Day 3: Top Takeaways from ASCO24    

Dr. John Sweetenham shares highlights from Day 3 of the 2024 ASCO Annual Meeting, including selected studies on the treatment of cancer cachexia, surgical approaches in advanced ovarian cancer, and advanced colorectal cancer with liver metastases. TRANSCRIPT Dr. John Sweetenham: I'm Dr. John Sweetenham, the host of the ASCO Daily News Podcast, with my top takeaways on selected abstracts from Day 3 of the 2024 ASCO Annual Meeting.  Today's selection features studies addressing the treatment of cancer cachexia and 2 studies of surgical approaches to the treatment of advanced ovarian cancer and of advanced colorectal cancer with liver metastases.  My full disclosures are available in the transcript of this episode.   Cachexia affects up to 80% of patients with advanced cancer and is thought to be directly responsible for 30% of cancer deaths, according to the National Cancer Institute. Despite these statistics, the condition remains understudied and there is no standard treatment. Current guidelines recommend dietary counseling and low-dose olanzapine or short courses of corticosteroids or progesterone analogues can be used to promote weight gain. However, the guidelines mainly point to evidence gaps. No drug therapy could be strongly endorsed to improve patient outcomes and no recommendations could be made regarding exercise.  Dr. Tora Solheim from the Cancer Clinic at St. Olavs Hospital in Trondheim, Norway, today reported results from the MENAC trial in LBA12007, which tested an intervention that combined treatment with nonsteroidal anti-inflammatory medication ibuprofen, home-based exercise to improve endurance and muscle strength, nutritional counseling, and supplements containing omega-3 fatty acids, which, based on previous research, may enhance muscle mass in patients with cancer cachexia. This trial enrolled 212 patients with stage III or IV lung or pancreatic cancer from 17 sites in 5 countries. All patients were receiving palliative chemotherapy and either had cachexia or were at high risk of developing it. Half were randomly assigned to the intervention and half to standard care. For the exercise components of the intervention, patients were encouraged to engage in aerobic activity such as walking, swimming, or even household chores at least twice a week. They were also encouraged to perform strengthening exercises such as half squats, bicep curls, and knee lifts 3 times per week.  Over 6 weeks, the trial found average body weight stabilized in the intervention group compared with a loss of 1 kg in the standard care group, but there were no differences between the two groups and the secondary endpoints of muscle mass and daily step count as measured by ActiGraph. Dr. Solheim pointed out that 6 to 8 weeks may be too early to observe any anabolic effects on muscle mass or function, but that this timeframe was chosen, she said, because previous studies, including her team’s own feasibility study had encountered high dropout rates among similar patient groups after 6 to 8 weeks.  Although these are interesting data, I think they also pose many questions: Is maintaining 1 kg of body weight a meaningful endpoint? Did the patients report any improvement in other symptoms? How was at-home exercise monitored for compliance? Did we know whether the patients were fulfilling adequate amounts of exercise? And there are many more questions. I think the investigators should be congratulated for demonstrating the feasibility of conducting a randomized trial in this challenging patient group, and this will hopefully provide a basis for future studies exploring new interventions. In LBA5505, Dr. Jean-Marc Classe presented data from the CARACO study, a randomized trial evaluating the use of retroperitoneal lymph node dissection in patients undergoing primary surgery or interval cytoreductive surgery after neoadjuvant chemotherapy for advanced epithelial ovarian cancer.   To provide some context, an earlier study, the phase 3 LION trial, assessed the role of RPLD in patients with advanced ovarian cancer with complete resection and normal lymph nodes after primary surgery. In this trial, RPLD provided no significant improvement in overall or progression-free survival and was associated with a significant increase in serious postoperative complications and 60-day mortality. In recent years, the use of neoadjuvant chemotherapy and interval surgery has increased significantly in the U.S. and Europe, and it was unknown whether RPLD could have a benefit among these patients. The CARACO trial was undertaken to answer this question, enrolling patients treated with either primary surgery or neoadjuvant chemotherapy and interval surgery to reflect a real-world population. The multicenter trial enrolled 379 patients with FIGO stage III-IVA epithelial ovarian cancer with no suspicious retroperitoneal lymph nodes in whom optimal surgery was achievable with primary surgery or with interval cytoreductive surgery after neoadjuvant chemotherapy with residual tumor at less than 1 cm. Patients were randomly assigned to surgery with or without retroperitoneal lymph node dissection. Patients receiving primary surgery accounted for about 26% of the no RPL arm and 21% of the RPL arm. The primary endpoint was progression free survival, and secondary endpoints included overall survival, safety, surgical outcomes, and quality of life.  Although the trial initially planned to enroll 450 patients, enrollment slowed after the presentation of the results of the Lyon trial, leading to a premature closing of this trial to enrollment with 379 patients. The median age of enrolled patients was 64 - 65 years and 87% had serous or endometrioid carcinoma. Surgery was performed with no residual tumor in around 86% of the patients in the no RPL arm and 88% of patients in the RPL arm. Importantly, the median duration of surgery was 240 minutes in those with no RPL versus 300 minutes in the RPL arm, representing an additional hour for those who underwent retroperitoneal lymph node dissection. Severe morbidity within 30 days of surgery was significantly improved in the no RPL arm compared with the RPL arm as assessed by rates of transfusion or blood loss, re-intervention, and urinary injury. In an intent to treat analysis, there was no significant difference in progression-free survival in patients who did or did not receive retroperitoneal lymph node dissection. The respective median progression-free survivals were 14.8 and 18.6 months. Median overall survival was 48.9 months and 58.8 months, respectively, and on subgroup analysis, no benefit for retroperitoneal lymph node dissection was observed.   Although the results of this study are slightly confounded by the failure to reach their target accrual, the data shows strong evidence that these patients can be spared the additional surgery and subsequent surgical complications without compromising progression free or overall survival. Dr. Classe and his colleagues hope to determine whether retroperitoneal lymph node dissection is useful in patients with suspicious nodes.  The third selected abstract today is 3500, which describes a remarkable prospective study of chemotherapy plus liver transplantation versus chemotherapy alone in patients with unresectable colorectal cancer liver metastases. The results of the so-called TRANSMET study were presented by Dr. Adam from Villejuif, France, on behalf of a study group including centers from France, Belgium, and Italy. In the introduction to the study, the presenter pointed out that liver resection is currently the optimal treatment for liver metastases from colorectal cancer and offers the potential for long-term survival and even cure. But resection is only possible in 10% to 20% of patients. And although cytoreductive chemotherapy may convert some patients to a resectable status, this is relatively rare. The current standard of care is the use of chemotherapy, which may prolong survival but is not curative. Liver transplantation has been used in this context since the 2000s with apparent improvements in outcome, but TRANSMET is the first randomized trial to assess the benefit of adding liver transplantation to chemotherapy in this patient group.  The TRANSMET study evenly randomized 94 patients to either undergo chemotherapy and liver transplantation or only chemotherapy. The patients were highly selective in terms of age, performance status, resection of primary tumor, months of tumor control, previous line of therapy, and tumor markers. It's noteworthy that of the 157 patients eventually considered, 63 failed to meet the demanding eligibility criteria on the review of the trial committee. The 5-year overall survival rate in the intent to treat analysis was 57% in the chemotherapy plus liver transplant cohort and 13% in the chemotherapy-alone arm. Progression-free survival was 17.4 versus 6.4 months, respectively. 28 of the 38 transplanted patients suffered relapses, 15 of which were in the lungs. Surgical resection and/or radio ablation were used in many of these patients. The authors concluded that liver transplantation is an option which should be considered in this highly selective patient group and that the outcomes reported here are comparable to outcomes for liver transplantation and other conditions. Understandably, this is a small study in a highly selective group, and it's difficult to know where this will gain traction. With a shortage of organs for donation, prioritization of this small patient group may be challenging.   That concludes today's report. Join me again tomorrow to hear more top takeaways from ASCO24. If you value the insights that you hear on the ASCO Daily News Podcast, please remember to rate, review, and subscribe wherever you get your podcasts.   Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Follow ASCO on social media:  @ASCO on Twitter  ASCO on Facebook  ASCO on LinkedIn    Disclosures: Dr. John Sweetenham: Consulting or Advisory Role: EMA Wellness