American cancer society cleveland

Everything about the 38th Annual Meeting of the American Society of Clinical Oncology (ASCO) in May was huge. There were 26,000 attendees, many of whom came from Europe, Latin America and Asia. For nearly a week they converged on Orlando's convention center, to hear thousands of lectures, seminars and presentations. The Exhibition Hall was a multistoried bazaar of new therapies. Even the press room was gargantuan.

Yet, after four days, I came away with a hollow feeling. There were advances, to be sure. A study compared Gleevec (STI-571) to the standard therapy for chronic myeloid leukemia (CML). Gleevec resulted in significantly greater reductions in the number of cancer cells in the bone marrow, which led to the complete disappearance of cancer cells in 40% of the patients. Only six patients treated with Gleevec were in the dangerous "blast crisis" six months after therapy compared to 26% of those receiving standard therapy. Six months after treatment, leukemia continued to worsen in 8 patients taking Gleevec compared to 57 taking the interferon-based therapy.

"[T]he long-term results of STI-571 remain unknown," said its discoverer, Brian Drucker, MD, of the Oregon Health and Science University, Portland. However, he believes "it should now be considered as standard therapy for newly diagnosed CML." Gleevec was approved last year for the treatment of patients who no longer respond to interferon-based therapy or who are in the "blast crisis." This report will add to the drug's luster. Overall, however, I was disappointed by the lack of breakthroughs in the treatment of cancer.

Erbitux

One of the highlights of the meeting was the 2002 Karnofsky Lecture, "Targeting the EFG Receptor for Cancer Therapy," by John Mendelsohn, MD. Dr. Mendelsohn is the president of the M.D. Anderson Cancer Center in Houston and has had a distinguished medical career. Listening to him speak, I caught some of his excitement and could see why he was chosen to receive this high honor from his peers. Dr. Mendelsohn's speech, concerning the science behind a new drug called Erbitux (formerly known as IMC-C225), was enthusiastically received by an overflowing crowd.

Carefully targeted drugs like Erbitux are central to the oncology profession's latest strategy for conquering cancer. As the director of the National Cancer Institute, Andrew von Eschenbach, MD, said in another lecture, these newer drugs mark a transition from the "seek and destroy" strategy of 20th century chemotherapy to the "target and control" strategy of the 21st, from "weapons of destruction" to "interventions for control and prevention." In principle, advocates of complementary and alternative medicine (CAM) support such a development, since it represents a departure from the slash-burn-and-poison school of conventional cancer treatment. There are side effects of Erbitux, but they are relatively mild, and consist mainly of an acne-like rash. Who in their right mind wouldn't want these new drugs to succeed?

Dr. Mendelsohn was a pioneer in using monoclonal antibodies, or "guided missiles," to block the growth of cancer cells. The primary outcome of his work was the development of Erbitux, which targets epidermal growth factor (EGF) receptors. EGF is present in all cells that line our organs and skin, and high levels of EGF have been found to correlate with a poorer prognosis for cancer patients.

Preliminary research looked highly promising. At last year's ASCO meeting, the manufacturer of Erbitux, ImClone Systems, claimed a 22.5% response rate in patients with advanced cancer treated with a combination cf Erbitux and chemotherapy. The jubilation at ASCO culminated in a Doobie Brothers concert that ImClone sponsored for the doctors attending the conference.

In his lecture this year, Dr. Mendelsohn naturally emphasized the positive aspects of Erbitux. But the world's first phase III clinical trial of Erbitux was reported a few days after Dr. Mendelsohn's inspiring speech. In it, the standard drug cisplatin was compared to combination therapy using cisplatin and Erbitux in the treatment of head and neck cancer. The results were less than stellar. Just one patient out of 44 (2.3%) achieved a complete response and five (11.4%) had a partial response. The median disease-free survival for the group as a whole was 6.7 months and the median overall survival was just 7.2 months.

It turned out that the response rate, poor as it was, enclosed an even more sobering reality: the response rate among so-called "real world" patients (patients who received their treatment outside the rarefied atmosphere of clinical trials) was just 5.7 percent. And that was a measurement of tumor shrinkages, not survival. For the Erbitux-added patients, the median time until the tumors worsened was just 4.10 months, compared to 3.37 months for the control patients. This difference of three weeks was not statistically significant.

So, while on Saturday oncologists were applauding Dr. Mendelsohn for his brilliant insights, on Monday they were hearing that a treatment based on these insights simply did not work. If it were true that EGF "plays a critical role in the process that regulates tumor cell growth and survival," as ImClone still claims on its website, then one would expect a treatment that targets EGF to yield significant clinical results. It doesn't.

Because of the weak performance of Erbitux, the Food and Drug Administration (FDA) has refused to approve it. The company's stock, which traded at $75 per share at the end of last year, now hovers around $10. In the wake of the ASCO meeting, the president and CEO, Samuel Wachsal, resigned all his posts. According to ASCO, some of those involved in the current clinical trial of Erbitux received honoraria and funding from its co-marketer, Bristol Myers-Squibb, and own stock or serve on the board of ImClone. The search for a magic bullet for cancer detracts from the study of approaches that actually extend the lives of cancer patients while maintaining or improving their quality of life. It also detracts attention away from cancer prevention strategies using natural and nutritional substances. These less toxic (and less expensive) approaches represent for me, the real promise of cancer research.

ASCO's CAM Symposium

I also attended the ASCO-American Cancer Society symposium on "Complementary and Alternative Medicine: State of the Evidence," on May 17, 2002. Scholars from prestigious medical centers held forth on complementary and alternative medicine (CAM). Yet few of them had any direct experience with the field. Indeed, most made sure the audience knew that they did not personally practice any form of CAM.

David Rosenthal, MD, director of Harvard University's Health Services, introduced the speakers: Eric Winer, MD, of Dana-Farber Cancer Institute; Eric Small, MD, of the University of California, San Francisco; Maurie Markman, MD, of the Cleveland Clinic Foundation; Norman Farnsworth, PhD, of the University of Illinois; Jimmie Holland, MD, of Memorial Sloan-Kettering Cancer Center; and Michael Hawkins, MD, of the Washington Hospital Center.

I have nothing against any of these fine people, but none of them is a CAM practitioner. In fact, Eric Winer, MD, who described himself as a "traditional" medical oncologist, opened his presentation by asking, "Why am I here?" and then set the tone for the symposium by telling the audience of nearly 200 oncologists, "I have not done research in complementary therapies." Dr. Winer went on to speak about CAM use among women with breast cancer, although his derogatory attitude towards CAM was apparent when he stated, "We do a real disservice to our psychosocial colleagues to classify psychotherapy as a complementary therapy." In other words, the CAM label is a stigma.

Eric Small, MD, of the University of California, San Francisco, presented information on dietary and herbal approaches to prostate cancer, and reviewed research on the herbal formula PC SPES, a project he described as "not for the faint of heart." After showing that PC SPES was effective even in some hormone-refractory prostate cancer patients, Dr. Small had arranged a clinical trial to compare PC SPES to the drug DES in advanced prostate cancer. However, when he discovered a minute amount of DES in the herbal formula (3% of the dose used in the DES arm of the study), he and his colleagues cancelled the study. This was a decision I still could not understand, even after his attempt at an explanation.