institution will be on the same page when reading the PET scan from different institutions.Also consistent imaging technique such as daily quality control and machine calibration should be performed. Before the PET scan,patient must not eat 6 hour at least prior to scan;the blood sugar level must be <150 and the kidney function as measured by the creatinine level should be<2.0.
it also depends on the injection technique to avoid minor potential of misreading the result due to problems such as injection infiltration of the FDG ;forget to measure each time your height and weight and make sure you are fasting at least 6hours before the PET scan,(my suggestion is that use the same radiation technician if possible to do your PET scan each time and watch whether the above minimum requirement is done or not.) This way ,you can avoid the pitfall of the incorrect PET SUV reading as much as 4-10% in difference. In general, PET scan is about 40% less radiation you will received as compare to a CAT scan of the chest,abdomen and pelvis.
6. HEAT above 60 degree C can always destroy and kill the cancer without doubt. I was told by an intervention radiologist in his presentation.( Ie:using RFA or microwave,by the way using microwave seems to have a larger penetration effects to the surrounding outer boundary of the tumor, that is good- that means it will be left with a wider margin surrounding the the tumor treated site.)
7. Consider quality of life for older patient( That is 75 or older)and have existed pre-conditions like hypertension and lung and kidney disease.
8. Effective Targeted therapy treatment is still a long way to go,but gain a lot of momentum ; according to the presenter about micro environment of the cancer, that is his prediction that some thing on the horizon will be come out and therefore ,everyone please hang in there until they arrived.
9. They are no adjuvant chemotherapy that is successful in treating HCC.
God bless.June 5, 2012 at 1:05 am #61707
We seem to get close to something then….no cigar (WIN)! Guess we have to fight a little harder, pray a little longer and know that one day we will win! Thanks again Percy.June 5, 2012 at 12:11 am #61706
You are welcome my friends, Lainy and Gavin.
In a conversation with the poster presenter of the “FINAL analysis of the BINGO trial “( GEMOX+ cetuximab ,the study that claimed > 60% in PFS) , a stunning surprise to me at least is that , he indicated that the final result is a ” NO GO” in his own words. That means GEMOX+cetuximab is no better than GEMOX alone.( actually IT is about a month longer in PFS compared to GEMOX alone)
He told me at least for now, he will not spend another five millions dollars or euro(the study was done in France.) on it again.I will report more later .
God bless.June 4, 2012 at 7:33 pm #61705gavinModerator
Thanks for this Percy!June 3, 2012 at 11:23 pm #61704
Thanks for the update, Percy. For all the promising stuff, we have a saying, “From your mouth to God’s ears!”
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