More Developments for Younger Women In a related development, 2 additional studies recently reported benefits from the AI exemestane in the treatment of young women with hormone-sensitive breast cancer who also underwent postsurgical treatment to suppress ovarian function. The drug was found to be more effective than tamoxifen in preventing breast cancer recurrence in these patients. The combined results for the phase 3 randomized TEXT (Tamoxifen and Exemestane Trial) and SOFT (Suppression of Ovarian Function Trial) trials were presented at the 2014 ASCO annual meeting in Chicago and published in The New England Journal of Medicine.2 Treatment with exemestane plus ovarian function suppression reduced the risk of any invasive cancer by 28% and reduced the risk of invasive breast cancer recurrence
We are decades into this era of antiestrogen therapy for breast cancer, and we’re still learning about the optimal use of these various strategies. — Harold Burstein, MD, PhD by 34% compared with treatment with tamoxifen plus ovarian function suppression. At 5 years from the initiation of the study, 92.8% of women remained free from breast cancer after treatment with exemestane plus ovarian function suppression versus 88.8% after treatment with tamoxifen plus ovarian function suppression. AIs previously have been shown to benefit postmenopausal women with breast cancer by preventing the formation of estradiol, a female hormone. “This is a challenging study to discuss because the control arm of one of the trials was tamoxifen alone with no ovarian function suppression,” Dr. Hudis says. “We think we will get the answer when this third arm is presented at the San Antonio Breast Cancer Symposium in December.” Many Europeans assume that ovarian function suppression for young people is necessary and have found that exemestane is the better treatment in that case, but many Americans are not interested in that option for quality-of-life reasons, he adds. “In
San Antonio, we’ll get the last piece of the puzzle,” Dr. Hudis says. “It would be very unpredicted if exemestane and ovarian function suppression was not superior to tamoxifen alone, but we have to wait and see.” Dr. Burstein and Dr. Chavez Mac Gregor point to another study, ABCSG-12 (The Austrian Breast Cancer Study Group Trial 12), which demonstrated no difference in survival among premenopausal women receiving AIs versus tamoxifen.3 “That begs the more important question—what is the role of ovarian suppression in these women who also receive tamoxifen,” Dr. Burstein says. “If it turns out that there’s no real benefit to ovarian suppression in young women, then tamoxifen alone will be the standard of care.” Dr. Chavez Mac Gregor says she and colleagues at The University of Texas MD Anderson Cancer Center have concerns about how to put together the data from these various studies and whether putting young women into menopause is the best strategy. At the current time, they are not treating young women with ovarian function suppression and exemestane. “After carefully reviewing the literature, we want to wait until December when the 3 arms of the SOFT study are presented,” she says. “Once we have that piece, we may be able to put things into perspective.” Although much has been learned with regard to the treatment of hormone-sensitive breast cancers, Dr. Burstein adds, “We are decades into this era of antiestrogen therapy for breast cancer, and we’re still learning about the optimal use of these various strategies.”
References 1. Davies C, Pan H, Godwin J, et al; Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) Collaborative Group. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet 2013;381:805-816. 2. Pagani O, Regan MM, Walley BA, et al; TEXT and SOFT Investigators; International Breast Cancer Study Group. Adjuvant exemestane with ovarian suppression in premenopausal breast cancer. N Engl J Med. 2014;371:107118. 3. Gnant M, Mlineritsch B, Schippinger W, et al. Endocrine therapy plus zoledronic acid in premenopausal breast cancer. N Engl J Med. 2009;360:679-691. DOI: 10.1002/cncr.29034
Researchers Study Implications of Lung Cancer Screening
T
wo recent studies examined the implications of low-dose computed tomography (LDCT) lung cancer screening in patients. Based on findings in the National Lung Cancer Screening Trial, the US Preventive Services Task Force (USPSTF) recently recommended these screenings in patients aged 55 to 80 years with a 30 pack-year smoking history who currently smoke or quit within the past 15 years. In the first study, researchers from Roswell Park Cancer Institute in Buffalo, New York, and the Medical University of South Carolina found that the majority of current and former smokers would welcome screenings for lung cancer if their insurance covered spiral CT scans.1 The study surveyed more
2940
than 1200 adult current smokers about their attitudes toward lung cancer screening with spiral CT scans. Researchers found that 78.5% of current smokers and 81.4% of former smokers said they would be willing to be tested if they were advised to do so by a physician. Their reasons for not being screened included a lack of insurance coverage and a fear of being diagnosed with lung cancer . The most commonly cited reason for not being screened among former smokers was a belief that they did not have lung cancer. Andrew Hyland, PhD, chair of the department of health behavior at Roswell Park Cancer Institute, notes that the
Cancer
October 1, 2014
data indicate the need for insurance companies to cover the test. The National Lung Cancer Screening Trial reported a 20% reduction in mortality when lung cancer was diagnosed with spiral CT compared with annual chest x-rays. In addition to the USPSTF, other organizations recommending lung cancer screening with spiral CT are the American Association for Thoracic Surgery and the American Cancer Society. In a second study, presented by Joshua Roth, PhD, of the Fred Hutchinson Cancer Research Center in Seattle, Washington, as an abstract at the ASCO annual meeting in June 2014, researchers developed a model to forecast the 5-year incremental outcomes of implementing USPSTF screening recommendations for LDCT versus no screening. They estimated the number of lung cancers detected, LDCT scans, and the total and per-member per-month budget impact in 2 scenarios. The first scenario included complete implementation with all eligible patients offered screening in all years, whereas the second scenario was a phased implementation, with an
additional 20% of eligible patients offered screening each year. Their findings demonstrated that in the first and second scenarios, screenings resulted in 141,000 and 101,000 more lung cancers (mostly stage I) diagnosed, 37.5 million and 22.4 million more LCDT scans, and an increased overall expenditure of $27.4 billion and $17.6 billion, respectively. The researchers concluded that LDCT screening will increase the rates of lung cancer diagnosis and result in a greater number of cases diagnosed early while substantially increasing Medicare expenditures. They will next evaluate the resource demands of complete and phased screening in relation to current supplies of LDCT facilities and health professionals.
Reference 1. Delmerico J, Hyland A, Celestino P, Reid M, Cummings KM. Patient willingness and barriers to receiving a CT scan for lung cancer screening. Lung Cancer. 2014;84:307-309. DOI: 10.1002/cncr.29035
The Impact of Water Pipe and Tobacco Marketing on Young People esearchers recently evaluated the effects of 2 different phenomena on young people and smoking: water pipes and tobacco marketing. In the first study, young adults who smoked water pipes in hookah bars were found to have elevated levels of nicotine, cotinine, tobacco-related cancer-causing agents, and volatile organic compounds in their urine, thereby increasing their risk of developing cancer and other chronic diseases.1 After a single evening of water pipe smoking in a hookah bar, young men and women were found to have a 73-fold increase in nicotine; a 4-fold increase in cotinine; a 2-fold increase in NNAL, a breakdown product of tobacco-specific nitrosamine NNK; and a 14% to 91% increase in the breakdown products of volatile organic compounds such as benzene and acrolein. Researchers observed a substantial increase in nicotine levels, which makes them concerned about the potential addictiveness of water pipe smoking and the effects on the developing brains of children and young people who use water pipes, according to Gideon St. Helen, PhD, a postdoctoral fellow at the University of California at San Francisco. He adds that the results of the study show that water pipe smoking is not free of risk. A second study conducted by researchers at DartmouthHitchcock Norris Cotton Cancer Center found that despite many efforts to prevent youth exposure to the marketing of nicotine products, adolescents are still influenced by it.2 The authors explored whether exposure to tobacco coupons and Web sites would increase the chances that a young person would start to smoke. They found that 12% of individuals aged 15 to 17
years and 26% of individuals aged 18 to 23 years were exposed to either form of direct-to-consumer tobacco marketing. In addition, black and Hispanic youth in the study were found to be exposed more frequently than their white counterparts to direct marketing methods. The researchers recommend stricter security for Web sites and the increased enforcement of directto-consumer marketing.
References 1. St. Helen G, Benowitz NL, Dains KM, Havel C, Peng M, Jacob P 3rd. Nicotine and carcinogen exposure after water pipe smoking in hookah bars. Cancer Epidemiol Biomarkers Prev. 2014;23:1055-1066. 2. Soneji S, Ambrose BK, Lee W, Sargent J, Tanski S. Direct-to-consumer tobacco marketing and its association with tobacco use among adolescents and young adults. J Adolesc Health. 2014;55:209-215. DOI: 10.1002/cncr.29036
© GUZEL STUDIO, PRUDKOV | SHUTTERSTOCK.COM
R
Content in this section does not reflect any official policy or medical opinion of the American Cancer Society or of the publisher unless otherwise noted. © American Cancer Society, 2014.
Cancer
October 1, 2014
2941
We are decades into this era of antiestrogen therapy for breast cancer, and we’re still learning about the optimal use of these various strategies. — Harold Burstein, MD, PhD by 34% compared with treatment with tamoxifen plus ovarian function suppression. At 5 years from the initiation of the study, 92.8% of women remained free from breast cancer after treatment with exemestane plus ovarian function suppression versus 88.8% after treatment with tamoxifen plus ovarian function suppression. AIs previously have been shown to benefit postmenopausal women with breast cancer by preventing the formation of estradiol, a female hormone. “This is a challenging study to discuss because the control arm of one of the trials was tamoxifen alone with no ovarian function suppression,” Dr. Hudis says. “We think we will get the answer when this third arm is presented at the San Antonio Breast Cancer Symposium in December.” Many Europeans assume that ovarian function suppression for young people is necessary and have found that exemestane is the better treatment in that case, but many Americans are not interested in that option for quality-of-life reasons, he adds. “In
San Antonio, we’ll get the last piece of the puzzle,” Dr. Hudis says. “It would be very unpredicted if exemestane and ovarian function suppression was not superior to tamoxifen alone, but we have to wait and see.” Dr. Burstein and Dr. Chavez Mac Gregor point to another study, ABCSG-12 (The Austrian Breast Cancer Study Group Trial 12), which demonstrated no difference in survival among premenopausal women receiving AIs versus tamoxifen.3 “That begs the more important question—what is the role of ovarian suppression in these women who also receive tamoxifen,” Dr. Burstein says. “If it turns out that there’s no real benefit to ovarian suppression in young women, then tamoxifen alone will be the standard of care.” Dr. Chavez Mac Gregor says she and colleagues at The University of Texas MD Anderson Cancer Center have concerns about how to put together the data from these various studies and whether putting young women into menopause is the best strategy. At the current time, they are not treating young women with ovarian function suppression and exemestane. “After carefully reviewing the literature, we want to wait until December when the 3 arms of the SOFT study are presented,” she says. “Once we have that piece, we may be able to put things into perspective.” Although much has been learned with regard to the treatment of hormone-sensitive breast cancers, Dr. Burstein adds, “We are decades into this era of antiestrogen therapy for breast cancer, and we’re still learning about the optimal use of these various strategies.”
References 1. Davies C, Pan H, Godwin J, et al; Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) Collaborative Group. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet 2013;381:805-816. 2. Pagani O, Regan MM, Walley BA, et al; TEXT and SOFT Investigators; International Breast Cancer Study Group. Adjuvant exemestane with ovarian suppression in premenopausal breast cancer. N Engl J Med. 2014;371:107118. 3. Gnant M, Mlineritsch B, Schippinger W, et al. Endocrine therapy plus zoledronic acid in premenopausal breast cancer. N Engl J Med. 2009;360:679-691. DOI: 10.1002/cncr.29034
Researchers Study Implications of Lung Cancer Screening
T
wo recent studies examined the implications of low-dose computed tomography (LDCT) lung cancer screening in patients. Based on findings in the National Lung Cancer Screening Trial, the US Preventive Services Task Force (USPSTF) recently recommended these screenings in patients aged 55 to 80 years with a 30 pack-year smoking history who currently smoke or quit within the past 15 years. In the first study, researchers from Roswell Park Cancer Institute in Buffalo, New York, and the Medical University of South Carolina found that the majority of current and former smokers would welcome screenings for lung cancer if their insurance covered spiral CT scans.1 The study surveyed more
2940
than 1200 adult current smokers about their attitudes toward lung cancer screening with spiral CT scans. Researchers found that 78.5% of current smokers and 81.4% of former smokers said they would be willing to be tested if they were advised to do so by a physician. Their reasons for not being screened included a lack of insurance coverage and a fear of being diagnosed with lung cancer . The most commonly cited reason for not being screened among former smokers was a belief that they did not have lung cancer. Andrew Hyland, PhD, chair of the department of health behavior at Roswell Park Cancer Institute, notes that the
Cancer
October 1, 2014
data indicate the need for insurance companies to cover the test. The National Lung Cancer Screening Trial reported a 20% reduction in mortality when lung cancer was diagnosed with spiral CT compared with annual chest x-rays. In addition to the USPSTF, other organizations recommending lung cancer screening with spiral CT are the American Association for Thoracic Surgery and the American Cancer Society. In a second study, presented by Joshua Roth, PhD, of the Fred Hutchinson Cancer Research Center in Seattle, Washington, as an abstract at the ASCO annual meeting in June 2014, researchers developed a model to forecast the 5-year incremental outcomes of implementing USPSTF screening recommendations for LDCT versus no screening. They estimated the number of lung cancers detected, LDCT scans, and the total and per-member per-month budget impact in 2 scenarios. The first scenario included complete implementation with all eligible patients offered screening in all years, whereas the second scenario was a phased implementation, with an
additional 20% of eligible patients offered screening each year. Their findings demonstrated that in the first and second scenarios, screenings resulted in 141,000 and 101,000 more lung cancers (mostly stage I) diagnosed, 37.5 million and 22.4 million more LCDT scans, and an increased overall expenditure of $27.4 billion and $17.6 billion, respectively. The researchers concluded that LDCT screening will increase the rates of lung cancer diagnosis and result in a greater number of cases diagnosed early while substantially increasing Medicare expenditures. They will next evaluate the resource demands of complete and phased screening in relation to current supplies of LDCT facilities and health professionals.
Reference 1. Delmerico J, Hyland A, Celestino P, Reid M, Cummings KM. Patient willingness and barriers to receiving a CT scan for lung cancer screening. Lung Cancer. 2014;84:307-309. DOI: 10.1002/cncr.29035
The Impact of Water Pipe and Tobacco Marketing on Young People esearchers recently evaluated the effects of 2 different phenomena on young people and smoking: water pipes and tobacco marketing. In the first study, young adults who smoked water pipes in hookah bars were found to have elevated levels of nicotine, cotinine, tobacco-related cancer-causing agents, and volatile organic compounds in their urine, thereby increasing their risk of developing cancer and other chronic diseases.1 After a single evening of water pipe smoking in a hookah bar, young men and women were found to have a 73-fold increase in nicotine; a 4-fold increase in cotinine; a 2-fold increase in NNAL, a breakdown product of tobacco-specific nitrosamine NNK; and a 14% to 91% increase in the breakdown products of volatile organic compounds such as benzene and acrolein. Researchers observed a substantial increase in nicotine levels, which makes them concerned about the potential addictiveness of water pipe smoking and the effects on the developing brains of children and young people who use water pipes, according to Gideon St. Helen, PhD, a postdoctoral fellow at the University of California at San Francisco. He adds that the results of the study show that water pipe smoking is not free of risk. A second study conducted by researchers at DartmouthHitchcock Norris Cotton Cancer Center found that despite many efforts to prevent youth exposure to the marketing of nicotine products, adolescents are still influenced by it.2 The authors explored whether exposure to tobacco coupons and Web sites would increase the chances that a young person would start to smoke. They found that 12% of individuals aged 15 to 17
years and 26% of individuals aged 18 to 23 years were exposed to either form of direct-to-consumer tobacco marketing. In addition, black and Hispanic youth in the study were found to be exposed more frequently than their white counterparts to direct marketing methods. The researchers recommend stricter security for Web sites and the increased enforcement of directto-consumer marketing.
References 1. St. Helen G, Benowitz NL, Dains KM, Havel C, Peng M, Jacob P 3rd. Nicotine and carcinogen exposure after water pipe smoking in hookah bars. Cancer Epidemiol Biomarkers Prev. 2014;23:1055-1066. 2. Soneji S, Ambrose BK, Lee W, Sargent J, Tanski S. Direct-to-consumer tobacco marketing and its association with tobacco use among adolescents and young adults. J Adolesc Health. 2014;55:209-215. DOI: 10.1002/cncr.29036
© GUZEL STUDIO, PRUDKOV | SHUTTERSTOCK.COM
R
Content in this section does not reflect any official policy or medical opinion of the American Cancer Society or of the publisher unless otherwise noted. © American Cancer Society, 2014.
Cancer
October 1, 2014
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