ASCO sponsored a session on highlights of our ASCO annual meeting, which was held in June of 2024, especially as applicable to low- and middle-income countries. Our President in 2024, Dr Lynn Schuchter, kicked off the session. She highlighted the theme of the meeting which was her chosen theme for the year which was The Art and Science of Cancer Care from Comfort to Cure. So she wanted to place an emphasis, as a palliative care specialist, on the comfort part but also, as a melanoma specialist, on the cure part and try to balance that.
Dr Schuchter reviewed two important abstracts that were presented in our plenary; our plenary is only five abstracts felt to be the most important at the whole meeting. The first was on palliative care and it studied the use of in-person palliative care every four weeks versus telehealth palliative care every four weeks. It wanted to see if there were the same benefits with respect to what the patient felt in terms of symptoms and support, as well as what the caregiver and family felt. What they found was that it was equally effective. It was equally effective and what’s great about that and why it’s applicable, not just in low- and middle-income countries but even in the United States in more rural settings when there aren’t palliative care doctors close by, is that we can effectively deliver support and palliative care by telemedicine and not making patients go in to the hospital, travel long distances. In many settings we don’t have enough palliative care specialists anyway so this could be done from a central hub and then more patients would get benefit.
The other abstract that she highlighted from our plenary session was in her speciality of melanoma. It was a very important trial called the NADINA trial and what it looked at was in melanoma it compared giving two immunotherapy drugs and then surgery and at the time of surgery if the cancer had all been eliminated, what we call a pathologic complete response, they got nothing else. If they didn’t, the 40% that didn’t have a complete response, they went on to a year of further immunotherapy which, as you know, is quite expensive. The group that had a complete response was randomised to get no further therapy versus being randomised to go on and get an additional year of therapy. What they saw at the end of that was that the two groups did the same. If you had a good response, remember 60% of patients, you did not need that very expensive additional year of therapy. So this is very important to understand that while immunotherapy has made a tremendous difference in outcomes in melanoma patients, where survival is much higher than it used to be because of immunotherapy, this study importantly said you can get two doses of these two drugs and in the 60% who have a terrific response you do not need an additional year of therapy. That’s a way of thinking about how we can get these important immunotherapy drugs into low- and middle-income settings – if you don’t need a year’s worth of doses then maybe we can start to think about how we can afford that.
Are there any other highlights from this year’s conference that you would like to share?
We followed that with two speakers, Dr Chris Booth reviewed one of our education sessions which was called Common Sense Oncology. It was actually our ASCO/ESMO joint session. Common sense oncology is really a movement to make sure that we are designing trials and reviewing trials with respect to outcomes that matter to patients, which include overall survival and quality of life, primarily. So that was an important discussion – he gave a quick summary of all the tenets of what we need to do to get the best outcomes for our patients and we should be using common sense and not approving drugs based on tiny differences in outcome that are very expensive.
Then Dr Ajay Aggarwal reviewed a session, an education session that we did, on delivering quality care across the globe. I moderated that session at the annual meeting and we reviewed what are quality indicators that are applicable globally? What is it that we would use, whether you’re in a low-income country or high-income country, to show that we’re giving quality care? So he reviewed that. One of the very applicable presentations was from Dr Jackson Orem who is the Head of the Uganda Cancer Institute, he partnered with ASCO in a quality oncology practice initiative designed for low- and middle-income countries. He picked five major topics – quality indicators from our ASCO quality oncology practice initiative – and he wanted to see what the baseline was at the Uganda Cancer Institute and then went through a series of several quality training programmes to improve it.
The five quality indicators that he chose were pretty simple, I think that we would all agree that no matter where you are it should be in the patient chart. The first was is there a pathology report that documents cancer? The second is is there documentation in the chart of the stage of the cancer after diagnosis? The third is if systemic therapy is going to be given, is it documented what the intention is, what the dose is and how frequently it’s given and how many doses? Then a follow-up metric would be what did they actually get? Is that documented? Then the fifth one is is pain being monitored while the patient is on the study? He was able to show that at baseline there was a lot of missing data but after going through several rounds with all of his staff and his faculty and focussing on this, they were able to bring it up so they were 90+% compliant in all of those categories. Really terrific and it shows it didn’t take extra drugs or extra money, it took a focus on we want to make sure everybody seeing that patient chart knows what’s happening and what we’re intending.
I finished out the session looking at a couple of our other plenary abstracts in lung cancer and a few additional lung cancer. I wanted to make the point that in lung cancer, both non-small cell and small cell lung cancer, the introduction of immunotherapy and the newer targeted therapies has made a tremendous difference. I started by showing that with the beginning of targeted therapies – erlotinib approved many years ago, back in non-small cell lung cancer, it targets the epidermal growth factor receptor – in the United States we started to see a separation between the incidence and the mortality curves which could not be explained based on tobacco cessation because this was incident correlated. It really couldn’t be explained based on screening for lung cancer because that didn’t have great uptake in the beginning, but we are really seeing an improvement in 5-year survival, overall mortality in lung cancer and it totally correlates with the approval and introduction of immunotherapies and targeted therapies.
So I showed five abstracts, one targeting the epidermal growth factor receptor, one KRAS and some others, one an immunotherapy study in small cell lung cancer that showed a positive benefit in limited stage small cell lung cancer. That is the first improvement in 20 years that we have seen in small cell lung cancer. Now, you might say these are expensive drugs, these are new drugs, how are we going to get them? But this is what it’s going to take in order to make a difference in this very common cancer around the world in order to improve survival. We’ve got to be able to get the diagnostics that say do you have an EGFR or a BRAF or an ALK mutation, if you don’t would immunotherapy benefit you? Then, how are we going to get the drugs, some of which can be expensive but some of which are already on the WHO’s essential medicines list because they’ve gone off patent or because they are so impressive in terms of their results that they’ve been deemed to be something that you should have available for patients if you can afford them. But the immunotherapy drugs in melanoma, for example, are already on the WHO’s essential medicines list and we will be discussing them again for lung cancer with the 2025 update. All of these targeted agents, many of them are oral, most of them are oral. They’re starting to go off patent so we do need to take a look at how are we going to get these drugs for lung cancer, a very common cancer, and the diagnostics that are required to go with it, available in other countries.
In our partnership with ATOM, the UICC’s ATOM, the Access to Oncology Medicines coalition, we are looking at getting these diagnostics and these drugs into countries to test feasibility – can we deliver them, can we manage the toxicities? We’re having a lot of dialogue around beginning to ramp up to start the pilot of the ATOM coalition in several countries at this meeting here at UICC World Cancer Congress.
