By JAMES SALWITZ, MD

The 30,000 member American Society of Clinical Oncology is the world’s leading group of cancer physicians. ASCO is dedicated to curing cancer, supporting research, quality care, reducing treatment disparities and a heightened national focus on value. This month they released their annual Report on Progress Against Cancer, which highlights research, drug development and cancer care innovations.  This hundred-page document is important reading for anyone who wants to be up-to-date regarding cancer care.

Cancer related deaths in the United States are dropping, but still totaled 577,000 in 2012.  While world cancer research funding is rising, in the USA it continues to decrease, with the purchasing power of the largest funding source, the National Cancer Institute, having fallen 20% in the last decade, and a further 8% cut slated for January 1, 2013.   Development is dependent on government and private funding, as well as the willingness of more than 25,000 patients a year who volunteer to be involved in cancer trials.  All these critical supports are threatened. The Federal Clinical Trials Cooperative of the National Cancer Institute (FCLC, NCI) supports research at 3100 institutions in the USA.

The report discusses the many types of cancer which continue to be naturally resistant to cancer treatment, particularly chemotherapy.  In some cases, drugs do not penetrate a part of the body, such as the brain, in other cases even when they reach the tumor, they are not effective.  In such cancers the genetic code of the cancer cells has mutated (changed) such that the particular drug does not kill the cancer.  In 2012, there was increased interest in attacking each cancer cell at multiple targets either by using a single drug, which attacks in several different ways, or multiple drugs at the same time.  This concept improved cancer killing in GIST, colon cancer, certain lymphomas (ALCL) and medullary thyroid cancer.  In addition, unique targeted compounds, such as “tyrosine kinase inhibitors,” show increasing benefit in leukemia, sarcoma and breast cancer.

The area of “precision medicine,” designing cancer treatment around the genetics of the particular patient or cancer, continues to advance.  This personalized approach adjusts for variations in the genetic code between patients and between cancers.  In addition, research is focusing on the constant genetic change that occurs even within the cancer of the single patient, as the cancer grows or spreads.  In some cases, the genetic change may actually produce increased survival rates, but in other tumors a genetically targeted therapy may kill the original mass, but not kill spreading mutated cancer.  Highly unstable lung cancers may have hundreds of genetic mutations in a single tumor and in metastatic sites dozens more appear.  The Cancer Genome Atlas Project (CGAP) is identifying potential new gene targets to help develop new drugs and to reduce side effects.

The ASCO report indicates that at least one third of all cancer cases can be prevented through exercise, diet, decreased environmental exposures, or health screening.  The concept of reducing cancer mortality by several hundred thousand persons per year with these relatively low cost, heath improving measures is very exciting, especially in tight economic times.  In some cases doing less may produce more, as in a study that suggested flexible sigmoidoscopies might be able to replace colonoscopies in many patients.  On the other hand, once again, chest x-rays failed to prevent lung cancer deaths in smokers, although there is some evidence that CT scans may do better.

An extensive list of drugs received FDA approval for cancer treatment, and five current drugs were approved for new indications.  These included:

• Carfilzomib (Kyprolis) for Multiple Myeloma
• Micro-encapsulated vincristine (Marquibo) for relapsed leukemia
• Breast cancer therapies, Pertuzumab (Perjeta) and Everolimus (Afinitor)
• Enzalutamide (Xtandi) for metastatic prostate cancer
• Advanced basal cell skin cancer treatment, Vismodegib(Erivedge)
• Imatinib (Gleevec) for GIST already in remission, to prevent relapse
• Axitinib (Inlyta) for kidney cancer
• Pazopanib (Votrient) for sarcoma
• Three treatments for colon cancer, Cetuximab (Erbitux), Ziv-Aflibercept (Zaltrap) and Regorafenib (Stivarga).

New uses for certain available drugs produced improved benefit, such as the use of lenalidomide to prevent myeloma relapse after stem cell transplant, bendamustine as early treatment for mantle cell lymphoma and the continued development of T-DM1 to treat breast cancer.  It was noted that in 31 trials, there were 15% fewer cancer deaths among patients taking aspirin, although how aspirin may have this benefit or who should be taking it, is not clear.

ASCO legislative staff focused on the increasing problems with sudden national drug shortages.  They worked with Congress, COA, the AMA and The American Society of Health-System Pharmacists to increase awareness of this crisis and propose solutions.  Their three key recommendations were to:

1) Require manufacturers to provide six month warning of shortages

2) Require and support the corporate development of shortage contingency plans

3) Establish FSA user fees for generic drugs to improve funding and supervision of the generic drug process.

The changes described in the report were viewed by the 21 members of ASCO’s Editorial Board, as practice changing.  Together they cast 2012 as a year of significant advance in the war on cancer.  It is the commitment of oncologists and ASCO that the movement toward cancer cure, more lives saved, will continue in the year to come.   How these goals are threatened by decreased funding remains to be seen.